What is the simplest way to improve the diets of people who experience food insecurity? Arlene Jones, the founder and manager of Sprout food hub in central Minnesota, has a three-step answer: 1) give them nutritious food; 2) teach them how to prepare the food in ways that are appealing to the palate; 3) repeat.
For the past several years, Jones has helped organize an effort in Staples, Minn., to put this multi-part solution into practice. Through a program called Choose Health, she and a group of partners have enrolled dozens of food-insecure residents1 of the central Minnesota city of 3,000 in a community supported agriculture (CSA) program. In a CSA arrangement, individuals or families pay a set amount upfront in order to receive boxed shares of a food grower’s harvest for a given season. At regular intervals, the grower delivers the shares to designated drop-off sites where the CSA members pick up their boxes. In many ways, Choose Health operates like a typical CSA. Participating families visit drop-off sites regularly to pick up boxes of fruits, vegetables, and meats grown and raised on nearby farms. However, Choose Health participants receive their boxes free of charge.
What is Sprout?
Located in central Minnesota, the Sprout food hub aggregates, distributes, and markets food grown and raised on more than 50 family farms in Todd, Cass, Crow Wing, Morrison, Wadena, Ottertail, Aitkin, and Mille Lacs counties. In addition to its involvement in the Choose Health program, the food hub coordinates farm-to-school food contracts for six area school districts, wholesale arrangements for restaurants, and a CSA program that is available to the public. Additional information
Across the country, income-qualified people have access to a handful of programs that offer food assistance, such as the U.S. Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP), also known as food stamps; and the Women, Infants, and Children program. Food shelves also offer food-insecure people a range of food options. But taken together, there is no guarantee that the foods a family accesses through these programs add up to healthful eating. After all, a number of factors, including the availability of fresh foods at food retailers, the distance to those retailers, and simple monetary concerns, can keep food-insecure individuals from maintaining a nutritious diet.2
CSA-based programs are one approach for addressing food insecurity. In the Twin Cities area, a program called Fare for All is promoting food access through a cooperative buying model that makes groceries available at a discount. To learn more, watch our video feature: How Can Communities Help the Hungry Get Nutritious, Affordable Food?
But the Choose Health program, which is nearing implementation of its third year, is unusual in that it provides participants not just a regular supply of fresh, nutritious, unprocessed food, but also seeks to shift their diets in a way that will have longer-term positive effects on health.
“We’re giving people a lot of great food and showing them how to cook it,” says Jones, noting that a significant number of participants have increased their consumption of fresh produce. “We’re looking at nutrition access as a way to improve community health outcomes.”
Choose Health: By the numbers
For its inaugural summer season of June through September 2014, which was funded largely through grants from anti-hunger organization Hunger Impact Partners (hungerimpactpartners.org), the Choose Health program enrolled 51 participants, the majority of whom earned household incomes of less than $20,000 in 2013. Sprout packaged the CSA shares and made weekly distributions that totaled about 40 pounds per share. Participants were divided into two groups; in alternate weeks, each group picked up its shares at an outdoor farmers market held in Staples. To expose participants to a range of fare, the CSA distributed, over the course of the summer, 43 different fruit and vegetable varieties, such as broccoli, tomatoes, cabbage, and cucumbers.
Of the 51 summer CSA participants, 31 chose to continue the program through the winter, with 19 new families enrolling as well. Once a month from November 2014 through March 2015, all 50 participants received, again through Sprout, an even larger share—approximately 60 pounds total—that included hardier foods such as winter squash, potatoes, carrots, dried beans, and ground turkey. Instead of handing out the food at the farmers market, the program arranged for the CSA distributions to take place at a nearby senior center. The following summer, in 2015, local health care provider Lakewood Health System covered the program’s funding, and Choose Health expanded its enrollment to 80 participants. The program did not offer a winter share for 2015–2016, but enrollment is expected to increase to 100 when the CSA starts up again this summer.
Because of the public nature of a farmers market, program organizers were wary of participants being identified as people in need of food assistance when picking up their CSA shares. To help obscure their identities, the Choose Health program opened the CSA’s membership to two large local employers. Dozens of their employees signed up and are paying the retail cost of their CSA shares.
Conceptually, a CSA-oriented food access program seems pretty straightforward: give nutritious food to needy people. But according to Jones, organizers of such a program should consider some important questions if they want to increase the likelihood that a hunger-relief program will have positive long-term outcomes. For instance, should they add an educational component to the program? How should they track participant information to monitor the program’s effectiveness? And of course, how will they fund and sustain the program? Choose Health enlisted the help of a variety of organizations to meet different programmatic needs. (See the “Choose Health program partners” sidebar for a full list of the participating organizations.) While groups seeking to implement similar programs in their areas might recruit partners from a different composition of sectors, Jones stresses that whatever approach they take, they should make sure to explore the range of programmatic possibilities beyond simply giving away nutritious food. The Choose Health program’s approach, discussed in more detail below, hits on the main matters for consideration.
Choose Health program partners
Central Lakes College
Lakewood Health System
Region Five Development Commission
Todd County Public Health Department
University of Minnesota Extension
Serving up education
As part of the Choose Health program, participants attend brief food-preparation demonstrations on the days they pick up their CSA shares. Elizabeth Quillo, a SNAP-Ed Educator3 from University of Minnesota Extension, explains how she or an Extension colleague present the food items in each distribution.
“I lay all of the produce and herbs on a table so participants can see what they are getting, and then I give out recipes that use as much of the food as possible,” she says, noting that she distributes recipes and information sheets that participants organize in three-ring binders that are provided at the beginning of the CSA season. “I make a dish using ingredients from that week’s CSA share and have it out for sampling. I also show tips on preserving and storing the food if the recipients know they won’t be able to eat it right away.”
Quillo explains that because program participants aren’t all familiar with farmers markets, she teaches a course called “Cooking Matters at the Farmers Market,” in which she gives participants, many of whom receive food stamps, a tour of the Staples farmers market and distributes $10 to each, in the form of tokens, to spend at the various stands. The market also accepts SNAP benefits, which the U.S. Department of Agriculture loads onto EBT (electronic benefit transfer) cards that function similarly to debit cards. The impetus behind providing the $10 is to familiarize Choose Health participants with the payment tokens the market uses, which are dispensed from a debit machine that also accepts EBT cards.
“They can use the tokens to buy a variety of fruits, vegetables, and herbs,” Quillo says, noting that some program participants also take a diabetes prevention class. “And we have them interview a farmer. They’ll ask things like where the food comes from, if the farmer uses pesticides, and what he or she likes about farming. It’s basically a way for them to establish a connection to the person who grows the food they plan on eating.”
To aid in cooking at home, the program also provides participants with shelf-stable pantry items, such as rice and olive oil, and cooking utensils like measuring cups, cutting boards, and colanders.
Finding the funding
The first year of the Choose Health program—the 2014 summer and winter CSAs—was funded mostly through a series of grants the organizers applied for from Hunger-Free Minnesota, a now-sunsetted initiative of Hunger Impact Partners. Financial support also came from the Staples Community Foundation and from funds provided to Cass, Todd, Wadena, and Morrison counties under Minnesota’s Statewide Health Improvement Program. (For more on this program, known as “SHIP,” see the “What is SHIP?” sidebar.) According to Cheryal Hills, executive director of the Region Five Development Commission,4 which was the fiscal sponsor for the program during its inaugural year, the price for planning and setting up Choose Health came in around $50,000.
What is SHIP?
Operated by the Minnesota Department of Health, the Statewide Health Improvement Program (SHIP) offers grants to county health departments and tribal governments that seek to implement evidence-based strategies that address obesity, physical activity, and tobacco-use prevention. SHIP was launched in 2008 and has since distributed more than $100 million. Additional information.
“That’s a ballpark figure, but it includes a lot of costs that wouldn’t need to be repeated,” she says, noting that the funds, in addition to paying for the CSA shares, paid for a large refrigeration unit for food storage at the Lakewood hospital in Staples, a video to promote the program, and the program’s evaluation. The cost per participant, she said, was about $850.
Hills also says that the program’s partners view Choose Health as an economic development investment, since a portion of the funding spent on the program makes its way to the local farmers who grow the food for the CSA. In 2014, for instance, approximately $8,000 went to the collective of farmers who sell produce to Sprout.
The second year of the Choose Health program was funded through a grant of about $20,000 from Lakewood Health System, which covered just the cost of the actual CSA; the organization also contributed in-kind staff time to cover administration of the program. It plans to operate and fund the program for the foreseeable future.
Tim Rice, Lakewood’s chief executive officer, remarked that the health system’s involvement in this effort aligns with Lakewood’s public health purpose.
“We’ve just cracked the door and are getting started with this program,” he says, adding that a community health assessment the system conducted recently revealed that obesity is one of the key health issues in the region. “We needed to address this problem, and helping people gain access to nutritious food makes sense. We’re committed to doing this.”
A handful of Choose Health program organizers have recently been recognized for their work in addressing food insecurity and economic development. In 2014, the Region Five Development Commission received an Innovation Award from the National Association of Development Organizations for its role in helping organize the Choose Health program, and Lakewood Health System has received a Community Benefit award from the Minnesota Hospital Association, an Innovation Award from HealthPartners, and a Bush Community Innovation Award. The latter award included a $500,000 grant to advance work in addressing community health.
Selecting participants and collecting data
Choose Health participants are selected on the basis of referrals from health care providers operating out of Lakewood Health System. Patients attending well-child or obstetrician visits are asked to fill out a questionnaire containing the following two statements: 1) Within the past 12 months we worried about whether our food would run out before we got money to buy more; 2) Within the past 12 months the food we bought just didn’t seem to last and we didn’t have enough money to get more.5 If patients agree with either statement, a Choose Health program coordinator contacts them to gauge their interest in the CSA program. During the first year, 51 families that indicated some level of food insecurity also expressed interest in the Choose Health program and ultimately enrolled, and in the second year 75 families enrolled.
“Participants would then meet with me for an official prescreening, and I would answer questions they may have had and go over the program in more detail,” says Carmen Genske, who served as the Choose Health program coordinator in 2014.
Participants filled out pre- and post-program surveys, administered by the program coordinator, to provide information about their demographics, physical health, and eating behavior, including details about produce consumption, physical activity, and meal preparation. To compensate them for their time, participants were given $50 for completing both of these surveys. They also agreed to biometric screenings—blood pressure readings, weight tracking, diabetes testing, etc.—and to monthly surveys to review successes and barriers of the program.
“I would ask them if everything was going okay and if they needed anything else from us,” Genske says. “Were they getting food that they didn’t know how to prepare? Were they using all of their kitchen utensils, or did they need something else? The surveys were good opportunities to check in.”
Bringing in a “woodpecker”
According to Jones, Choose Health’s success largely depends on the involvement of the program coordinator, who is on site for all CSA distributions.
“That person is the ‘woodpecker’ of the program,” she explains, “constantly communicating, constantly working with the participants to pick up their shares and figuring out a way to get them their food if they can’t make it to the market.”
According to Genske, the coordinator for 2014, the two biggest obstacles for her and the participants of the Choose Health program were communication and transportation. Much of her job involved getting in touch with participants—via email, text, and phone call—to remind them to pick up their shares at the upcoming market. If they couldn’t make it to the farmers market, she brainstormed other ways to get them their food, usually at alternative pick-up sites.
“But in a lot of cases, people were able to get to the market without trouble and pick up their shares,” she says. “Sometimes they would even arrive before the trucks carrying their shares would show up.”
In preparation for distributing the shares, which took place on Thursdays, Genske and someone from Sprout, usually Jones, would talk about the contents of the next boxes. Genske, in turn, would share this information with the University of Minnesota Extension SNAP-Ed Educators, who would develop and prepare recipes for their demonstrations.
Results from the first year of the CSA program show promise. When the Choose Health organizers launched the program in 2014, they assumed they wouldn’t see significant measurable results in eating behaviors in a short time; the summer CSA season, after all, was just 16 weeks long. And by most measures, little in the way of eating habits changed. Nevertheless, according to the 28 matched pre- and post-program surveys that participants completed after the summer CSA ended, there was a modest but measurable increase in the average daily number of servings of fruit consumed, from 1.6 to 2.6, and an increase in vegetable servings from 1.4 to 2.0.
Survey responses from the same 28 respondents also indicated improvements, from pre-program to post-program, in their ability to plan and prepare a nutritious meal, as well as shop for nutritious foods. The ability to plan a nutritious meal increased from 64 percent to 82 percent while the ability to both prepare a nutritious meal and shop for nutritious foods increased from 64 percent to 86 percent.6
Imitation is the sincerest form of flattery
Two of Lakewood Health System’s central Minnesota neighbors—CHI (Catholic Health Initiatives) St. Gabriel’s Health and CentraCare Health—have taken notice of the Choose Health program and are now creating similar CSA-oriented food access programs for residents of their service areas. CHI St. Gabriel’s Health, which operates about 40 miles southeast of Staples, in Little Falls, Minn., is currently recruiting 50 participants to enroll in its Eat Smart program, which will operate much as Choose Health does—with CSA shares, nutrition education, and pantry and kitchen items. Eat Smart’s organizers plan to start distributing CSA shares this summer. Just as it does for Choose Health, the Sprout food hub will aggregate and distribute the Eat Smart CSA shares, but rather than handing out the food at the outdoor farmers market in Staples, it will distribute the food at its new indoor marketplace in Little Falls.
According to Kate Bjorge, executive director of Live Better Live Longer, the community outreach wing of CHI St. Gabriel’s Health that is administering the Eat Smart program, the Little Falls-based health system helped fund the construction of a demonstration kitchen at the marketplace that will host nutrition-education sessions.
“People will pick up their shares and literally walk 10 to 20 feet to the demonstration kitchen, where they’ll be able to see a familiar face and can learn what to do with something like kale,” she says, noting that the cost per Eat Smart participant will run about $620 and will be footed by a CHI Mission and Ministry Fund project grant. “They’ll walk out knowing what to feed their families that night.”
Bjorge says that Eat Smart intends to have a winter CSA, again modeled after Choose Health, and that it is collecting the same pre- and post-program survey data that Lakewood collects so it will be able to share and pool its data with other health institutions operating food-access CSA programs.
This list of programs includes Lakewood’s Choose Health and another CSA-oriented program currently under way at CentraCare Health-Long Prairie, about 25 miles west of Little Falls. CentraCare Health’s program, which will initially cost about $10,000 to operate, will offer half-shares of a Sprout-distributed CSA membership to about 25 participants, starting in June 2016 and running through the end of September. It is keeping open the possibility of a winter share and plans to operate the program for a minimum of three years. The pick-up site will be the parking lot at the CentraCare Health-Long Prairie hospital. Although the program administrators haven’t yet determined the location of a demonstration kitchen, they plan to provide nutrition-education programming in partnership with SNAP-Ed Educators from University of Minnesota Extension.
For Dan Swenson, administrator of CentraCare Health-Long Prairie, providing some of the low-income, food-insecure residents served by his hospital access to nutritious food is a matter not just of community health but of economics.
“Nutrition is a big part of a person’s health,” he says, “and we want to make sure that we provide people with the tools to improve their health sooner in life rather than later. From a health care standpoint, it costs much less to provide individuals with good food and education now than to treat them for chronic health problems in the future.”
The tax-related nutrition connection for nonprofit hospitals
In order to maintain their tax-exempt status, nonprofit hospitals must provide charitable health-promoting activities to qualifying residents within their communities. Support comes in different forms, such as subsidizing health services that are vital to a community but are costly to sustain (such as a burn unit) or providing free immunizations to low-income families. But these “community benefits” can also include cash and in-kind contributions, which can be directed to support programs or activities that address community health needs.
According to a December 2014 Internal Revenue Service (IRS) ruling, adequate nutrition is now a recognized category of need. The ruling means nonprofit hospitals could gain a tax benefit for supporting any of a broad range of nutrition-related efforts, from sponsoring mobile farmers markets to defraying the costs of healthy school lunches. Lakewood Health System’s $20,000 investment in the Choose Health program in 2015 was likely among the first to fall under the IRS’s nutrition-related ruling. Other nonprofit hospitals might look to their own community benefit expenditures as a source for funding similar food-access programs.
Information on community benefits is from Erik Bakken and David Kindig, “Can Data from Nonprofit Hospital Tax Returns Improve Community Health?” What Counts: Harnessing Data for America’s Communities, Federal Reserve Bank of San Francisco and the Urban Institute, 2014. Information on the December 2014 IRS ruling is from the January 6, 2015 issue of The Hagstrom Report.
1 Generally speaking, “food-insecure” people are those who experience bouts of hunger throughout the year or sometimes lack the financial means to purchase an adequate amount of food to feed themselves and their families.
3 SNAP-Ed Educators (formerly known as Community Nutrition Educators) conduct outreach and demonstrations to teach SNAP recipients and other members of the public to shop for and prepare healthy meals. Additional information.
4 Minnesota’s nine Regional Development Commissions (RDCs), which were established by statute in 1969, work with local units of government to help promote economic and community development across their multi-county jurisdictions. The RDCs often provide technical assistance and grant-application and -administrative services for local projects. The Region Five Development Commission serves Cass, Crow Wing, Morrison, Todd, and Wadena counties. Additional information.
5 These statements, and the patient responses, were written out on paper because the Choose Health organizers believed they would receive more candid responses that way.
6The Choose Health partners contracted with Dr. Stacey Stockdill of EnSearch to analyze outcome data for the program’s inaugural year. Additional information.