How to Address Food Insecurity with your Patients | Dr. Shreela Sharma

In this episode of Inside the Texas Heart Studio, Dr. Joseph G. Rogers, president and CEO of The Texas Heart Institute, sits down with Dr. Shreela Sharma, a professor of epidemiology and the founder of Brighter Bites. Dr. Sharma discusses the challenges of food insecurity, from limited access, to healthy options, to the phenomenon of "intimidation by produce."

Dr. Rogers and Dr. Sharma will talk through how to:

• Discover the food insecurities that your patients might have.
• Connect your patients to the necessary resources.

For more information, visit www.texasheart.org/heart-health

Watch the sit-down interview here.

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Chapters

• 1:03 Screening Patients for Food Insecurity
• 3:18 Navigating the Conversation about Food with your Patient
• 5:59 Intimidation by Produce
• 8:42 The Sandwich Approach
• 11:45 What Role does the Healthcare System play in the issue of Food Insecurity

Transcript

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Hi, I am Dr. Joe Rogers, president

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and CEO of the Texas Heart Institute,

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and I'm joined here in the studio this

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afternoon, uh, with Dr.

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Sila Sharma. Dr.

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Sharma is a professor of epidemiology in the School

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of Public Health at the University of Texas,

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and the director of the Center for Health Equity Srila.

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I, you, your grand rounds today was just, um, so, um,

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perfectly targeted to help us begin thinking about

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the challenges of nutrition, not just in the United States,

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but really globally,

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and how we begin to think about it in a systematic way

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and begin to devise solutions.

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So I just wanted to thank you for joining us

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after grand rounds for a few minutes just to sort

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of expand on some of the things we talked about. Sure.

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Well, thank you for the opportunity

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and yeah, I'm happy to dig in deeper.

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So, um, a lot of the people that watch this segment, um,

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we'll finish watching

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and start practicing, you know,

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back in their offices this afternoon or, or on Monday.

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And, and I was really struck by this idea

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that we all have an opportunity

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to screen our patients in a different way,

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to understand their nutritional status and the, and,

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and their food insecurity in a practical manner.

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For people who ne aren't necessarily affiliated with a large

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medical center or a medical school

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and have tools built into their electronic health records,

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how do, how does the average practitioner go about

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that in a, in a time efficient,

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but thoughtful way that at least helps us

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identify the right patients?

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Um, great question.

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Um, so I, I mean, the good news is that for a lot of the,

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these measurements related to bud, they're short and sweet.

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There's two questions.

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Uh, so even, you know, a practitioner who may not have, uh,

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uh, a lot of, uh, you know, support in regards

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to their EMR systems or whatnot, can still incorporate that.

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In fact, a lot, a lot

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of these screeners are sometimes even done on like an iPad

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or something simple like that.

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I think the part that is important is to, um, uh, to,

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to understand, uh, what the ecosystem, the food environment

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of your patient is, right?

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Uh, especially if you're working with, uh,

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patients from underserved communities

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or living in environments

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that are not conducive to healthy eating.

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Honestly, it's just about having a conversation with them,

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asking them about their food and what does that look like,

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and do they have enough access to food?

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I think a big part of the food insecurity

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and nutrition security, you know, the two pieces

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that we like to look at is honestly about, uh, caring

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for your patient from a social standpoint.

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And so it's about bringing

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that social care into the healthcare.

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Uh, so, uh, it may not be in the form of a screening.

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The screener helps standardize, right? Mm-Hmm.

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But, uh, as a, as a, as a provider, uh, you can still have

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that conversation to ask them about, uh,

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what does their food environment look like?

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And then thinking about, I think the, the part of it that's

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probably most critical is what do you do about it? Oh,

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Well, that was, that was my next question.

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I think it's, um, it can, it's, it's not only

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seemingly an expansive topic to begin to discuss

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with a patient, right?

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Right. But I think so few of us are well prepared to deal

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with the answers that we get.

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Yeah. And what what do you do when you find out someone is

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either food or nutritionally insecure?

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Because I think for, for many practices in the United States

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and, and certainly worldwide, we don't have

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that next connection that allows us to say,

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I've identified a problem

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and now I'm gonna propose a solution to you. Yeah.

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Uh, and that's, that's actually both an ethical question

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and a medical question, right?

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Because you don't wanna screen someone for something, um,

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like food insecurity, which is just not having enough food

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and then not do something about it.

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And so that's the ethical side of it.

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The good news is that, uh, I,

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I don't believe there's an expectation for, um, you know,

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health systems to start having farms within their premises.

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That's not the, the, the solution that's, uh,

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likely sustainable, but it's about building partnerships.

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Um, there's an incredible level just in, in our region,

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there's over 50 different kinds of providers,

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community providers for-profit organizations

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that are offering solutions like produce prescription

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programs, 15 of them, 53 to be precise.

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And so, um, so there's a lot of resources out there

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and, uh, some of the work that we do is connecting,

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you know, those resources

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because it has to be the right approach

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for your patient, right?

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Meet them where they're at.

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And so, um, so that's a lot of the work that we do is, uh,

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connecting the health systems, doing that assessment

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and connecting them to the resources and the response, uh,

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and the interventions, you know, that they need.

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But the good news is

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that there's a lot out there in terms of the solution.

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So I'll give you, uh, an example

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of the Houston Food Bank, right?

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The Houston Food Bank has a program called Food for Change,

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and as part of the program,

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they offer produce prescription program.

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And so any patient can receive a prescription to go to any

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of their pantries and redeem it,

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and they get, uh, either a home delivery

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or they can pick it up right there, about 30 pounds

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of fresh produce, and they can get it consistently for, um,

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six months and they can then renew the prescription.

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So their solutions out there, um,

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and it's about, uh, the, the provider sort of saying,

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I want to do this.

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And making sure if you're starting the screening to ensure

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that, that there's a response attached to it.

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I, I think they have to go hand up, go. So

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Go to the next step in this thought process.

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So you, I think you made a very compelling argument

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that we eat the way we grew up.

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Yes. And so I could easily imagine handing someone 30 pounds

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of produce and saying,

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now we've given you food problem solved,

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and people go home with those bags of food

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and think, I have no idea what to do with any

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of this food that I just received.

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What, so what, what's that next step then? Yeah.

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Um, great, great question.

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Um, so, uh,

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there's this very real phenomenon called

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intimidation by produce.

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You know, you go to the grocery store for all of us, um,

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we buy what we are familiar with, that we know how to cook,

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and that we know our kids and our family will eat.

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Yep. That's the bottom line, right?

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And what that, that's where the intimidation comes at.

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If I only have $2 in my pocket, am I going

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to spend it on the Brussels sprouts that I have no idea what

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to do with, or my kids are not gonna like it, right?

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Mm-Hmm. So I'm not going to spend it.

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I mean, I, as an immigrant came to this country

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and, uh, circled the broccoli for about six months.

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'cause I'd never seen broccoli before,

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and I didn't know how to cook it until my roommate said,

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like, all you have to do is roast it.

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And I put some all on salt

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and pepper, it's gonna taste great.

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And to this day, that's how I eat it, and my boys eat it.

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So there's, someone has to hold your hand in terms

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of breaking down those barriers, uh,

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to demystify the produce.

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And, um, I'll tell you a real story real quick.

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We had, um, uh, one of the programs, uh, food

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as Medicine programs that, uh, we've developed,

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and it's scaled now, it's called Brighter Bites.

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And we were working with this mom,

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and she, um, said, this is with pediatric populations.

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And she said, you know, I never bought Brussels sprouts

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because when I was growing up, my mom used to boil them.

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And she hated the taste of, well, nobody likes boils.

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But, um, and through brighter bites, we taught, um, them how

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to just roast it.

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And her boys loved it so much

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that even when she doesn't get it through the program,

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she now feels comfortable spending her money in the grocery

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store on buying brighter bread.

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And to me, that's not just the behavioral,

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it's an economic impact too.

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Right? Now she's spending that money

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on buying a healthy product, which she didn't use to before.

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Yeah. So I think there's a, you know,

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there's a value proposition even from the economic side of

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It. So as

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a, I wanna get your perspective

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as a clinical trialist Yeah.

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With this next question. So, um, today, it seems like a lot

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of this is hand to hand combat.

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You know, when you're teaching someone how to

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eat differently or cook differently, it's a very sort

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of personal one-on-one kind of intervention.

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Mm-Hmm. How do you scale it?

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I mean, how, how are we going to change the way populations

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of people consume food, prepare food in ways

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that are gonna make them healthier in the long run?

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Yeah, they're gonna use the sandwich approach.

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Tell me more. So

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The sandwich approach is where, um, we are at,

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at the, at the, the bottom.

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We are going to have to, uh, make it the norm, right?

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Where, uh, we are creating these partnerships, uh,

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to implement produce prescription types of initiatives.

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Uh, and, and so that's the, you know, from the policy.

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So the top layer is the policy layer.

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And, uh, you know, as I mentioned in the grand runs,

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we do now have the policy mandate from CMS, right,

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in regards to screening for social drivers of health.

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So health systems are now going to start thinking,

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incorporating it,

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but we have to be ready

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for it equally from a clinical trial, you know,

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with interventions that are actually effective

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and efficacious and improving outcomes

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for the patient populations that they are screening.

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Mm-Hmm. Right? Because otherwise you run the risk

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of implementing something that doesn't work, right?

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And so, uh, or, or the uptake of it, it's really low.

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So, you know, in the space of clinical trial,

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we think about implementation outcomes in

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to drive then efficacy and effectiveness.

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And so, um, uh,

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when you think about the implementation outcomes,

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that's then when you can think about scale, right?

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Because if you've done your job right,

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in thinking about dosage and thinking about reach,

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and thinking about uptake, adoption, all

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of those components, then your patients are going to adopt.

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They're gonna pull it in. Yeah. Right?

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And then that's how you can, you, you're going to scale it

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because it's, the adoption is, uh, is at its, you know,

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best you're gonna see the impact.

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I will say the other part of it that we are paying a lot

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of attention to is the cost, right?

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Ultimately, there's, uh, that, that component to it

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and, uh, make ensuring that we are documenting, you know,

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what it takes to scale these, uh, these programs.

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And there are, there is efficiency of scale, there's,

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there's huge efficiency of scale in these

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because it's much easier for, uh, community organizations

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that are doing this work to feed a thousand than it is

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to feed a hundred to provide this program.

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So there is efficiency

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of scale even from the community organizations, uh, side

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of things, uh, as well.

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So, but a big part of it is also bridging the data gaps

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and making sure that we're building out the model, keeping

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that sustainability and scalability in mind.

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I mean, I'm just so appreciative

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that you're putting science behind this.

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I think it's gonna create the most compelling argument.

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I have one more question Yeah. Before we wrap up.

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Um, I, I'm very interested in the fact that this is one

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of the pillars of the social drivers of health is,

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is food insecurity and nutrition insecurity.

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But you talked about the interrelatedness of,

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of the different pillars.

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It, it's, you know, economic security, it's, uh, you know,

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sort of early childhood experiences.

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And, and, and I guess the question for us to think about

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as, as a medical community is how much

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of this will be solved by medicine?

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And how much of this is really going to require

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that we begin having conversations

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with very different groups of people?

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Because I don't think medicine's gonna be able

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to address all of those things that are so,

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so highly interrelated.

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Yeah, no, uh, and you're a hundred percent right.

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Uh, the intent is not for the health system

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to take all of this on.

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Uh, the intent is for, uh, the health system to be part

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of a larger conversation, uh,

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where we need all different forms of sectors.

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And starting with as school, you know, our school systems,

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if you're, if we really wanna think of prevention,

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you know, that's where we need to.

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So we need, you know, the, the home environment.

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We need the parents, we need the, the,

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the provider community.

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We need school systems.

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We need multi-sectoral approaches to this work.

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You know, for the longest time, I mean, you know,

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this nutrition education has vanished.

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It's in from our schools.

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It's not a part

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of the medical curriculum in any substantial way or nursing.

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So it's, it's gone away from our lives.

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So how can we expect our parents, our providers, our, uh,

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you know, school teachers to talk about these things

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that has, is never been part of the ecosystem,

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but what has been part of the ecosystem

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is fast food restaurants ultra present.

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There's, there's extensive exposure to that, right?

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So that then becomes part of your conversation, right?

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So how, so a big part about this is not about health

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systems, sort of taking this on, uh, in, in its entirety,

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but being at the table in having these conversations where,

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um, along with everybody else,

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because I think the part that's important

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to remember is the solutions that are going

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to be most sustainable ones are the ones

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that are driven by policy.

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Yeah. To be honest with you.

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And so how do we, um,

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but we need everybody at the table

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to help drive those policy conversations. Alton,

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I, I think you and I probably could go on Yes.

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You know, and talk about this for another hour, which means

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that we're gonna have to invite you back

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for grand rounds sometime soon.

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I'm here for it. So thank you so much for spending time

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with us at the Texas Heart Institute,

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and thank you again for Grand Rounds

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and for spending a little bit of time in the studio.

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This is Joe Rogers from the Texas Heart

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Institute, thanking Dr.

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Sharma for a really terrific day. Thank you very much.

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Thank you.