2023 Innovation Issue: Tackling the widespread problem of food insecurity

Many Hoosiers—one in nine, according to the national food bank network Feeding America—don’t know where their next meal is coming from. Or they make do with low-quality food that is harming their health.

A new Indiana University School of Medicine and Eskenazi Health initiative, called Food Resources and Kitchen Skills (FoRKS), hopes to address food insecurity and help Hoosiers make healthier food choices. The initiative, which includes a study and recently received a $2.9 million grant from the National Institute on Minority Health and Health Disparities, will provide participants with healthy food, cooking classes and even cooking utensils to attempt to move the needle forward.

“In Indianapolis, food insecurity is as bad as the national average [a bit over 10% of the U.S. population, according to the U.S. Department of Agriculture],” said Daniel Clark, associate professor of medicine at the IU School of Medicine and one of the principal investigators for FoRKS. “As much as one in three people in some areas report food insecurity.”

The problem is as deep-rooted as it is pervasive. According to recent statistics from Chicago-based Feeding America and its Indiana affiliate, Feeding Indiana’s Hungry, one in six Hoosiers (1.1 million people, some 33% of whom are children) use food pantries and food service programs. About 85% of Indiana’s food-insecure households report purchasing cheap, unhealthy food because they simply can’t afford better options.

Perhaps to no surprise, 34% of those same households include a member with diabetes, and 64% include someone with high blood pressure. National studies have long linked lack of regular access to affordable, nutritious food to health problems such as Type 2 diabetes and hypertension.

Clark and his co-principal investigator, Richard Holden, chair of IU’s Department of Health and Wellness Design, conceived the program after years of observing what sorts of diet-related intervention efforts did and didn’t work.

“I think we’ve been thinking for decades about ways to get people to eat healthy foods,” Holden said. “But we realized that not everybody could eat healthy foods because they didn’t have access to them.”

For instance, the investigators observed classes in which dietitians and physical-activity coaches would tell people to exercise and eat superfoods like kale. But when they followed up to see whether patients put the advice into practice, they’d hear again and again that the patients didn’t know where to find such items and had no idea how to prepare them.

“It kind of dawned on us that we can give all the information we want, but if we don’t help people figure out how to use that information, it’s not going anywhere,” Holden said.

The program itself is something of a community effort between IU and Eskenazi Health’s team of dietitians.

“We worked with them, brainstorming what a program would look like if it not only addressed the lack of calories faced by people with food insecurity, but also long-term nutrition and disease challenges,” Clark said. “We wanted to address the underlying challenge of nutrition in the context of food insecurity and, oftentimes, health illiteracy.”

With the new grant, researchers will soon launch a randomized trial in Indianapolis with 200 patients that will follow a 2021 pilot program that showed some success.

The small group of pilot participants selected from food-insecure patients in the Eskenazi Health system had low-sodium, low-carbohydrate meals delivered to their homes. They also received a set of cooking tools and were loaned a tablet to participate in virtual cooking classes to teach them how to prepare food in a healthy way. They also joined Eskenazi Health’s hypertension-management course.

“What’s new and groundbreaking about this is, we’re combining healthy food with health education and cooking skills and food delivery with a scientific study to see if this actually does move the needle on key outcomes like blood pressure and diabetes,” Holden said.

That pilot included 67-year-old retiree Jerome Williams, whose own lack of good food options, coupled with his dearth of cooking skills, contributed to myriad health problems, including hypertension. By the end of the program, he could competently make a number of healthy dishes, including Asian-style chicken and rice, he said.

“I can’t speak for anyone else, but for me it made a difference,” Williams said. “And they taught us a lot more than just how to cook.”

The classes will be overseen by Eskenazi Health dietitians, including outpatient clinical dietitian Mariah Adams, who also helped teach the FoRKS pilot class.

“I think there’s a range of kitchen abilities with the participants we see,” Adams said. “Most had some basic kitchen knowledge but were maybe not as familiar with cooking from a recipe or using fresh ingredients.”

She hopes to see programs similar to FoRKS spread around the country—programs that take a holistic approach to healthy eating and spend more time on the “hows” of home food preparation, rather than just explaining why it’s important.

“We talk about a lot of different food-related topics throughout the program, including budget-friendly shopping,” Adams said. “My hope is that, as group members graduate, they’ll be able to use those skills for life.”

Whether the FoRKS concept expands will depend on what sort of hard data comes out of the current program. Results from the pilot were promising; class attendance averaged 87.1%, participants’ blood pressure and weight declined, and their food security improved. Ideally, the program could provide a relatively low-cost way to reduce cardiovascular-disease risk factors among adults with food insecurity and hypertension.

In other words, heading off a problem that can be quite expensive to treat, simply by helping people access healthier foods and teaching them how to cook healthier meals.

FoRKS is currently lining up students for its first official session, which will begin in a couple of weeks. Clark and Holden will monitor participants carefully to see whether first and foremost, they develop lower mean systolic blood pressure. Also, to determine if they stick with the new approaches to food selection and prep.

“We’re focused on being the first scientific study of this sort of project to assess blood pressure outcome,” Holden said. “That is our No. 1 concern. And taking it one step further, it would be wonderful if none of the program participants drop out. It will be great if the dietitians conducting the program love it, the health system loves it, and most importantly, the patients love it.”

The grant will fund the program for five years, but Holden is hopeful it will last longer.

“As much as I want to see that it works and improves blood-pressure control, my overarching goal is to make sure it’s implemented and stays in the system forever and ever.”•
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