Food insecurity rates have been increasing in the last two decades and this has been exacerbated by the Covid-19 pandemic (Srinivasan 2021). For example, 50% of SF Food Bank clients did not use food programs before the pandemic (SF Food Security Task Force, 2022). Fortunately, food programs for patients are on the rise (De Marchis 2019).

The Division of General Internal Medicine (DGIM) at Mt. Zion has created a successful food bank for patients. However, healthcare workers are 5 times more likely to have food insecurity compared to clinicians (Srinivasan 2021). A new, ongoing survey of DGIM staff members, residents and fellows found that 42% had mild food insecurity and 27% had severe food insecurity. Appallingly, 71% of DGIM staff members (without resident or fellow data) have mild food insecurity and 48% have severe food insecurity. (See Phase 2 Information below, rates are lower with more surveys collected). 

These are higher rates than our patient clientele. These are vulnerable populations hidden within our healthcare system because they are not patients. These rates are also higher than the San Francisco rates of 25% therefore this is an unmet need (SF Food Security Task Force, 2022). To our knowledge, there is only one published article on food insecurity among healthcare workers and no published articles on food insecurity among medical residents. There are no food programs at UCSF for staff members, residents or fellows. This will be a novel program and we will work to share our work with others over time.

Our DGIM food program for Staff, Residents and Fellows will include:

• A weekly meal. Staff, residents and fellows will choose which meals (ie breakfast, lunch, or a combination), food sources, and types of meals ordered.
• Weekly nutrition tips, cooking instructions, and menus. They will be culturally appropriate and budget friendly. This information will be prepared by Dr. Diana Thiara, Director of Culinary Medicine at DGIM.
• A monthly $5 UCSF Cafeteria coupon to supplement food purchased at UCSF.
• A $20 supermarket gift card in December.
• Support for one Medical Assistant (MA) and one Nurse Practitioner (NP) to help run the program that is staff- and resident/fellow-focused.

Needs and perspectives of the intended beneficiaries have been integrated into the plan. As noted, this program is a direct action in response to input from staff, residents and fellows about their food security status. We will hire an NP and MA to lead staff  inclusion. We will also work directly with residents and fellows working at DGIM.They will choose the dates, times for meal distribution, meal choices, and restaurants used. 

 List of Goals

• Reduce food insecurity among staff, residents & fellows
• Finish collecting Staff, Resident, and Fellow surveys; distribute the survey to faculty
• Include all staff, residents, fellows and a DGIM Wellness champion in planning & executing this program
• Distribute our program information to other MZ practices as well as other UCSF clinical programs
• Write academic articles outlining our program as there are little or no publications on this topic
• Look for sustained funding to continue this program

Summary of healthcare-related needs being addressed

Food insecurity is associated with poor health outcomes such as heart disease, diabetes and depression. It is also associated with missed primary care appointments, increased Emergency Room visits, and an increase in all-cause mortality. Reducing food insecurity reduces these risks. Thus, providing healthy meals for our employees is helping to improve their health-related outcomes

Partners

We partner with the UCSF Health Nutrition & Food Services department, to purchase UCSF Cafeteria Coupons. We will work with Christy Carrillo, CDM, CFPP, manager of the Mount Zion Café, who has already sent us information about ordering coupons and working with UCSF catering. We will purchase meals from Farming Hope, an organization that works with formerly incarcerated or homeless adults to create meals for food-insecure people in San Francisco. They offer job training and source “cosmetically imperfect” (read: funny-looking) produce. Other meals will come from restaurants chosen by our trainees and staff based on their preferences. If possible, we will target women- and minority-owned restaurants.

Evaluation plan

We created a questionnaire that includes the two-question Vital Hunger Sign, a validated instrument to screen for food insecurity. It also includes a USDA question about eating unhealthy due to financial constraints. These are quantitative questions. We asked if it would be helpful to have meals available at work and why (for morale, financial reasons or convenience). These are qualitative questions. We have collected 94 surveys to date and will continue to collect them until we reach 75% participation rate. We will create and distribute a follow-up survey that is more extensive. It will include questions about food insecurity, unhealthy meals, food budget, and satisfaction questions. We will also ask about gender, race and ethnicity, and job titles to further analyze demographics. 

Name, title, division of individuals who will lead the project

• Gina Moreno-John, Director of Diversity, Equity and Inclusion and Medical Director of the DGIM Food Pharmacy.  She has been leading the DGIM Food Pharmacy since 2019 and helping 3 other clinical programs at UCSF who have started clinical Food Programs.
• Diana Thiara, Medical Director of the Culinary Medicine Program in the DGIM Food Pharmacy and Medical Director of the UCSF Weight Management program. She created menus and food demonstrations with Culinary Medicine principles.
• DGIM leadership has agreed to support this program.
• A Medical Assistant and a Nurse Practitioner will be supported to help run this program.

MZHF values the project embodies

• Service (Avodah): This project is serving residents and staff, who are vulnerable populations due to salary constraints.
• Social Justice (Tikkun Olam): This project aims to reduce the inequity of residents and healthcare workers not having the same access to food as clinicians.  In addition, DGIM staff are largely comprised of Latinx, African American and Asian employees, thus we are aiming to reduce racial and ethnic social disparities as well.
• Community Building (Kehilah): We will build community and morale at DGIM with a food program for employees. 96% of survey responders say that having meals at work will be helpful for the following reasons, in order: Morale, Financial Support, Convenience.
• Innovation (Hidush): To our knowledge, there are NO published articles about food insecurity among primary care healthcare workers an NO published articles about food insecurity among medical residents. The programs we develop will be the first of their kind and will be shared widely over time, at UCSF and disseminated through academic journal articles.

Plan for sustained funding

The Hellman Foundation is helping to support the DGIM Food Pharmacy and we will discuss expanding support to include staff members, residents and fellows. UCSF leaders have expressed support for food programs at UCSF. We will continue to engage them to create future, ongoing support. Finally, Gina Moreno-John is meeting with Janna Cordeiro from the SF Department of Public Health to discuss programs potentially tailored to support this effort.

Project start date and duration (earliest start date is January 1, 2023): February 1, 2023 – January 31, 2026.

Estimate of total budget requested from MZHF: $149.350 annually (see new amount below in Phase 2 Info below)

Applicant

• Gina Moreno-John, M.D., M.P.H., Professor of Medicine, Division of General Internal Medicine.
• Community Partner Affiliations: 1) Food as Medicine Collaborative of the SF Department of Public Health, 2) Farming Hope.

Contact info:

• DGIM, 1545 Divisadero St., San Francisco, CA 94115
• Gina.Moreno-John@ucsf.edu
• (415) 652-8299

PHASE TWO INFORMATION INCLUDING NEW BACKGROUND INFORMATION AND SURVEY DATA

1. Background Introduction and Survey Data

Food insecurity is defined as a lack of consistent access to enough food to live an active, healthy life according to the USDA. In 2013, one in four San Francisco residents were at-risk for food insecurity. The number is higher due to the Covid-19 pandemic. In a recent San Francisco Marin Food Bank (SFMFB) survey, half of the respondents had not used food programs prior to the pandemic and 72% stated that they have not recovered financially after losing a job or earning less money due to the pandemic. The SFMFB has given out 67% more food in the last year (2021) compared to the year before. The number of SF residents on CalFresh (a federally mandated food program for low-income people) has increased by 40% (SFDPH, SFMFB). Unfortunately, many workers make incomes that are too high to qualify for assistance programs but are too low to meet the food needs of their families and even with stable incomes; rising expenses make food insecurity more likely at any given income level (Srinivasan). It is critical to address food insecurity because it has been identified as a social determinant of health and has serious implications for mental and physical health. People with food insecurity have a higher risk of obesity, chronic diseases such as diabetes, heart disease, and hypertension, malnutrition and depression, among other medical conditions(Holben, SFMFB, Srinivasan).  

Risk factors for food insecurity include low wages, a high cost of living and lack of affordable housing (Feeding America, SFDPH). Unfortunately, even when food programs exist, people may avoid utilizing resources due to the associated social stigma and shame (Gould-Werth, SFDPH). There is a misconception that individuals experiencing food insecurity are homeless when in fact, only 5% of clients at the local food bank are unhoused (SFMFB).  Children, seniors, single parents, unemployed persons and low-wage workers are the majority of clients at the SFMFB. National studies identify these other populations as high-risk for food insecurity: pregnant women, low-income families with children, immigrants, residents of single-room occupancy hotels, African American, Latinx, Native American populations, LGBTQI+ group, people who identify as non-binary, as well as people with disabilities (Cerasani, Riddle, Goldric, Coleman-Jensen). Food insecurity is a health issue as well as a racial and social justice issue. 

Food insecurity is a pervasive issue in healthcare affecting not only the patient populations but also healthcare employees who are staffing these clinical practices. In addition to patients with food insecurity at the Division of General Internal Medicine (DGIM), many DGIM staff members and internal medicine residents experience food insecurity. DGIM leadership will address this issue by 1) ordering meals at more DGIM and staff meetings, 2) requesting that faculty members order food for small group meetings when they can, 3) streamlining the process by which faculty members are reimbursed when ordering food for meetings, 4) supporting the publication of a DGIM cookbook that includes a “budget tip” from each member and 5) discussing this issue widely among all DGIM members to create group solutions for this critical problem. With support from the Mount Zion Health Fund, we will build off of the successful DGIM patient Food Pharmacy as we create a novel program with meals, food coupons, nutrition and food budgeting education for the people who keep DGIM doors open and working. This project will re-affirm DGIM as a leader at UCSF in addressing social determinants of health for all, including residents and healthcare staff.

Health Care Worker Food Insecurity

To our knowledge, only one study has reviewed food insecurity among health care workers. In a study of 5,516 healthcare workers in hospitals, ambulatory care facilities and residential care facilities, the food insecurity rate for diagnosing/treating clinicians was 1.7%, and 19.7% for health care support workers. Food insecurity rates were also higher among health care workers with children than among those without (Srivinasan). The healthcare industry is the largest employment sector in the U.S. and the wellbeing of healthcare workers impacts the health of patients, making this a critical issue (Srinivasan, Sunesan).

At DGIM, staff member salaries range from $40,000 per year for Medical Assistants (MA) to $160,000 for Nurse Practitioners (NP). We found an initial mild food insecurity rate of 71% among staff members. It is now much lower.  We hypothesize that staff members with the most need responded to the survey right away.  Later, as Nurse Practitioners and Staff Managers also responded, the rate fell.  In the future we will separate staff members by job title as many likely have much higher rates of food insecurity than seen here. The current rates of food insecurity found in 84 DGIM staff respondents (67% participation rate) is seen below (Table 1). For comparison, there is a 3.7% food insecurity rate among DGIM faculty members.  

TABLE ONE

Resident Food Insecurity 

UCSF medical resident salaries are $5,363 per month. Average student loan debt payments are $2,480 per month and average rental prices in San Francisco are $2,356 per month (educationdata.org, rent.com). After paying rent and student loans, residents only have $527 monthly for utilities, healthcare, clothing, household goods and food. The average resident does not have enough income to meet the cost of living for a single person in SF, especially if they have student loan debt (numbeo.com).

Despite both professional decrees stating that a healthy diet is essential for resident wellness (ACGME 2022, Parsons) and residents’ beliefs that their eating habits are vital to their well-being as physicians (Diaz Baez), there are no studies in the literature reviewing food insecurity in medical residents. Medical students are believed to have a food insecurity rate of 28%, but no data exists as of now for medical residents (DeMunter). 

At UCSF, residents get $240 per month for food when they are working at the UCSF hospital on Parnassus Avenue. They get substantially less when working at the VA Hospital or the Zuckerberg SF General Hospital. When working in ambulatory clinical rotations, they get even less.  While local leadership hopes to address this element of resident wellness by appropriately advocating for healthy food programs (Montgomery), a gap currently exists in ensuring residents are food secure.  

A total of 72 UCSF internal medicine residents care for patients in the DGIM practices. A recent all-clinic survey at DGIM found significant food insecurity rates in 52 resident respondents (72% participation rate) below (Table 2). For comparison, the same survey found that DGIM Fellows have a 0% food insecurity rate. 

TABLE TWO

2. Specific aims

Aim 1. Assess Needs and Trends: collect Staff, Resident, Fellow and Faculty Food Insecurity rates at DGIM.  We created a survey that includes the two-question Vital Hunger Sign, a validated screening instrument for food insecurity. We also included a USDA question about eating unhealthy foods due to financial constraints.  This survey is on-going, and we will continue to collect responses until we have at least a 75% participation rate among staff members and residents. Before we begin distributing meals to residents and staff members, we will create a new baseline food insecurity questionnaire and collect data by job title, gender, race, and ethnicity to further analyze demographic differences. Among staff, we hypothesize that staff members with lower incomes (ie MAs) will have higher rates of food insecurity than NPs. A follow-up survey will be conducted at 12 months. Evaluation Summary: data analysis will be performed on the current screening survey, the upcoming baseline survey and the 12-month follow-up survey for trends on food insecurity at DGIM.

Aim 2. Reduce food insecurity among DGIM staff members and residents. This aim will be achieved with a combination of free meals and UCSF cafeteria coupons and food budgeting information. Below is a summary of the program we will implement. We will work with community partners from Farming Hope, the UCSF cafeteria program, and caterers and restaurants. We will include all staff, residents in planning & executing this program. Evaluation summary: We will measure participation by tracking the number of meals and coupons dispersed. We will send a follow up survey at 12 months to assess employee satisfaction with the program and success in reducing food insecurity. 

PROGRAM SUMMARY 

- For DGIM Staff Members: Take-home meals from Farming Hope twice a month, Restaurant meals once a month and $11.00 UCSF Cafeteria Coupons once a month.  Total: equivalent of 4 meals a month

- For DGIM Fellows: Take-home meal from Farming Hope monthly

- For DGIM Residents: $25 UCSF cafeteria coupons or 2.5 meals per month every month OR 6 meals per month when they are based at DGIM. This will be based on resident preference. Total: equivalent of 2.5 meals each month or 6 months when working at DGIM 

- For 5 DGIM Staff Consultants: $200 Supermarket gift card each, once

Aim 3. Improve DGIM employee understanding of the impact of food on health outcomes. Nutrition education and resource management skills can improve food security and healthy eating. One randomized intervention study of a low-income population found that nutrition education, which included information about food preparation and budgeting, improved food security status (Eicher-Miller). A second study of low-income residents who received the USDA’s Expanded Food and Nutrition Education Program also demonstrated increased food security (Farell). By providing staff and residents with programming that includes nutrition tips, meal plans, budgeting skills, and cooking demonstrations (building off of other nutrition pilot programs for patients at DGIM), we hypothesize that increased education around nutrition and resource utilization will also address food security. Evaluation Summary: We will administer a baseline and follow up survey with questions regarding patients’ fruit and vegetable intake and self-efficacy regarding the use of food as medicine, to evaluate a change in knowledgeabout healthy nutrition. 

Aim 4. Distribute program information to other MZ practices, UCSF residency programs and to other clinical practices outside of San Francisco.  As there is limited literature addressing the important issue of food insecurity among healthcare staff members and residents, we will publish our findings and program data through UCSF newsletters, peer-reviewed articles, academic conferences like SGIM and ACP, and medical-related and mainstream social media platforms. Evaluation summary: we will evaluate our impact by the number of citations and requests for information for other practices and programs. 

Aim 5. Secure funds for program sustainability.  Janna Cordeiro from the Food as Medicine Collaborative, supported by the SF Public Health Initiative, will look for programs potentially tailored to support this effort. The Hellman Foundation is helping to support the DGIM patient Food Pharmacy, and we will discuss expanding support to include staff members and medical residents in the future. UCSF leaders have expressed support for food programs at UCSF, and we will meet with executive leadership to review the data for food insecurity among staff members and medical residents.  We will continue to engage them to create future, on-going support. Evaluation summary: We will evaluate the impact of our program by the number of ambulatory practices and residency programs at UCSF who collect food insecurity data on staff members and medical residents.  

3. Anticipated benefit for underserved or vulnerable communities in San Francisco

Helping people become less food insecure means that adults are less likely to eat one meal a day, ration their food or purchase fast food in order to make food last. Ensuring staff and residents are food secure means adults are not forced to choose between spending money on rent, utilities or medical care over food. In light of the aforementioned data [EK10] that food insecurity has a disparate effect on communities of color, our program would address health implications of food insecurity and thus improve glycemic control and increase patients’ fruit and vegetable intake, self-efficacy, and medication adherence. When patients are food secure, there is less emotional distress. Reducing food insecurity also reduces associated risks of acute and chronic diseases, reduces no-show rates at medical appointments, and reduces Emergency Department visits.  

Another benefit includes higher morale. Approximately 96% of DGIM survey responders say that meals at DGIM will be helpful for the following reasons, in order: Morale, Financial Support, then Convenience. We also expect increased employee engagement. Addressing occupational stress especially as related to an identified inequity is known to result in higher employee engagement (Qualtrics). Finally, there is an anticipated benefit to DGIM patients. As healthcare workers’ health and morale improve, they can provide better care to patients. 

4. How the project addresses UCSF Mount Zion priorities and compelling San Francisco healthcare needs. 

Healthcare workers are a vulnerable community. Women are overrepresented in the US healthcare workforce, accounting for nearly three-quarters of this group. Women of color are more likely than White women to have low-wage positions in healthcare (Srinivasan).  As noted, people of color are more likely to be food insecure than their white counterparts (Coleman-Jensen). This is related to income inequality. In SF, the White population makes almost twice the income of those in the next highest group (Asians) and almost three times the income of Native Americans, Latinx and Black/African American populations (SFHIP). 

At DGIM, there are higher representations of Asian, African American and Latinx staff members compared with physicians. It’s disheartening that just over 1 in 4 DGIM staff members have food insecurity, higher than the rates found in the one published article on this topic. This rate mirrors the SF rate of 25% and it is considered an unmet need (SFDPH). DGIM staff members are an especially vulnerable population hidden within our health care system because they are not patients whose needs and gaps in care are regularly tracked.

The SF Food Task Force and the SF Health Improvement Partnership (SFHIP) mandate that we focus on critical food programs to help communities of need to obtain nutrient-dense, culturally relevant food (SFDPH, SFHIP).  Bringing food through our innovative program to DGIM staff, who are mostly women and are racially diverse, addresses an important SF healthcare need. 

Our program also reflects MZHF values by improving the physical, financial, and emotional health of DGIM staff members and residents, both vulnerable populations in SF. As noted in our proposal, this project also aligns with core values rooted in the history of the MZ hospital: Service (Avodah) serve residents and staff who have financial and food constraints; Social Justice (Tikkun Olam ) reduce inequity for healthcare workers, residents and fellows; Community Building (Kehilah) build deeper community and improved morale at DGIM; Innovation (Hidush) create one of the first food programs for healthcare workers.

5. Type and duration of campus-community partnership

We have been working with the Food as Medicine Collaborative (FAMC) since the summer of 2019 before we opened the DGIM Food Pharmacy. We begain discussions first with Erin Franey and now with Zoe Womack and Janna Cordeiro. The FAMC is supported by the SF Public Health Initiative. They offer expertise in running patient Food Pharmacies, write grants to support our food programming and distribute funding for produce for Food Pharmacy patients. We have been working with Farming Hope for 12 months. They provide take-away meals onc a month for our Food Pharmacy patients since January 2022.  By working with Farming Hope, we also support their mission of training formerly incarcerated and/or homeless clients to build business and restaurant job skills. 

6. How the community partner's experience and expertise was integrated into proposal development

Farming Hope works with formerly incarcerated or formerly homeless adults to create meals for food insecure people in San Francisco. They offer job training and source “cosmetically imperfect” (read: funny-looking) produce.  Farming Hope has given us a list of their typical meals to make sure that they are healthy and acceptable to our clients. They offer vegetarian meals when requested.  They have reassured us that they have the resources and personnel to create meals for our staff members and medical residents as well as our Food Pharmacy patients.  

We will also partner with the UCSF Health Nutrition & Food Services department, to purchase UCSF Cafeteria Coupons. Christy Carrillo, CDM, CFPP, manager of the Mount Zion Café, sent us information about ordering coupons and working with UCSF catering. We integrated her suggestions into our budgeting plan. 

Other meals will come from restaurants chosen by our trainees and staff members. If possible, we will target women- and minority-owned restaurants. We will listen to their expertise when creating meals and menus for DGIM employees. 

7. For each community partner (if applicable): Farming Hope

• See the attached IRS exemption letter verifying 501(c)(3) status for Farming Hope
• Farming Hope Board of Directors: 
  • Lyndsey Boucherle
  • Shelley Dyer
  • Michael Fu
  • Lucia Gaia Pohlman
  • Xochitl Hernandez
  • Sheena Jain
  • Ilana Lipsett
  • Savannah Schoelen
  • Salim Zymet 

8. Total proposed project budget with justification

• Justification: we have several leaders for this new program: A medical director responsible for overseeing the project, creating and analyzing surveys, and disseminating academic information. Two residency directors who will share responsibility to work with residents and their schedules to distribute food. A Wellness Champion who is also a staff member to oversee distribution of meals to staff members. A nutrition specialist to create education for all DGIM members. The majority of the budget will be to purchase food coupons and meals. We will distribute 1 meal a week to staff, 2.5 meals a month to residents when they are working in clinic, monthly meals to fellows, and supermarket gift cards for the 5 DGIM staff member consultants. 
• Requested grant period: 2023 - 2026
• Line-item breakdown of revenue and expenses, including individual project team members' percent effort included in budget