Conversations About Food Insecurity

Find all supporting materials at the Hunger Vital Sign explainer series website.

This episode features an interview with Katy Davis, Community Health Initiatives Director at Hunger Free Vermont.

Part One of this series featured Children's HealthWatch - find their Hunger Vital Sign materials and background research here.

Audio Editing and Post-Production Provided By Evergreen Audio

Transcript

LABUN:

Welcome to episode number eight in our series of short explainers for the Hunger Vital Sign tool. I’m your host, Helen Labun. We began by speaking with Richard Sheward, the Director of Innovative Partnerships at Children’s HealthWatch about the origins of Hunger Vital Sign. Last episode we began a conversation with Katy Davis of Hunger Free Vermont. 

DAVIS:

My name is Katy Davis and I am the community health initiatives director at Hunger Free Vermont. Hunger free Vermont is a mission driven organization with the goal of ending the injustice of hunger and malnutrition for all Vermonters.

Instead of beginning with a health care focus and moving into hunger, Katy began with a hunger focus and moved into health care. The Hunger Vital Sign helps her organization look for systemic changes. It offers a screening tool that can be employed in any health care practice in Vermont, making universal screening possible. It also reflects larger trends in health care to pay greater attention to non-clinical elements of good health. 

DAVIS:

I've been at Hunger Free Vermont for a little over 10 years and I remember when I first started trying to work with medical professionals to talk about the hunger vital sign -- talk about, you know, why working on food access really played a role in their work. I was begging people to talk to me. And it's really been amazing the evolution over the past few years with the onset and kind of large adoption of the idea around social determinants of health, I think that, has really been a turning point. And increased community voice about being concerned about food access and in different areas of the state. In the beginning, I would work with an individual practice or a particular nurse who was really excited about something. And now I  try to work with larger systems.

LABUN:

In the last episode we talked about how starting with a basic risk screen, like Hunger Vital Sign, instead of a detailed diagnostic tool, or a patient’s eligibility for different nutrition programs, invited a broader recognition of the ways food security is an issue for many people. 

DAVIS:

Ideally there would continue to be more and more of a recognition that food access is really an issue for a broader swath of the population than we wanna admit or than feels comfortable talking about.

LABUN:

The introduction of Hunger Vital Sign also removed limiting categories around who within a health care practice worked on food related issues. 

DAVIS:

. . . I think when the validated screen initially came out, there was finally a thing to be able to talk about. So it wasn't just talking generally about hunger, where you were often funneled to go talk to the dietician when it's not necessarily a dietetics issue, it's a resource issue. And so how do you start to actually assess that in a clinical setting? So the hunger vital sign really opened that door.

LABUN:

Talking to a dietitian would be especially difficult in rural primary care practices, which often don’t have dietitians on staff. Our podcast has a whole separate series on the health care practice staff positions built over the last generation to address resource issues like accessing nutritious food. We also recently completed an overview of the landscape of nutrition services in Vermont. Ideally patients would have access to both types of assistance when they’re experiencing food issues - so that those who face resource constraints and medical nutrition therapy needs can receive the right mix of services. We’ll link these reference materials in the show notes.   

As a tool for health professionals, Hunger Vital Sign was extensively researched, validated, tied to a range of health outcomes, designed specifically for a clinical setting - with an active community of both researchers and medical colleagues putting it into practice. Hunger Free Vermont has created many tools for partners over its history, but they would never have been able to create a resource like Hunger Vital Sign on their own. 

DAVIS:

. . .  our delightful colleagues at Children's HealthWatch did the heavy lifting on that.

LABUN:

This validated tool changed the nature of the conversation between anti-hunger advocates and medical professionals. 

DAVIS:

Prior to having a validated tool the feeling was that the conversation that you got to have with the medical professional was a favor, versus being able to actually provide a useful tool that was practical and could be implemented and had tested well for validity. . . .now  you could actually have a course where you could provide continuing education credits. . . there were more supports that you could provide along the way. And it gave it real structure. . . You could move away from just the morality argument of like, “don't you think this is something you should be talking to your patients about”, but you could stand a little bit more on the ground of “this is something you should talk to your patients about; food access is related to health”. And really feeling like you had another tool in your toolbox rather than just to trying to kind of bend heartstrings and share disparate data. But it was something that was implementable. It was something that was real and usable and other people had said so too. In a way that felt like it had power. 

LABUN:

And Hunger Vital Sign didn’t just change the context of the conversation with the health care providers, it also changed the context of the conversation with patients. Having this validated tool put food insecurity into the realm of conditions commonly discussed as part of office visits and check-ups, and standardized screening meant no patient needed to feel singled out on nebulous grounds. . . or *not* asked, on equally nebulous grounds. 

DAVIS:

You can't tell if somebody is struggling with food access just by looking at them. And the idea that you can is both insulting and untrue. And I think that in some ways that's something that maybe some of us say, because it makes us feel safer that it couldn't be you, but I think one of the things that the pandemic has shown us is that there's things that can happen in life and in the world that make it so that when you you're okay one day, not too many days down the road you're not okay.

LABUN:

Another way to think about the question of how providers know who to ask about food insecurity is: how else would they have made that call, prior to having a standard system, except by asking people who they thought might need help? 

You could choose based on clinical indications - but that was the whole point of the original Childrens’ HealthWatch research, by the time those indicators appeared, you already missed the chance for prevention. And most of our food support system is set up with a goal of adequate diets for prevention - not to treat specific conditions. You could ask at known risk points, like when a new child joins a family or when patients reach their sixties . . . but remember that a lot of our food security research was being built at the same time as the Hunger Vital Sign, the research that provides those risk flags is often contemporary with implementing screening systems. 

Even if a provider decided to simply ask everyone walking through the door, what would they ask?  Once you take the question of food security out of the natural flow of a conversation about related concerns, how should it be phrased? As we discussed in previous episodes, it’s not necessarily intuitive. 

DAVIS: One thing I really like about the hunger vital sign to is, within the two questions, one of the questions is asking about actual scarcity of resources to be able to buy food, but the other question is asking about the worry around it. And I think that's really important. I'm so happy that that's captured in there. I think it does a lot to acknowledge how stressful not being sure where your next meal's gonna come from, or how you're gonna pay for your bill at the grocery store. And that, that is truly impacting your food access and that, that stress means something. So I appreciate that piece of the hunger vital sign

LABUN:

Plus, as Richard Sheward explained, one measure of a successful risk screen is social acceptability

SHEWARD:

It needs to have a certain level of acceptability, meaning that that tool is not embarrassing or socially unacceptable, that it's acceptable to the individual completing it.

LABUN:

Acceptability is partly in the phrasing of the questions. It’s also in how the screen is presented - and that has a lot of elements. We’ve discussed how applying the screen to all patients sets the expectation that food resources are a standard part of conversations about health. And that expectation isn’t just a screening policy and procedures issue, it also involves working with individuals doing the screening - who are usually screening for many different concerns; they aren’t dedicated food resource specialists, they’re reviewing dozens of risks for every patient every day. 

DAVIS:

This is one of the places where hunger free Vermont is the most helpful. . .  if folks who are delivering the screen, even if it's just delivering the piece of paper so you’re not verbally asking the questions, but you're delivering it on a paper screen, how you deliver it, how you talk about it, the whole time is important. I've been told stories of, you know, folks going to their doctor. And they were asked the questions where it was framed. “I have to ask you this.” And that's not gonna elicit a response that's in any way truthful, if somebody's struggling with food insecurity. Who wants to respond that they're having trouble when somebody is already assuming that you're not?

. . .  if you think about it at all, food is hugely emotional for all of us. It's how we celebrate together. It's what we often gather around. If you had any trouble getting the food you needed when you were a kid, there's all sorts of things that come up for you as an individual as you're trying to think about that. There's so many judgments that we make about people just along the way, and we all do it. . . . And when I talk about the cultural piece of things, it's an opportunity for all of us to kind of think back and, and think about what our judgments are, because we all have them.

LABUN:

Through paying attention in their routine screening, health professionals can build their approach to helping people feel more comfortable talking about food resources. Repetition helps the people responding to the screen as well. 

DAVIS:

. . .I remember the first time I went to the doctor and they asked me if I felt safe in my home. And I was like, what? Like nobody's ever asked me that question before, but they're the only people who have ever asked me that question. And they asked it to me in a way where I felt like they were asking because they cared about it, because they felt like it mattered. And if I was ever in a situation where I didn't feel safe in my home, they would be the first people that I ever thought of.

. . . . So it might not be that I'm struggling right now, but the next time you ask me, I might be ready for that question, and I might know it's coming. And I might be ready to let you know that I need some help. 

LABUN:

And, of course, a risk screening tool can open up a conversation. . .  but it doesn’t close the conversation. It always leads to a next step. Yes, Hunger Free Vermont wants everyone to feel comfortable expressing their food concerns, but the ultimate goal is helping patients then address those concerns. It’s an opportunity to set a tone for how patients perceive their health providers as working with them on what they identify as their greatest health needs. Both experience and research has shown that those greatest health needs often aren’t clinical in nature. Through its role in building these relationships, Hunger Vital Sign is about more than just food. 

DAVIS:

I think that some of it is, how are you able to be connected to resources? And that over time piece of really seeing your or medical provider as a trusted resource can go a really long way to starting to build the notion that that food is related to your health. And really seeing that as a place where you as an individual have some autonomy and can make some decisions and you actually have the resources to be able to make those decisions. 

LABUN:

In other words, we can promote good health twice over: through the food itself and through helping patients build a network of trusted resources to support their health throughout their lifetime, including as their needs change.  

As mentioned before, the potential of Hunger Vital Sign to reframe the conversation about food and food insecurity is a great opportunity, one that could be a first step in system-wide changes that reach far beyond implementing a basic risk screening system.

DAVIS:

. . . We're in many ways, you know, changing the culture and the way that we think about ourselves when we need assistance, the way that we think about others. And I think there's a lot of far reaching implications outside of healthcare that having this habitual conversation can really start to start to change the way that we think about food access and the way that we think about asking for help when you're struggling. And the way that we think about designing and devising programs to meet these needs.

LABUN:

In our episodes with Richard Sheward, we talked about how the early Hunger Vital Sign research aimed to change our overall approach to food insecurity, by creating a brief screen that could be employed reliably in many different settings and that alerted health professionals to risks before patients developed potentially serious medical conditions. 

Through implementation, groups like Hunger Free Vermont discovered more ways that Hunger Vital Sign could be useful. It changed the dynamic of conversations between health professionals and community organizations, providing a specific tool designed for a health care setting that could be the starting point for collaboration - hunger was a problem, and now there was an accepted first step in a solution, which could lead to many more steps as partnerships evolved. It could change the dynamic of conversations with patients, too, providing a system for universal screening and for repeated screening, allowing patients to become comfortable with the conversation and also offering a known starting point for seeking assistance if their food situation changed.  

The flip side of this opportunity is a need to set reasonable expectations for how much of the work that goes into addressing hunger is shouldered by health professionals. Next episode, we’ll get into strategies to keep an opportunity as an opportunity, not another crisis for a workforce that’s already stretched too thin.