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Food is medicine: the intersection of food insecurity and chronic disease management

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Food is medicine: the intersection of food insecurity and chronic disease management

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Food Is Medicine: The Intersection of Food Insecurity and Chronic Disease Management
by
Christine Going

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

May 2021

© Copyright by Christine Going 2021
All Rights Reserved

The Committee for Christine Going certifies the approval of this Dissertation

Douglas Lynch
Anne Utech
Bryant Adibe, Committee Chair

Rossier School of Education
University of Southern California
2021
iv
Abstract
The high prevalence of food insecurity in patients with low socioeconomic status (SES) with
chronic diseases represents a significant health risk. The relationship of income and reported
poor health is five times greater for people living below the poverty level. Low SES Americans
have increased rates of chronic diseases, including heart disease, diabetes, stroke, and other
chronic disorders, compared to wealthier Americans. This problem of practice is important to
address because the relationship between food insecurity and health outcomes impacts the
overall healthcare system. Research linked food insecurity with high healthcare expenditures,
demonstrated by increased admissions, readmissions, and pharmaceutical needs. As part of the
resources available through a variety of nonprofit organizations, medically tailored meals
represent a unique approach to improving healthcare outcomes utilizing the concept that food is
medicine. The purpose of this study is to understand the relationship and impact of home-
delivered medically tailored meals to seriously ill, food insecure patients, in conjunction with
individualized nutrition therapy on the food insecurity cycle. A qualitative approach was used,
with semi-structured interviews of patients and the dietitians who treated them. The findings
were viewed through the theoretical framework of the socio-ecological model. Five categories or
emerging themes were identified. The findings showed the majority of the patients had
hypertension, followed by diabetes; 100% of the patients indicated having more than one
diagnosis, while 90% of the patients interviewed indicated a sense of anxiety over having food
prior to receiving MTM delivery services. Benefits of the dietitian and nutrition education were
noted by the patients in this study, leading to improved outcomes, demonstrated by the patients
sharing their increased strength, decreased anxiety, and increased activities outside the home. A
good organizational culture outweighs any noted barrier within the program, resulting in strong
v
patient satisfaction and employee loyalty. The findings will be used toward program
improvement.

Keywords: Food insecurity, medically tailored meals, food is medicine, nutrition education, role
of the dietitian, organizational culture, socio-ecological model.

vi
Acknowledgements
A dissertation, like raising a family, takes a village. This dissertation took the collective
efforts of my family, friends, and faculty of University of Southern California to afford me the
opportunity to complete my goal of obtaining my doctorate. My committee chair, Dr. Bryant Adibe
provided the environment for me to grow as a doctoral student in the development and
actualization of this dissertation. Dr. Doulas Lynch started my doctoral education and set me on
the path to my problem of practice, and ultimately the organization that I conducted this study
with. His dedication to ensure that innovation, creativity, and the value of connecting with people
to learn something, can never be underestimated. I am eternally grateful to him for always knowing
just how hard to push me. Dr. Anne Utech has consistently been the force behind my success both
professionally and now academically. Her quiet and brilliant way has enabled me to challenge the
status quo, create something from nothing, and represent a major federal agency in front of
Congress on multiple occasions. Her friendship and support cannot be undervalued, I am forever
in awe of her and in debt to her generosity of time and spirt.
This dissertation is the capstone of the years of course work leading to the completion of
this study. The many faculty I had the privilege to learn from cannot go without mention. The
opportunity to learn from the likes of Dr. Monique Datta, Dr. Jennifer Philips, Dr. Alexandra
Wilcox, and Dr. Courtney Malloy was a privilege and gift of this program. I truly view the world
and problems differently because of my time at the Rossier School of Education at USC.
This study would not have been possible if not for the support of Nutrition Delivered. The
staff and patients graciously and enthusiastically allowed me to learn from them through hours of
interviews, site visits, and monthly calls to ensure I fully understood the scope and breath of their
work. The ability to peek inside their organization and see the gift that food can be to our most
vii
vulnerable neighbors both humbled me and gave me great hope in my fellow human beings. The
dedication to their mission is something we can all embrace.
Finally, none of this would have been possible without the love and support of my husband
Ken. His steadfast support of me pursuing my dream is nothing short of amazing. His patience
with my chronic need for tech support and his ability to pivot when I decided to change jobs and
cities midway through this program allowed me the ability to succeed when others may have failed.
I am your unwavering partner in life and cannot thank you enough for this journey.

viii
Table of Contents

Abstract .......................................................................................................................................... iv
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
Chapter One: Overview of the Study .............................................................................................. 1
Context and Background of the Problem ............................................................................ 1
Purpose of the Project and Research Questions .................................................................. 6
Importance of the Study ...................................................................................................... 7
Overview of Theoretical Framework and Methodology .................................................... 8
Definitions........................................................................................................................... 9
Organization of the Dissertation ....................................................................................... 11
Chapter Two: Literature Review .................................................................................................. 12
Review of Literature ......................................................................................................... 12
Theoretical Framework- Socio-Ecological Model............................................................ 39
Conceptual Framework ..................................................................................................... 41
Summary ........................................................................................................................... 43
Chapter Three: Methodology ........................................................................................................ 45
Research Questions ........................................................................................................... 45
Overview of Design .......................................................................................................... 46
Research Participants ........................................................................................................ 47
Research Setting................................................................................................................ 48
Data Sources ..................................................................................................................... 48
ix
Validity and Reliability ..................................................................................................... 53
The Researcher.................................................................................................................. 54
Ethics................................................................................................................................. 54
Chapter Four: Findings ................................................................................................................. 56
Participating Stakeholders ................................................................................................ 57
Determination of Themes ................................................................................................. 58
Results and Findings for Microsystem Causes ................................................................. 59
Results and Findings for Mesosystem Causes .................................................................. 66
Results and Findings for Exosystem Causes .................................................................... 72
Results and Findings for Macrosystem Causes ................................................................ 76
Summary ........................................................................................................................... 79
Chapter Five: Recommendations and Discussion......................................................................... 83
Discussion of Findings and Results .................................................................................. 83
Recommendations for Practice ......................................................................................... 86
Limitations and Delimitations ........................................................................................... 92
Recommendations for Future Research ............................................................................ 93
Conclusion ........................................................................................................................ 94
References ..................................................................................................................................... 96
Appendix A: ................................................................................................................................ 106
Appendix B: Code List ............................................................................................................. 1108

x
List of Tables
Table 1: Cost Comparison of Medically Tailored Meals vs. Non-tailored Meals 35
Table 2: Topics Discussed by Patients and Dietitians Leading to Themes 59
xi
List of Figures
Figure 1: The Cycle of Poor Nutrition 4
Figure 2: Nutrition Delivered Diagnosis Served Distribution 6
Figure 3: Percent Food Insecure by Race/Ethnicity 17
Figure 4: Well-Being Justice 38
Figure 5: Conceptual Framework 43
Figure 6: Relationship of Findings and Conceptual Framework 82
Figure 7: Relationship Summary 91

1
Chapter One: Overview of the Study
The high prevalence of food insecurity in patients with low socioeconomic status (SES)
with chronic diseases represents a significant health risk. Food insecurity is a social determinant
of health and plays a role in population health strategies (Cohen et al., 2020; Health Research &
Educational Trust, 2017). The United States Department of Agriculture (USDA) defines food
insecurity as “a lack of consistent access to enough food for an active, healthy life” (USDA,
2017, p. 1). Unsurprisingly, 30% of high hospital utilizers, thought of as people with frequent
hospital admissions due to complex social and medical needs, is classified as food insecure
(Phipps et al., 2016, p. 414). Wang et al. (2015) confirm the relationship between food insecurity
and the poor management of hypertension, diabetes, HIV disease, and depression. This problem
of practice is important to address because the relationship between food insecurity and health
outcomes impacts the overall healthcare system (Berkowitz et al, 2019; Garcia et al., 2018;).
Understanding the behavioral, social, and environmental significance of social determinants of
health is a major contributor to keeping people healthy and serves as the focus of this study.
Individuals suffering from both acute illnesses and chronic diseases can benefit from medical
nutrition therapy, representing the idea of food as medicine. The aim of the study is to improve
organizational practice related to patient outcomes.
Context and Background of the Problem
The connections between healthcare issues and food insecurity are essential for a holistic
understanding of one’s overall health (Cohen et al. 2019; Ramsey et al., 2011). Socioeconomic
factors such as access to affordable food, physical environmental factors, including the lack of
grocery store access, and clinical care factors, such as the high cost or lack of access to health
care, all produce difficult tradeoffs and have effects on overall health (Ma et al., 2018). In 2018,

2
the average percentage of food insecure households in the United States reached 11.7%; in 2008,
the value was 12.2%, reflective of the nominal strides in addressing the ongoing challenges
(Wells, 2019). The cycle of food insecurity and chronic disease management is most prominent
in low SES populations (Wells, 2019). As a person declines in health, the likelihood of missing
work, increased healthcare costs, and the financial burden leading to difficult tradeoffs fuels the
continuation of the food insecurity cycle (Cohen et al., 2020; Health Research & Educational
Trust, 2017;). In the absence of good nutrition, chronic diseases can worsen, often leading to
increased usage of the healthcare system (Health Research & Educational Trust, 2017). Wang et
al. (2015) support the idea that food insecurity alone will result in poor outcomes. The provision
of health education, specifically on healthy eating, can impact the current relationship between
food insecurity and poor nutritional practices (Beccerra et al., 2016). When left unsolved, the
cycle of food insecurity and chronic disease will continue, resulting in a significant public health
issue. Figure 1 illustrates the cycle of poor nutrition, the relationship to disease management, and
access to food (Cohn & Waters, 2013).
Woolfe et al., (2015) notes the relationship of income and reported poor health is five
times greater for people living below the poverty level. Low SES Americans have increased rates
of chronic diseases, including heart disease, diabetes, stroke, and other chronic disorders,
compared to wealthier Americans (Woolf et al. 2015). The limited resources associated with
poverty result in a variety of coping strategies in an attempt to extend a household’s budget.
These actions can include underutilization of medications, skipping medical care, and avoiding
certain foods for therapeutic diets, like low sodium or diabetic diets (Food Research Action
Center, 2017). Food insecure individuals are usually not meeting the minimum standard of
clinical care for their needs, demonstrated through reduced medical visits, tests, and procedures

3
(CHAIN, 2011; Seligman et al., 2014). These types of behaviors can worsen existing diseases
and reduce overall health (Cohen et al., 2020; Food Research and Action Center, 2017).

4
Figure 1
The Cycle of Poor Nutrition

Note. From Food as Medicine by D. Cohn and D. Waters, 2013 (http://servings.org/food-health-
policy).

On an annual basis, the USDA measures food insecurity by using an 18-question survey
(Gunderson and Ziliak, 2018). Additionally, the USDA runs 15 nutrition assistance programs,
supporting a wide range of Americans from infants through seniors and native Americans.
Gundersen and Ziliak (2018) explain how these programs, specifically the Supplemental
Nutrition Assistance Program, known as SNAP, represent the national safety net for food
insecure individuals and families. In addition to SNAP, nonprofit organizations provide
additional resources to food insecure individuals through food banks, food rescue, nutrition
education, and research programs (e.g., FeedingAmerica.org). As part of the resources available
Poor Food Access
Lack of food, limited mobility resulting from disease, lack of financial
resources, inability to prepare food, lack of nutrition knowledge)

Poverty
(loss of job, reduced income,
loss of health insurance)
Disease/disease complications
(disease complications, nutrition-related disease, poor access to
healthcare, poor medical compliance)

Poor Nutrition
(nutrient deficiencies,
medically inappropriate
nutrition, wasting, obesity)

5
through a variety of nonprofit organizations, medically tailored meals represent a unique
approach to improving healthcare outcomes utilizing the concept that food is medicine. People
with chronic and serious illness, representing 5% of patients making up 50% of the healthcare
costs, are delivered meals designed for them by Registered Dietitian Nutritionists
(FIMcoalition.org). Berkowitz et al. (2019) findings are consistent with prior studies indicating
that the use of medically tailored meal delivery programs results in lower overall medical costs,
supporting the notion that food insecurity is a risk factor that can impact healthcare outcomes.
Nutrition Delivered (ND) (a pseudonym) is a non-sectarian organization preparing and
delivering medically tailored meals to people who, because of their illnesses, are unable to
provide or prepare meals for themselves. ND also provides illness-specific nutrition education
and counseling to their clients, families, care providers, and other service organizations. The
mission of ND is to improve the health and well-being of their clients living with HIV/AIDS,
cancer, and other serious illnesses by reducing hunger and malnutrition (ND.org, 2019). All
services are provided free of charge to clients in a large city in the northeast and neighboring
communities. Nutrition Delivered delivers on average 2.1 million meals per year, or
approximately 8,000 meals delivered per week (www.ND.org, 2019). Of the clients served, 90%
live below the poverty level. The majority of clients, representing 87%, are over 50 years old.
The most commonly treated medical conditions are cardiovascular disease at 17%, cancer at
16%, and HIV/AIDS at 15%. Figure 2 shows the distribution of medical diagnosis among the
patients served by ND (www.ND.org, 2019).

6
Figure 2
Nutrition Delivered Diagnosis Served Distribution

Purpose of the Project and Research Questions
The purpose of this study was to understand the relationship and impact of home-
delivered medically tailored meals to chronically ill, food insecure patients. Additionally, the
study sought to understand the impact nutrition therapy has on this population. Lastly, the study
sought to understand the relationship that medically tailored meals and education have on the
food insecurity cycle. The research questions guiding this study were:
1. What is the relationship between medically tailored meal recipients, food insecurity,
and chronic disease in conjunction with individualized medical nutrition therapy?
0
2
4
6
8
10
12
14
16
18
Diagnosis
%

7
2. What are the knowledge and motivational influences related to low socioeconomic
status patients with chronic diseases and how they meet their hunger needs?
3. Following the receipt of medically tailored meal delivery services, how do patient
attitudes and behaviors impact their relationships, social interactions, support groups,
and cultural context?
4. How do organizational influences impact low socioeconomic status patients with
chronic diseases meet their nutritional needs?
Importance of the Study
Food insecurity is a social determinant of health and impacts a person’s ability to meet
their daily requirements of a healthy, well balanced diet (Health Research & Educational Trust,
2017). In the absence of good nutrition, chronic diseases can worsen, often leading to increased
usage of the healthcare system (Health Research & Educational Trust, 2017). Substantially
higher healthcare costs occur in food insecure U.S. households, as explained by Gundersen and
Ziliak (2018). Research has linked food insecurity with high healthcare expenditures,
demonstrated by increased admissions, readmissions, and pharmaceutical needs, as described by
Berkowitz et al. (2019). Additionally, Gurvey et al. (2013) suggested a relationship between the
availability of appropriate nutrition, medical nutrition therapy, and its direct role on healthcare
costs. The provision of health education, specifically on healthy eating, can impact the current
relationship between food insecurity and poor nutritional practices (Beccerra et al., 2016).
Attention on healthcare improvement in the United States remains a focus nationally.
Improving care for the most vulnerable, including the poor and chronically ill, means turning
attention to population health initiatives. The Centers for Disease Control (www.cdc.gov) defines
population health as the ability to shine a light on health concerns that will allow attention for

8
resources and related social needs to focus on overcoming problems that drive poor health. When
left unsolved, the cycle of food insecurity and chronic disease will continue, resulting in a
significant public health issue. The impact is seen by increasing healthcare costs, increased
absenteeism at school and work, resulting in financial challenges for the affected households,
and decreased quality of life (Gurvey et al., 2013; Health Research & Educational Trust, 2017).
Investigating this problem through the socioeconomic model provides a variety of layers in
understanding the different aspects of the idea of food as medicine.
Overview of Theoretical Framework and Methodology
Bronfenbrenner’s ecological model, often referred to as the socio-ecological model
(SEM), focuses on how the individual impacts their environment and their development within
the system (Gardiner, 2018). Ostensibly, the model outlines the relationship between the multiple
layers of the environment called microsystems, mesosystems, ecosystems, and macrosystems
(Gardiner, 2018). The SEM establishes the framework for examining food insecurity within this
population through the multiple social systems of the environment and effectively provides the
setting to evaluate health as it affects the relationship to the individual, the community, and the
environment. The SEM describes the microsystem, mesosystem, exosystem, and macrosystem as
nested around each other (Gardiner, 2018).
The microsystem is the primary level closest to the individual and represents direct
interaction, for example, in the home. The mesosystem is the second level that ties together the
microsystem or the individual’s home to the next level, the community. This level contributes to
the linkage or understanding from one setting to another. Settings that are beyond the
individual’s home setting but interact with the individual are the third level, the exosystem. An
example of this formal setting would be ND, or the local community health center or hospital. A

9
less formal setting could be the individual’s extended family. The last level is the most complex
system in the model and includes the customs, values, and laws that are important to the induvial
within their society. This level determines what is considered acceptable compared to
unacceptable behaviors and attitudes (Gardiner, 2018). Additionally, SEM allows for the
inclusion of physical, social, and political perspectives and their impacts on the problem under
review, as well as the inclusion of policy in the evaluation of the problem of food insecurity and
chronic disease management through the lens of the macrosystem (Gardiner, 2018).
Definitions
The following definitions used throughout the study are central to understanding the
overall concepts of this dissertation. The definitions primarily utilized from the relevant literature
on the study topic are presented below.
Body Mass Index (BMI) defines body mass as a factor of health by accessing a person’s
fatness. The mathematical calculations are defined by a person’s body weight divided by height
squared (Nuttail, 2015).
Chronic Disease Management is an approach to managing illness. The combination of
care treatments may include clinical screenings, well visits, monitoring and patient education
(healthcare.gov).
Food Desert is an area, either rural or urban, that is a long distance from, or has a low
volume of, retail food stores with healthy food (Hesterman, 2016).
Food Insecurity (FI)is a lack of consistent access to enough food for an active healthy life
(FeedingAmerica.org).

10
Food Justice involves the many components surrounding the food system, including but
not limited to, the idea of food deserts. Access to food resources is a key issue for low-income
communities, often communities of color (Hesterman, 2016).
Medical Nutrition Therapy (MNT) consists of the diagnostic, therapeutic, and counseling
services for disease management furnished by a registered dietitian or nutrition professional.
MNT is a specific application of the nutrition care process in clinical settings focused on the
management of diseases. MNT involves in-depth individualized nutrition assessment
(eatrightpro.org).
Medically Tailored Meal (MTM) are meals designed by RDs to meet the specific needs of
the patient’s medical condition with the goal to improve their health outcomes (FIMcoaltion.org,
2019).
Non-tailored Meal Program (NTM) meal program provided by Meals on Wheels or
similar vendor, providing nutritious meals that are not medically tailored (Berkowitz & Waters,
2018).
Population Health is the ability to shine a light on health concerns that will allow
attention for resources and related social needs to focus on overcoming problems that drive poor
health (cdc.gov)
Registered Dietitian (RD) is a healthcare professional with an expertise in human
nutrition and the regulation of diet. A dietitian alters their patient's nutrition based upon their
medical condition and individual needs. This credential means that someone has completed a
higher level of training and passed a registration exam (wikipedia.com).
Socioeconomic Status (SES) is a combination of an individual’s education, income, and
place of residence. A person’s SES may impact their access to resources (apa.org, June 2020).

11
Supplemental Nutrition Assistance Program (SNAP) is a federal nutrition program that
helps individuals stretch their food budget and buy healthy food. It is a federal entitlement
program run by the USDA and was formerly called food stamps. (getting foodstamps.com).
Organization of the Dissertation
This five-chapter study organizes the themes, patterns, and influences associated with the
negative effects that food insecurity has on chronic disease management. Chapter One provides
an overview of the problem of practice and the surrounding influences of diet, disease, and
disease management in the face of food insecurity. Additionally, Nutrition Delivered (ND), a
medically tailored meal delivery organization, is introduced, as well as the role it plays in
reducing food insecurity among clients with illnesses that prevent them from preparing their own
meals. Chapter Two provides a review of the literature, (social determinants of health, food
insecurity in different demographic groups, chronic disease management and nutrition, food
justice, deserts and access, food pantries, SNAP and food as medicine), the socio-ecological
model framework for this study, as well as an explanation of the conceptual framework and
associated theories. Within Chapter Three is the research methodology for the data collection.
This includes the study design, data sources, data collection, and overall study strategies used to
ensure credibility. Chapter Four provides the study findings, organized by the SEM model,
research questions and emerging themes. Chapter Five provides a connection of findings to the
literature, recommendations for practice, and future recommendations based on the study.

12
Chapter Two: Literature Review
This literature review examines food insecurity in low-income patients with chronic
diseases through the lens of the socio-ecological model. The review covers many topics that
influence and inform the problem of practice. The topics are organized from broad sweeping
concepts such as social determinants of health, then, as with a funnel, proceed to more focused
reviews on subjects like access to food, SNAP, and the concept of food as medicine. The
complete list of topics includes social determinants of health, food insecurity in different
demographic groups, chronic disease management and nutrition, food justice, food deserts and
access, food pantries, SNAP, and food as medicine. The literature review is followed by a
discussion about the theoretical framework, specifically the socio-ecological model, and the
conceptual framework for the research study.
Review of Literature
The relationship of socioeconomic factors to the causes of food insecurity and the effects
of food insecurity and the increasing impact they have on chronic disease and mental illness
highlight the need to better understand these connections. Pruitt et al. (2016) reported significant
differences in the prevalence of self-reported poor health status, higher BMI, diabetes, smoking,
depressive symptoms, and a high number of functional limitations in food insecure respondents
compared to food secure respondents. The study looked at food assistance programs, overall
health, access to healthcare services, functional indicators, and behavioral risk factors measured
in a cross-sectional analysis with nearly 17,000 adult respondents. The results confirmed
previous findings that people positive for food insecurity are experiencing a significantly greater
degree of adverse health conditions and access to healthcare compared to food secure people.
O’Brien (2019) reviewed the importance of screening for social determinants of health by

13
healthcare facilities in all settings, including inpatient, outpatient, etc. The growing disparities in
communities of color warrant the attention of healthcare providers; several disparities are evident
when comparing groups of white patients to black patients. According to O’Brien (2019), black
patients have shorter life expectancies, increased mortality rates, and, most significantly, have
increased mortality rates in seven of the top ten causes of death. These disparities include social
factors associated with poverty such as increased stress, poorer diets, limited exercise, access to
healthcare, and increased likelihood of living in densely populated environments (O’Brien,
2019). The inter-connection of social support to an individual’s physical well-being can impact
individual life expectancy more negatively than cigarette smoking, obesity, hypertension, and
limited physical activity. Significant social support has demonstrated it to be a protective factor
against mental and physical illness, reducing both genetic and environmental factors, supporting
the need to screen patients.
Social Determinants of Health and Impact of Poverty on Food Insecurity
Food insecurity is a social determinant of health that is part of a population health
approach to overall wellness (Health Research & Educational Trust, 2017). A number of socio-
economic, physical, and mental clinical factors impacting health are also associated with food
insecurity. Chronic food insecurity is likely to lead to obesity and diabetes (Health Research &
Educational Trust, 2017). Inadequate food intake or malnutrition is a risk factor for hypertension,
cardiac disease, and behavioral issues such as depression and anxiety (Health Research &
Educational Trust, 2017). The relationship between food insecurity and reduced health is
complicated and often a cycle that is difficult to break according to Cohen et al. (2019).
Referenced by the USDA (usda.gov), 11.8% of the US population in 2018 was food insecure.
Food insecure households employ a variety of coping strategies in response to financial

14
limitations. These strategies include the use of high-calorie, nutrition-poor food that is usually
less expensive, the skipping of meals, underuse of medications, and delays in medical care
(Cohen, et al. 2019; Health Research & Educational Trust, 2017). Understanding the relationship
between health, nutrition, and economic outcomes as they impact society is important to public
health policy.
Many chronic diseases are preventable when public health strategies are effectively
implemented, and nutrition is considered a significant contributor to modifying non-
communicable disease outcomes (Lenoir-Wijnkoop et al., 2012). In a white paper, Lenoir-
Wijnkoop (2012) outlines the relationship of nutrition economics and the role nutrition plays in
morbidity and mortality when measured in years of life lost and financial expenditures for
medical treatment for nutrition related conditions. A strong relationship was found between low
dairy product consumption and occurrence of risk factors, specifically osteoporosis, obesity,
hypertension, ischemic heart disease, stroke, and diabetes when measured in Australia. The
review also found that 65% of the population measured failed to meet the recommended two-
three daily servings of dairy. This resulted in healthcare expenditures associated with the six risk
factors identified, costing over AU $2000 million, this amount is significant because the total
public health budget in Australia is AU$ 2265 million. Lenior-Wijnkoop (2102) concluded that
nutrition interventions along with lifestyle changes represented a cost-effective alternative to
pharmaceuticals and traditional medical interventions. The linkage of poverty and food
insecurity as social determinants of health represents a serious problem that impacts overall well-
being.
The positive relationship of health and wealth is strong. Income is a predictor of health
and identifying health disparities (Woolf et al., 2015). In a white paper, the data indicated that

15
22.8% of respondents noted fair or poor health when making less than $35,000 per year,
compared to 5.6% reporting fair to poor health when making $100,000 or more annually (Woolfe
et al., 2015). Specifically, the prevalence of diabetes was 11% in the participants making below
$35,000 annually compared to 5.9% in the $100,000 annual income category. There is an
economic impact associated with the risk for increased illness. Low SES employees have
increased healthcare needs, increased absenteeism, and cost their employers directly through
increased healthcare expenses and reduced productivity (Woolfe etal., 2015). Additional studies
reported similar results.
Drewnowski et al. (2004) explained the relationship between poverty and obesity as a
result of low-cost energy-dense food selections. The selections are informed by a biological
factor or craving for sweet and/or high fat food, a physiological factor associated with the
glycemic index of food and fat tissue metabolism and a behavioral factor related to the degree of
nutrition knowledge, environmental impacts, and the role of advertising on food selection.
Questions remain if reducing the caloric density of food can achieve improvement without
increasing the cost and palatability of the product (Drewnowski, 2004). Ramsey et al. (2010)
mailed surveys to 1000 individuals (53% return rate), followed by a chi square analysis looking
for the relationship between food insecurity, sociodemographic, and health outcome factors. The
likelihood of seeing a medical provider or being hospitalized within the last 6 months was two to
three-fold greater in the food insecure demographic. Most significantly, Ramsey et al. (2010)
indicated that there was up to a six-fold increase in the prevalence of depression in the food
insecure population compared to the food secure respondents. Households with lower incomes
are likely to experience food insecurity and experience poorer health compared to households of
median to high annual income (Ramsey et al., 2010). Additionally, the impact of race and

16
ethnicity presents a consistently higher risk for food insecurity, contributing to a growing public
health issue.
The Impact on Ethnic, Racial, Children, and Veterans Subgroups
The prevalence of food insecurity distributed among ethnic or racial groups is uneven.
People of color are significantly more food insecure compared to their white counterparts,
including being native or foreign born (Meyers et al., 2017). In a qualitative review by Meyers et
al. (2017) of the National Health and Nutrition Examination Survey (NHANES) data, 32,464
adults’ food insecurity status, race/ethnicity, socioeconomic, and educational status represented
the main variables in the study. Using a regression analysis model, the results for race/ethnicity
indicated that foreign-born Latinos were most food insecure at 0.76 compared to foreign born
Blacks at 0.58 and compared to foreign-born Whites at 0.16.(Figure 3, Percent Food Insecure by
Race/Ethnicity). The study further showed that the higher the socioeconomic and educational
status of the participant, the more significant the reduction in food insecurity. Meyers et al.
(2017) concluded that the prevalence of food insecurity sorted by race/ethnicity was significant,
while nativity status was not, across all race/ethnicity categories.

17
Figure 3
Percent Food Insecure by Race/Ethnicity

Papas et al. (2016) investigated the relationship of food insecurity and obesity in low-
income Hispanic mothers and children. In a cross-sectional study of 74 Hispanic mothers and
children, Papas et al. (2016) conducted in-person interviews in both English and Spanish and
utilized a chi square and t test regression analysis. The results indicated 68% of the mothers and
45% of the children were overweight or obese. The association of food insecurity to childhood
obesity was limited to children with overweight or obese mothers, with the adjusted odds ratio
for child obesity at 1.0 for normal weight mothers compared to 9.9 for overweight/obese mothers
(Papas, 2016). The rates of obesity within the study sample were higher than the national
average. The rate of obesity for Mexican Americans continues to increase, while the rates for
non-Hispanic Whites and Blacks have been decreasing. Kollannoor-Samuel (2012) investigated
the association between food insecurity and healthcare access among Hispanics with diabetes. In
0
10
20
30
40
50
60
70
80
Foreign born Latino Foreign born Black Foreign born White
Percent Food Insecure by Race/Ethnicity

18
a randomized controlled study, they conducted in-person interviews measuring health access and
utilization compared to demographic and socioeconomic, psychosocial, cultural, and clinical
variables and performed t test or chi square test analysis. High food insecurity was a risk factor
for a lack of enabling factors and medication access, as well as forgetting to attend doctor
appointments and taking medication. The high prevalence of food insecurity among non-white
populations increases their risk for obesity, especially for women and children, additionally
impacting barriers associated with healthcare access and utilization (Kollanoor-Samuel, 2012).
The important role food insecurity plays in children’s health and academic progress supports
additional review of the literature.
Impact on Children as a Subgroup
Food insecurity in children impacts their development nutritionally and psychologically,
resulting in poor health and educational outcomes. Harvey (2016) reported that the majority of
parents in the sample were not able to provide a balanced diet. This result confirmed previous
findings that fruits, vegetables, and meat were not available, resulting in the use of low-cost,
high-fat, energy-dense food. The study used a mixed methods approach with a survey of parents
and semi-structured interviews with children in the United Kingdom. The parents reported 80%
of the time not providing their children with a heathy diet because they could not afford to
purchase the right foods. Johnson et al. (2018) noted evidence that food insecurity in children
between 9 months and 2 years old consistently experienced social emotional outcomes and
approaches to learning, to include conduct problems. This longitudinal national study included
over 10,700 participants in four waves of data collection and noted that 80% of the participating
families experienced food insecurity when the children were between 9 months and 2 years old
and 86% experienced food insecurity during the child’s second year. As a result, Huang et al.

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(2016) highlighted the positive impact that school feeding programs have on food insecure
children and their families’ nutrition and health outcomes associated with malnutrition. The
study analyzed the national school lunch program in the low-income population, and it showed a
decrease in the food insufficiency rate between January and May of 4.3% compared to summer
months of 4.6-5.0% when school was not in session. Both the availability of food and the time of
food insecure periods during the development of the child can have significant impact on their
growth and behaviors (Huang, 2016). Similarly, disparities in health and food insecurity among
veterans compared to the overall public is worthy of a focused review.
Impact on Veterans as a Subgroup
The rate of food insecurity among US Veterans seems to vary by subgroups, creating a
challenge for healthcare systems that care for this population. Wang et al. (2015) suggested that
food insecurity alone would provide a route to poorer health outcomes above a lack of access to
medical care and medications. Wang et al. (2015) reported food insecurity among Veterans
receiving care in the Veterans Affairs (VA) healthcare system to be independently associated
with marijuana use, depression, worst control of hypertension, diabetes, HIV disease, as well as,
being poor, a racial minority, unemployed, or recently homeless. (Wang et al., 2015). A large
observational cohort study analyzed 6,709 subjects from eight VA facilities across the country.
Reporting food insecurity 24% of the time by the subjects, 85% of the food insecure Veterans
were either a racial or ethnic minority, 83% were unemployed, and 28% were recently further
showed that 12% used marijuana and cocaine, compared to 8% and 7%, respectively, for food
secure Veterans, supporting the impact of co-morbidities like low SES and drug use. High blood
pressure (chi square, p = 0.01) and diabetes (chi square, p < 0.001) were independently

20
associated with higher rates of food insecurity, even after adjusting for race, age, and gender.
Similar findings have been reported by a number of researchers within this specific demographic.
O’Toole et al. (2017) found screening for food insecurity in VA Primary Care Homeless
clinics highlighted the need for an interdisciplinary approach to treating this population. A total
of 270 veterans screened at six different VA Primary Care clinics and specifically focused on the
homeless population. A review of the screening results, in addition to responses from clinic staff
members interviewed about the screening initiative, showed 48.5% food insecurity. Of those
who reported food insecurity, 87% prepared their own meals, 54.2% got food from soup kitchens
and food pantries, and 22.9% utilized shelters for food. Most Veterans, specifically 55%,
indicated eating two meals per day, while 27.3% ate one meal per day. As noted in other studies
and confirmed by O’Toole et al. (2017), the following diagnoses were present in the food
insecure Veterans: depression (22.1%), psychosis (22%), alcohol abuse (22.1%), diabetes
(19.8%), and 43.5% reported experiencing hypoglycemia when they went without food. The
hypoglycemia data are higher than expected based on the number of Veterans with diabetes in
the study, suggesting that effects associated with medication and alcohol abuse may contribute to
hypoglycemia when Veterans go without food. Additional studies reported similar results.
Pooler et al. (2018), confirming that food insecurity rates overall are lower in Veterans
than the general public; however, subgroups of Veterans have significantly higher rates. Pooler
et al. (2018) used the National Health Interview Survey data and analyzed the 30-day food
insecurity rate among more than 25,000 veterans age 21 and older between 2011-2017. The
overall rate of food insecurity was 6.5%; the poverty status was 5.2% of the sample; and SNAP
utilization was less than one third of the food insecure households. The age of the Veteran
suggested a likelihood of food insecurity decreasing with age: 10.3% reported food insecurity

21
under age 45, 4.3% for those 65-74%, and 2.3% for those 75 and older. Females were more
likely to be food insecure over their male counterparts at 10.8% versus 6.3%. Educational levels
followed expected outcomes: 9.2% of Veterans without a high school degree were food insecure
compared to college educated veterans at 2.9%. Hispanic Veterans and non-Hispanic Black
Veterans were food insecure at 8.2% and 12.4%, respectively, compared to non-Hispanic White
Veterans at 5.3% food insecurity rate. When the National Health Interview Survey data was
sorted by health characteristics, 35.2% of veterans with serious mental illness were food insecure
(Pooler et al. 2018). The research provides insight into understanding that individual subgroups
have significantly higher rates of food insecurity (Veterans with mental illness, diabetes, younger
veterans, etc.) and require specialized treatment by an interdisciplinary team to identify them
through screening in Primary Care clinics and mobilizing the clinical services based on their
individual needs. Therefore, the overall resource of food and where to get it is equally important
to the general population of sick people.
Relationship between Food Insecurity and Chronic Disease
Patients who are food insecure and have a chronic disease have increasing healthcare
costs compared to food secure patients, highlighting the need to better understand this
relationship. Garcia et al. (2018) reported on a four-year study that analyzed two different
surveys looking at healthcare costs of hypertension, coronary heart disease, stroke, emphysema,
asthma, cancer, chronic bronchitis, arthritis, and diabetes in a population that was also
experiencing food insecurity. The analysis posited that higher healthcare costs were present
when patients were both food insecure and suffered from a chronic disease. Miner et al. (2013)
conducted a cross-sectional study over three consecutive years that showed an increase in the
percentage of food insecure patients presenting to a level one trauma center emergency

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department for medical care, demonstrating the upward trend and burden on the healthcare
system. The study enrolled 8,044 participants; the rate of food insecurity increased in the
emergency department during the study period from 20.0% the first year to 22.6% the third year.
Additionally, Phipps et al. (2016) noted that the availability of healthy and adequate food was a
challenge for most of the study participants, which raised health concerns based on the diet
sensitive diagnoses of the study population. Greater than 50% of the participants received their
food from food pantries, churches, or home food delivery programs. The empirical study
conducted in a 770-bed tertiary care teaching facility serving a low-income population
highlighted the significance of nutrition therapy in the treatment of high medical care utilizers,
impacting the cost to the healthcare system. The cost of healthcare in the food insecure
population is a problem, in addition to the impact food availability has on medical care
management.
Access to Food, Supermarkets, and Food Justice
Consistent availability of healthy food in the low SES food insecure population has a
significant impact on diabetes management, including hypoglycemia. Seligman et al. (2010)
found statistically significant associations between food insecurity and self-management
indicators for diabetes and hypoglycemia. The study included 315 patients and compared
outcomes between food insecure and food secure participants utilizing a five-item chronic illness
general self-efficacy scale; the mean self-efficacy score for food insecure participants was lower
than the food secure participants. Accordingly, Seligman et al. (2014) showed that
hypoglycemic, low-income patients had more frequent hospital admissions at the end of the
month in response to inadequate food budgets than the high-income hypoglycemic patient.
Consequently, the study asserted the rate of admission for the low SES, hypoglycemic cohort

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increased from 230 per 1,000,000 total admissions the first week of the month, to 290 the last
week of the month. Similar studies support findings with diabetic patients with food insecurity.
Knight et al. (2016) conducted a cross-sectional analysis using a national representation
of survey data from the National Health Interview Survey to evaluate the prevalence of food
insecurity in adult diabetics and the relationship to medication use. The study showed a 17% rate
of food insecurity in the reviewed sample; specifically, females are more likely than males to
identify as food insecure, and Black and Hispanic diabetics are more likely than their White
diabetic counterparts to be food insecure. Of note, 18.9% of the overall sample reported cutting
back on their prescribed medication. The analysis concluded that food insecurity was positively
associated with reduced prescribed medication use, with a six-fold increase if the patient was
food insecure and diabetic, compared to a food secure diabetic. The findings lead to an increased
risk of adverse clinical outcomes such as hypoglycemia. The negative effect food availability has
on diabetes management is well documented. Access to a supermarket is important in low-
income underserved communities, inviting the need for further investigation into the effect it has
on the communities’ health behaviors.
Access to Supermarkets and Healthy Food
Understanding the role of community food resources and the location of supermarkets
with healthy food is essential in improving the health of a neighborhood by reducing food
insecurity in underserved communities. Ma et al. (2018) studied the shopping frequency,
community resources, and types of transportation in low-income areas of South Carolina to find
patterns associated with healthy food access. A cross-sectional study evaluated food hubs’
influence on healthy food access in 466 participants. The study found three classes of
participants based on their use of community resources, frequency of grocery shopping, and type

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of transportation used occurred. Class 1 used community resources, infrequently shopped, and
utilized public transportation or someone else’s car. Class 2 used community resources, for
example, SNAP, shopped more frequently and closer to home; these are called proximal
shoppers. Class 3 did not use community resources and were distal shoppers. Class 1 participants
showed a significantly greater perception of inadequate access to food shopping compared to the
other two classes (Ma et al.,2018). Similar findings regarding access to healthy food have been
observed.
The perception of decreased access to healthy food was highly associated with a lack of
vehicle ownership. Chrisinger (2016) conducted a qualitative study in a Philadelphia
supermarket to study consumer behaviors in relationship to the store environment. Thirty-two
participants were recruited, 23 of them reported being SNAP participants, 27 were women, and
31 African American. Transportation was among the barriers sited by participants to shopping,
and included the challenges of public transportation, the cost of drivers, and the challenges of the
supermarket-provided shuttle impacted access to the supermarket. Store cleanliness contributed
to store selection, with the perception that the clean store had fresher food and a better supply of
items on sale compared to discount markets. Lastly, positive social interactions, such as being
polite and helpful, were important to shoppers compared to the discount stores. Most shoppers
indicated their desire to buy healthy foods because of a chronic health condition, e.g., diabetes or
hypertension. The location of the study store allowed shoppers to make more frequent trips,
which reduced the difficulty outlined due to transportation barriers. In line with the previously
noted studies, Hossfeld et al. (2017) examined a number of programs in southeastern North
Carolina that strived to decrease the gap of affordable healthy food for low-income communities.
Hossfeld conducted semi-structured interviews with 16 participants of the food sovereignty

25
program about food purchasing and eating habits. The results showed an increase in the use of
nutrition food labels reported by 60% of the participants, and 23% noted an increase in the
amount of fruits and vegetables they consumed. Additional findings supported the benefits of the
cooking, nutrition, and after-school programs as facilitating improvement with the relationship
between the food at the stores and the food eaten at home, in a positive manner. The relationship
between the location of the food store and the actions necessary for change warrant further
review.
The choice involved in selecting the type of food eaten may include factors beyond the
location or type of store available to the consumer. Renner et al. (2012) posited that the reason a
person selects a certain food can provide insight into future policies associated with public health
initiatives. Utilizing three different studies, Renner et al. developed the Eating Motivation
Survey. The survey was given to over 2,500 participants and showed significant findings
surrounding the motivation behind the food selections sorted by 15 different factors. The survey
confirmed previous findings that motives surrounding health and body weight are considered
core to food choices among women. Economic motives, specifically price and convenience, were
seen in different samples and accounted for another reliable factor impacting motivation. Lastly,
the motive of eating to be social was supported by the Motivation Survey, as well as prior
research. Cummins et al. (2014) investigated the presence of increased access to grocery stores
and supermarkets in low SES areas and the change it had on dietary habits. A quasi-
experimental, pre- and post-longitudinal design was used in two Philadelphia neighborhoods.
Both areas were considered food deserts, and a total of 1440 respondents made up both groups.
One neighborhood, however, received a new supermarket, the results measured BMI, daily fruit
and vegetable intake, and perception of food access. The intervention group showed 26.7%

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adoption of the new store as their main store, with 51.4% utilizing the new store for any type of
purchase. There was not a statistical difference when comparing BMI or daily fruit and vegetable
consumption. Perception of food choice and quality was improved in the intervention group.
Similar studies found motivation an important factor.
Taylor et al. (2016) continued to pursue the thesis that food access for low SES
households would improve dietary choices. A total of 4,826 households were surveyed using the
FoodAPS dataset, which allowed the data to determine the distance to food stores for each
participant. The food store choices were sorted into nine categories, and the sample was
categorized into SNAP and non-SNAP recipients. Superstores showed significant preference to
supermarkets and other categories in both SNAP and non-SNAP groups, including a willingness
to pay more for access to the superstore. Specifically, households would pay between $12-$17
per week in travel to have access to a superstore, supermarket or fast food compared to the other
categories, which included farmers’ markets. Supporting the idea that motivation and new stores
alone may not impact behavior change associated with healthy choices, leading policy makers to
look at the inclusion of educational programs and promotions to impact the reasons or
motivations a shopper selects a healthy diet. The relationship of food store access, the quality of
food, and degree of food insecurity in low-income communities warrants additional review.
Access to affordable, healthy food and access to transportation, affordable housing, and
nutrition assistance programs as a measure of the economic strength of a community are key
factors in facilitating food security. Bartfeld et al. (2010) performed anonymous surveys focused
on the relationship between contextual factors and food insecurity on 8,396 households in
Wisconsin. The findings indicated that with a $100 increase in rent, there was an associated 21%
increase in the risk of food insecurity in that household. Access to public transportation reduced

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the risk of food insecurity by 32%, while living more than 15 miles from a supermarket
increased the risk of food insecurity by 67%. There was a 44% greater risk of food insecurity in
urban households compared to rural areas. Lastly, the presence of an adult with a college degree
significantly reduced the risk of food insecurity for that household (Bartfeld et al., 2010).
Additional studies have suggested similar findings.
Gordon et al. (2011) studied the impact of the neighborhood on residents’ health through
food availability in New York City in a block-by-block survey conducted in Harlem and
Brooklyn low-income neighborhoods with largely Black and Hispanic residents. An assessment
of the types of healthy and unhealthy food stores included in the study led to the creation of a
food desert index. A low score represents less access to healthy food with increased access to
unhealthy food and alcohol. Gordon et al. (2011) explained that the Black block groups had
significantly lower food desert scores, with less stores characterized as healthy, compared to the
Hispanic block group’s food desert scores. The White block groups had significantly more
healthier food stores, resulting in even higher food desert index scores, and lastly, blocks with
the highest median household income had the highest food desert index score compared to all
other groups. The distribution of resources is uneven throughout society with low SES
communities encountering more crime, lower quality educational systems, and limited access to
healthcare and healthy food (Prilleltensky, 2012).
The Role of Food Justice
Prilleltensky (2120) posited that fairness is equal to justice, and further explained that
justice is about how resources and treatment of people is done in a fair and equitable manner.
The concept of food justice aligns with this concept of wellness as fairness across the different
levels of our ecological societies. Accordingly, Roselle and Connery (2016) reviewed food

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insecurity through the lens of Dewey’s theory on democracy, with the aim to make citizens live
life to its fullest. Food democracy addresses food access inequity and the nutritional impact it has
on public health, specifically children’s physical and mental health, and academic achievement
leading to their economic success. A review of the impact of the Hartford Food System program
in Connecticut demonstrates the use of a youth program focusing on social and food justice
issues (Roselle & Connery, 2016). The program resulted in a gardening club and the production
of food for their school cafeteria, hot breakfast and lunch options, as well as spices that
encourage alignment with cultural practices. The study incorporated a survey process that
identified the problems and solutions. The urban farming programs highlighted the following
concerns as their primary focus—food insecurity, education, and community building—
concluding that this type of program allows students to address inequities in both the food
system and society. Access to healthy food plays a key role in predicting the level of food
insecurity in a neighborhood. This idea runs parallel to the lens of social justice, which states the
level of wellness of a neighborhood is directly related to the level of justice of the neighborhood
(Prilleltensky, 2016). Food insecure people’s ability to meet the nutrition guidelines is related to
access of healthy food, leading to the next important avenue of review.
Nutrition Guidelines and Food Pantries/Food Banks
Food insecure individuals are not meeting the dietary guidelines to support good health
and prevent diet-related chronic diseases like obesity, hypertension, diabetes, and cardiovascular
disease. Millen et al. (2016) conducted a review of the 2015 Dietary Guidelines for Americans
using the socioecological model to identify influences and relationships that can be changed to
impact health throughout the lifespan. The review identified nutrients that have been over-
consumed and resulted in negative health outcomes, specifically, saturated fats and sodium.

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Positive relationships exist between certain eating patterns and preventable diseases, including
increased use of fruits, vegetables, low fat dairy, seafood, beans, and nuts. Three eating patterns
emerged from the review to meet the Dietary Guidelines and essential nutrients
recommendations: a healthy United States eating pattern, the Mediterranean style pattern and a
plant-based (vegetarian) pattern. These patterns increased positive health outcomes by reducing
the risk of developing chronic diseases. Johnson et al. (2018) conducted a review of peer-
reviewed literature between January 1995 through October 2016 to evaluate food insecure
women and their ability to meet the dietary guidelines. The results included a statistically
significant difference in the under-consumption of dairy products, fruits and vegetables, and the
number of meat servings in food insecure women compared to food secure women. The findings
extended to identify seven additional groups and nutrients to conclude that food insecurity
impacts the entire diet, as well as the macro- and micro-nutrients needed to maintain health.
Food Pantries ’ Role in Meeting Nutritional Needs of Clients
In response to the association of decreased health related to food insecurity, Gany et al.
(2012) studied emergency food services, finding they do not provide good accessibility or
appropriate food options for the medically ill. The study reviewed 60 food pantries randomly
selected from 48 zip codes in New York City, finding that 53% were open less than three hours
per week, most limited the number of times a person could receive food, and the majority
provided canned foods. Simmet et al. (2017) conducted a systematic literature review to
understand the nutritional quality of food pantries through the lens of socioeconomic inequalities
of low-income individuals. A total of 16 studies highlighted the poor diet quality of female
pantry users with the Healthy Eating Index (HEI) scoring system. The higher the score, the
closer to aligning to the guidelines. Out of a total of 100, the mean score was 42.8. A score

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below 50 is associated with a poor diet. Both males and females demonstrated less than
recommended caloric intake, leading to the conclusion that food bank users consumed
inadequate diets compared the general U.S. population. Additional studies reported similar
findings.
Martin et al. (2019) supported the development of a system to promote nutrition
education and incorporate the dietary guidelines into pantry management because food pantries
routinely focus on the quantity of food over the quality of the food provided. A green, yellow,
and red stoplight system named Supporting Wellness at Pantries (SWAP) facilitated the food
pantry staff’s ability to provide health information to the clients. The review compared SWAP,
the American Diabetes Association (ADA), and the American Heart Association (AHA)
recommendations. The SWAP met all ADA sugar guidelines and most AHA requirements.
SWAP provided a system well accepted by staff and patrons, allowing improved inventory
control of healthy foods, while easily communicating which pantry products had less, fat,
sodium, and sugar. The importance of the Dietary Guidelines, eating behaviors, patterns, and the
role of food pantries supports previous study findings that the demographic that uses food
pantries is both food insecure and more likely to have a chronic disease. The idea that a food
pantry environment is perfectly suited to promote healthy behaviors supports further review of
the literature.
Food Banks ’ Role in Meeting Nutritional Needs of Its Clients
The emergency food system, which includes over 200 U.S. food banks, supports the
front-line partner agencies for the 46.5 million people annually who use soup kitchens, food
pantries, shelters, etc., to meet their household need for food (Wetherill et al. 2019). This
community resource represents an opportunity to impact food insecure households and overall

31
health through improved nutrition. In response to this need, Wetherill et al. (2019) conducted a
qualitative study of 30 food bank executives to understand their perspectives and experiences
related to nutrition focused food banking. Four major themes emerged from the research: build
healthier food inventories; enhance health food access, storage, and distribution programs;
utilized community-based nutrition education; and provide community settings for healthy food
distribution. The emerging idea was the use of healthcare partners to expand the functions and
reach of the present-day food bank into community nutrition education. To assess the nutritional
quality of food banks, Nanney et al. (2015) conducted an observational study of invoices to
evaluate the quality of the food ordered for two large food bank groups in Minnesota using the
HEI 2010. The mean score of the 269 items evaluated was 62.7 out of 100, indicating a need for
improvement, with scores for protein and vegetables the highest and whole grains the lowest.
The use of this tool in a food bank setting facilitated the alignment of the dietary guidelines with
the products made available to individuals utilizing food banks (Nanney et al. 2015).
Additionally, the tool allowed for improved inventory control and ordering to support increased
nutritional quality of products.
Food banks provide an opportunity to interact with vulnerable individuals who are not
utilizing traditional healthcare settings for the treatment of diseases like diabetes. Seligman et al.
(2018) conducted a randomized trial of Feeding America food banks, including a 6-month
intervention for a diabetes self-management program. The study observed statistically significant
improvement for patients in the control group regarding food stability and fruit and vegetable
intake, with 80% of participants reporting they preferred the diabetes food packages over the
regular pantry food. When asked if the program helped them control their diabetes better, 64%
agreed and 94% indicated they would recommend the program to friends or family. Food banks

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represent a community resource with excellent access to our most vulnerable populations,
specifically those at greatest risk for food insecurity and chronic disease management. There is
an obvious relationship between public health initiatives and the community partners that are
associated with food banks (Seligman et al., 2018). The connection of these not-for-profit
agencies and the USDA safety net (SNAP) suggests the need for additional research to
understand how to maximize the impact on low-income, chronically ill, food insecure
individuals.
Supplemental Nutrition Assistance Program
The SNAP has the unique ability to improve the health of food insecure Americans by
improving the quality of their dietary intake. In a white paper written by the Food Research and
Action Center (2017), the authors noted that at least 54 million people received SNAP benefits
for at least one month per year, and nearly 50% of American children will receive the benefit
during their childhood. The size of the program and its scope position it to impact both the
quality and health of participants, as well as reducing the cost of healthcare. The average cost of
healthcare was $1,409 lower for SNAP recipients compared to non-SNAP participants, noting
greater cost discrepancies when the participants had a chronic disease like hypertension or heart
disease (Food Action and Research Center, 2017). Berkowitz, et al. (2017) conducted a
retrospective cohort study linking the results of the National Health Interview study and the
Medical Expenditure Panel Survey for a total of 4,447 participants. Using a standard regression
analysis, they showed statistically significant data in favor of SNAP participants’ healthcare cost
being less than non-SNAP participants. Specifically, they showed that SNAP participants who
received Medicaid had a mean reduction in cost annually of $2,544; if disabled, the mean
difference was $3,958; when the SNAP participant had hypertension, the difference was $2,654;

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and $4,109 if the participant had coronary heart disease. Similar results have been noted in
additional studies.
Sachdev et al. (2019) conducted a systematic review looking into the outcomes of SNAP
recipients in relation to food expenditure, diet quality, and obesity. The review indicated that
there are many factors that influence diet quality among SNAP recipients, specifically, food cost,
family size, knowledge of food quality, access to fresh foods, transportation, and cultural factors.
The SNAP program is impacted by the geographic differences in food prices; the USDA does
not adjust the amount of money distributed by regional food costs. This has led recipients in the
South and Midwest to purchase greater amounts of fresh fruits and vegetables compared to the
Northeast because of food costs. Sachdev et al. (2109) noted a monthly increase in groceries of
$19.48 when a monthly $30 per capita increase in SNAP occurred. The increased spending
resulted in an increased purchasing of healthier foods, partnered with a decrease in food
insecurity. The impact of SNAP on body weight varied among men, women, and children. The
review noted a decrease in obesity of 0.2% when SNAP subsidized fruits and vegetables. The
quality of the diet and the impact it has on weight is related to the price of healthy food and the
individual’s ability to increase their intake to improve their health. The connection of healthy
foods with improved health invites the pursuit of the notion that food can act as medicine.
Food as Medicine
Individuals suffering from both acute illnesses and chronic diseases can benefit from medical
nutrition therapy, resulting in improvement in their health outcomes while lowering costs of
healthcare and food insecurity. Berkowitz et al. (2019) conducted a retrospective cohort study of
807 participants comparing medically tailored meal (MTM) recipients with those who did not
receive them. Using instrumental variable analysis, participants receiving MTM showed

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significantly fewer inpatient admissions at 0.51with a confidence index of 95%. The monthly
mean cost of healthcare was $3,838 for recipients of MTM compared to $4,591 in the non-
treatment cohort. Patients receiving MTM had far greater medical conditions compared to the
overall pubic, leading the authors to conclude that the combination of clinical, nutritional, and
social factors, as outlined in the SEM framework, intersects with MTM programs. Additional
studies reported similar results.
Palar et al. (2017) conducted an evaluation of MTM intervention to measure the impact on
nutritional, mental, and physical health, disease management, and healthcare utilization by
assessing t-test and McNemar extract tests that compared 72 participants. Statistically significant
outcomes included a decrease in food insecurity from 59.6% to 11.5%, and the quality of the
diets impacted several categories, including a decrease in fatty foods from 3.19 times per day to
2.21 times. Participants with diabetes’ BMI decreased from 36.1 to 34.8, while the overall study
cohort showed a decrease from 31.2 to 30.1. The study showed a significant reduction in
depressive symptoms from 7.58 to 5.84, as well as a decrease in binge drinking from 26% to
13.5%. Participants reported 34.6% of the time before the intervention of giving up healthcare
for food, with only 19.2% reported after the intervention. In a white paper evaluating the impact
of medically tailored meals, Berkowitz and Walters (2019) examined two different meal
programs, specifically, MTM and NTM. The cost comparisons between the two programs are
reflected in Table 1.

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Table 1
Cost Comparison of Medically Tailored Meal vs. Non-tailored Meal
Monthly Item MTM NTM
Monthly program costs $350 $146
Monthly cohort medical costs $843 $1007
Monthly medical costs without the program $1413 $1163
Monthly net savings $220 $10

Berkowitz and Walters (2018) results indicated a reduction in medical cost in both
groups, with the MTM group resulting in less emergency department, inpatient admissions, and
emergency transportation services compared to the control group. The NTM group had less
emergency department visits and emergency transportation services than the controlled group.
The use of meal delivery programs improved the healthcare outcomes and costs of recipients,
while the use of NTM programs improved outcomes for food insecure, relatively healthy
individuals. The use of MTM showed significant improvement in individuals with chronic
medical conditions, e.g., cardiovascular disease, diabetes, and cancer. Mozaffarin et al. (2019)
discussed the challenges and advantages of integrating MTM into mainstream healthcare.
Recipients of MTM showed significantly (49%) fewer inpatient admissions and 72% less nursing
home admissions, with a 16% relative reduction in healthcare mean expenditures over a two-year
period. The study did not identify the reason the MTM program achieved positive outcomes. The
research suggests several contributing factors collectively build on each other, nesting one upon
another to generate the environment that yields the desired outcome. This connection supports

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the use of the SEM in the evaluation of this problem of practice and the idea that food is
medicine.
Connecting Socio-Ecological Model and Food as Medicine Principles
The nutrition quality of the food consumed by an individual with an acute illness or
chronic disease impacts the degree of their disease progression. Cohn and Waters (2013)
investigated the impact that food has on poor nutrition and the health cycle. The benefits of MNT
support the idea that food as medicine, seen in practice as MTM programs, improves health
outcomes and cost. Cohn and Waters (2013) continue to connect the importance of these
outcomes to the demand on the current healthcare system and the urgency to identify cost-
effective policies to impact health at a national level. Food systems connect all levels of society
and represent a significant portion of the national economy (Hesterman, 2016). Change in food
incentive programs, like “Double Up Food Bucks” (http://www.fairfoodnetwork.org), which
match SNAP benefits spent at farmers’ markets and grocery stores on fruits and vegetables,
result in increased healthy eating while supporting local farmers. Hesterman (2016) concluded
that programs like this address affordability and access, as well as supply and demand,
illustrating the need to find creative solutions to feed our most vulnerable populations.
According to Prosperi et al. (2016), the food system is a social-ecological system, with
food security the main outcome, made up of biophysical and social factors associated through
feedback loops. Through the lens of a resilience and vulnerability framework, the study reviewed
the literature on sustainable food systems, noting the answers may lie at the intersection of
nutrition, the environment, and population health. Prosperi et al. (2016) further posited a focus
on nutritionists, agriculturists, public health professionals, educators, policy makers, and food
industry leaders, who hold the answers based on the scientific analysis, building on the idea of

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community-based programs driving policy to generate healthier behaviors, leading to improved
outcomes.
Subica et al. (2016) outlined an innovative approach to evaluate community-based health
promotion. The authors summarized the outcomes of the initiative to combat the social
conditions among children of color and the obesity epidemic, to include the over consumption of
calorie-dense, nutrient-poor food. The study identified food insecurity as a primary population
level risk factor. A three-lens approach—the social justice lens, culture-place lens, and
organizational capacity lens—framed the work. Subica et al. (2016) concluded the approach
supported grassroots organizations, community partners, and health professionals’ development
of health promotion programs in communities of color to address health disparities, support
community leaders to plan and operationalize their efforts, and integrate non-health related
activities to impact health change. In a literature review of food insecurity in the United States,
Gundersen and Ziliak (2018) reviewed the causes and consequences associated with the mature
body of literature and made recommendations for future research needs. Noted are the coping
mechanisms of low-income families and the effect of these mechanisms on avoiding food
insecurity, the unintended impact of them on health, and the causal relationship on food
insecurity and health outcomes. This confirmed the initial assertion that food insecurity is
considered a major health crisis in the United States due to the size of the problem and the
negative outcomes related to overall health and healthcare costs.
Prilleltensky (2012) affirmed that different types of social justice, specifically distributive
and procedural, impact the health of individuals within and across all socio-ecological levels.
The author suggested that a continuum exits between an individual who is thriving compared to
one that is suffering and that movement between the continuum is a condition of social justice,

38
political influences, and personal agency as outlined in Figure 4, Well-Being-Justice Continuum
(Prilleltensky, 2010).
The idea that individuals are embedded within interpersonal relationships, organizations,
and communities demonstrates the flow and impact that justice or injustice can have on the
individual, as well as the individual on the different levels of the system (Prilleltensky, 2012).

Figure 4
Well-Being Justice Continuum
Prevention
Individual pursuit
Avoidance of
comparision
Resilience
Adaptation
Downward
comparison
Critical experience
Critical action
Righteous
comparison
Oppression
Helplessness
Upward comparision
Well-being Continuum
Justice Contiuum
Thriving Coping Confronting Suffering
Optimal
Suboptiomal
Vulnerable
Oppressed

39
Theoretical Framework- Socio-Ecological Model
Bronfenbrenner (1979) defined the ecology of human development, also referred to as the
socio-ecological model, to explain the individual human as actively interacting with its
environment. The interactions are bi-directional, resulting in both the individual changing and
responding to the environment and the environment changing and responding in return to the
individual (Gardiner, 2018). Gardiner (2018) explained that the individual’s perception of their
environment impacts their behavior, while influencing how they experience the different layers
of their world. This model, best described as a nesting of the different layers of our environment,
referred to as the microsystem, mesosystem, exosystem, and macrosystem, supports the focus of
this problem of practice as outlined by the research questions.
Over the next few paragraphs, a review of SEM outlines its use in this study. The
microsystem is the center of the model, the closest to the individual representing structures to
include the immediate family and the home setting—this is where face-to-face interactions take
place and behaviors develop and are impacted by the individual’s social position (Gardiner,
2018). The physical environment impacts the development and interaction of the individual,
including the size of their living space, the number of people in their home, and the setting their
home is in, i.e., urban, suburban, or rural—all interact in how the individual establishes their
social behaviors, values, and basic human developmental skills (Gardiner, 2018).
The second system within the model is the mesosystem, which is the link between two
environments, the individual and the next layer of their world, for example, a child to their
school. The mesosystem is the knowledge, attitudes, and behaviors that connect the child to their
school (Gardiner, 2018). Each environment provides the individual with important knowledge to
use to maneuver their environment. In the example of a child and school, the parent teaches the

40
child the values and skills important to the family. The teacher provides the skills to motivate the
child to learn. Gardiner (2018) explains the mesosystem as the link between the two; the parent-
teacher conference represents the two environments working together to help the child improve
in school by gaining assistance from the parent on their study habits at home. In the case of
medically tailored meals, it is the interaction between the patient, the dietitian, and staff of ND
that connects the individual to their environment through values and skills related to food and
wellness.
The exosystem represents the third layer from the individual, which may not have direct
impact on the individual; however, it will interact with their environment. Continuing with the
child example, the exosystem is the healthcare system that supports the child and their family.
The healthcare system supports the child’s family and represents an impact on the quality of the
family’s life and establishes social norms that impact and interact with the child. If the system
provides screenings and free healthcare checks, that creates an environment that promotes the
value of preventative healthcare to the child and their family (Gardiner, 2018).
The last system to review as part of SEM is the macrosystem. This layer is the most
complicated because it represents the accumulation of all the knowledge, values, and principles
of the different levels of the culture in which the individual exists (Gardiner, 2018). The
macrosystem provides the structure for the norms of behavior for the culture or society the
person lives in. This layer impacts all the previous layers, making it the most complex. Gardiner
(2018) explains that Bronfenbrenner’s model focuses on the idea that each system interacts with
each other and the individual, making the relationship iterative, and ever changing.
The socio-ecological model enhances our understanding and measurement of health-
related behaviors through the relationship of the individual and the social determinant of their

41
environment (Ma et al. 2017). Multiple studies have concluded that SEM informs us on the
development of the individual’s behaviors based on the four systems represented by the
individual (micro), their interpersonal relationships (meso), values, beliefs (macro), and their
community (exo) to provide the holistic setting to review the impact of food insecurity, chronic
disease management, and the use of food as medicine (Ma et al. 2017, cdc.gov/violence
prevention,2020, Lee et al., 2017). Lee (2017) provides evidence of successfully utilizing the
socio-ecological model to assess community interventions in low-income inner-city African
American communities associated with best practices related to nutritional programs. Gundersen
et al. (2018) discusses the need to further explore the distribution of the food system and its
influence on food insecurity, as well as understanding the coping behaviors of food insecure
families in underserved areas. These questions clearly link the multi-level approaches to the
development and understanding of behavior development based on the environment in which the
food insecurity is occurring (Lee et al.2017). Using this model to set the stage for an
understanding of the impact the economics or the macro system has on this problem is worthy of
further review.
Conceptual Framework
The conceptual framework used to investigate this problem nests the ecological model
within the key concepts of food insecurity, disease management, and food justice and is
illustrated in Figure 5. The outer boxes represent the key concepts of this study as they flow from
one to another, with the inner circular shapes highlighting the ecological system at play and the
inter-relationship of them to each other. The microsystem is the food insecure patient with a
chronic disease. The next level is the mesosystem, represented by the management of the disease
and the knowledge of the individual to impact change within their environment. As the layers of

42
the system build upon each other, the exosystem represents the individual’s access to healthcare
and community resources like SNAP. The most complicated layer is the macrosystem, with this
last piece is represented by access to food, the norms and behaviors of the patient’s environment
that impact and determine their interactions with environmental and governmental systems. The
SEM effectively provides the setting to evaluate the impact of health by the relationship to the
individual, the community, and the environment. SEM allows for the inclusion of physical,
social, and political perspectives and their impacts on the problem under review (Gardiner,
2018). Additionally, SEM accommodates the inclusion of policy into the evaluation of the
problem of food insecurity and chronic disease management through the lens of the macrosystem
(Gardiner, 2018).

43
Figure 5
Conceptual Framework

Summary
The literature review provided several ideas that build one upon the other to create the
foundation of the problem of practice. Starting with the broadest concept of social determinants
of health and the inclusion of food insecurity as a determinant of health and its role in population
health models (Prosperi et al., 2016), the linkage of poverty, race, and ethnicity begins to narrow
the focus and identify the impact food has on specific demographic groups and their overall
Norms & Behaviors of Society
(Macrosystem)
Environmental & Governmental systems
Access to Healthcare
(Exosystem)
Access to resources
(SNAP,Not for Profits, Insurance)
Disease Management
(Mesosystem)
Knowledge to impact change
Food insecure person with a
chronic disease
(Microsystem)

44
wellness. The next main idea connects the relationship of food, chronic disease, and increased
healthcare costs. The idea of food access explores how food availability impacts food insecurity
because of location and costs in urban and rural areas. Focusing on the next layer of the system,
the idea of nutrition guidelines and the intersection through food pantries illustrate the impact
these community resources provide to this vulnerable population (Hesterman, 2016). Beyond the
provision of food, the idea of the quality of the food available versus the quantity of the food
connects the idea of food as medicine (Simmet et al., 2017). The final idea continues to narrow
the focus of the literature review to connect food and medical nutrition therapy in the treatment
of ill, food insecure patients with medically tailored meals. The review encompassed broad
topics that support the problem of high prevalence of food insecurity in low SES patients with
chronic diseases and the significant health risks they represent.

45
Chapter Three: Methodology
This study addresses the problem of food insecurity and the increased effect it has on the
management of chronic diseases. Patients who are high hospital utilizers, defined as people with
“complex health and social needs with frequent hospital admissions,” have been found 30% of
the time to be food insecure (Braitman, Cooblall, Hares, Phipps, & Singletary, 2016, p. 414).
Wang et al. (2015) confirms the relationship between food insecurity and the poor management
of hypertension, diabetes, HIV disease, and depression, which demonstrates that this is a
problem. This problem is important to address because the relationship of food insecurity and
health outcomes impacts the overall healthcare system (Garcia, Haddix, & Barnett, 2018).
Understanding the behavioral, social, and environmental significance of social determinants of
health is a major contributor to keeping people healthy. Food insecurity is a social determinant of
health and plays a role in population health strategies (Health Research & Educational Trust,
2017). The purpose of this study is to understand the relationship and impact of home-delivered
medically tailored meals to seriously ill, food insecure patients, in conjunction with
individualized nutrition therapy on the food insecurity cycle. This chapter outlines the research
questions, study design, setting, data collection, and analysis. The participants, instrumentation,
and interview protocols are outlined to include the validity and reliability of the study, as well as
the ethical issues associated with the conducting of the research.
Research Questions
1. What is the relationship between medically tailored meal recipients, food
insecurity, and chronic disease in conjunction with individualized medical
nutrition therapy?

46
2. What are the knowledge and motivational influences related to low
socioeconomic status patients with chronic diseases and how they meet their
hunger needs?
3. Following the receipt of medically tailored meal delivery services, how do patient
attitudes and behaviors impact their relationships, social interactions, support
groups, and cultural context?
4. How do organizational influences impact low socioeconomic status patients with
chronic diseases and meet their nutritional needs?
Overview of Design
A qualitative approach was used to support a transformative worldview. This approach
supported the use of open-ended questions, which allowed for the identification of themes and
patterns within the marginalized population under review (Creswell, 2018). The study sought to
examine the food insecure, chronically ill patient through individual interviews when in receipt
of medically tailored meal delivery services and medical nutrition therapy for a minimum of 6-9
months. The participants were English-speaking, had a chronic disease, and were food insecure
as defined by the Hunger Vital Sign screening tool(childrenshealthwatch.org). Interviews with
the dietitians providing the clinical services were conducted to provide a different perspective
into this population. The intent was to triangulate the different data sources to increase the
validity of the study. Additionally, the use of rich, thick descriptions of the patients interviewed,
with bias clarification, was part of the validity strategy and has been thoroughly described
previously (Creswell, 2018). The use of the two different interview groups provided a way to
increase the consistency between the results obtained and the information collected (Merriam &
Tisdell, 2016).

47
For this study qualitative data was collected through face-to-face interviews using open
ended semi structured questions. The aim was to invite the participants to share their ideas,
experiences and opinions on the topic of receiving medically tailored meals and nutrition
therapy. The researcher sought to understand, the perspectives of the participants and the impact
medically tailored meals had on this population (Merriam & Tisdell, 2016). This approach
matches with the research questions, specifically, the intent to learn about strategies, attitudes,
and behaviors of the individual interviewed in addition to understanding the impact and role of
this service on the food insecure chronically ill person. The interview protocol supported the
conceptual framework that explores the different roles each system (microsystem, mesosystem,
macrosystem, and exosystem) plays regarding the problem of practice. The use of a semi-
structured interview supported the need for structure in the form of demographic questions, for
example age, medical history, etc., contrasted with the use of open-ended questions in a less
formal interview. The qualitative nature of the interviews allowed the interviewer to explore
emerging ideas based on the respondent’s answers, and these methods have been thoroughly
described previously (Merriam & Tisdell, 2016).
Research Participants
The study included ten patients and the dietitians who provided clinical services to the
population through ND. Eligible participants were in receipt of services from ND for a minimum
of 6-9 months to ensure they experienced at least two encounters with the dietitian. The
participants were adults (greater than 18 years old), inclusive of all gender identities, and had an
acute or chronic illness. Inclusion of the dietitians was important in the study to access the
impact that MTM had on the attitudes and behaviors of the participants, as well as evaluating the
participants’ abilities to make healthy food choices. This was important to support research

48
question one, “How do medically tailored meals impact patients with food insecurity and chronic
diseases?” The topic of food insecurity can be considered embarrassing by some. The
interviewer had to be sensitive to the circumstances associated with this social situation. The
patient interviewed may be harmed if the study protocol is not sensitive, professional, and
respectful of the individual’s needs and circumstances. The patient and clinical staff may be
harmed if the information obtained during the interview is not kept confidential. This study was
reviewed and approved by the Institutional Review Board for Human Subjects at the University
of Southern California.
Research Setting
Video conferencing was offered to both the clients and the dietitians; if preferred, the
telephone was offered. As a result of the Coronavirus disease2019 (COVID-19) pandemic, this
setting allowed clients and dietitians to participate in the research while maintaining personal
safety precautions. The researcher contacted the participants, agreed upon the time and date of
the interview, and ensured the participant was familiar with using a video platform and had
access to a computer or phone to facilitate the interview.
Data Sources
Access to the study participants was obtained through the collaboration of ND staff. The
study used a random sampling of patients receiving the services of ND, medically tailored meal
delivery with nutrition services. The study included ten patients and the dietitians that provide
clinical services. The participants were English-speaking, had a chronic disease, and were food
insecure defined by the USDA Hunger Vital Sign screening tool. The researcher conducted
qualitative interviews with the patients and the dietitians of ND using either a video conferencing
platform or the telephone. The interviews of the patients allowed for observation of their

49
knowledge and ability to apply the nutrition information, increasing credibility and validity of
the process (Creswell & Creswell, 2016). The dietitian interviews provided the clinician’s
perspective of the barriers, knowledge, and motivation of their clients, and potential
opportunities for improvement from a system perspective.
Instrumentation
The qualitative nature of the interview allowed the researcher, as the interviewer, to
explore emerging ideas based on the respondent’s answers (Merriam & Tisdell, 2016). The
interview enabled the researcher to learn things that cannot be observed, and the use of a semi-
structured interview provided insight into both staff and patient observations in support of the
conceptual framework (Patton, 2002). The use of a semi-structured interview also supported the
need for structure in the form of demographic questions, e.g., age, medical history, employment
status, etc., and contrasted with the use of open-ended questions in a less formal interview. The
demographic questions were asked first and were asked in an open-ended manner. The goal was
to use the demographic questions to establish a rapport with the patient while beginning to
understand how they see themselves as related to others (Merriam & Tisdell, 2016). The semi-
structured interview included 24 questions that supported the research questions. The questions
started out broadly by asking how the patient obtained food before receiving the services of ND,
then progressed to learn about the patient’s feelings and beliefs about the connection of food to
their health and disease management. The questions went on to identify barriers the patient may
have experienced in accessing food, as well as understanding the knowledge the patient had
regarding their food budget and how to prepare healthy food. The topics moved on to the impact
MTM had on the patient emotionally and physically. The interview ended with the patient

50
explaining how they felt now compared to before they received MTM and why they think they
felt that way.
The dietitian interview consisted of thirteen questions, which included identifying
barriers their patients experienced in meeting their nutritional needs. The dietitian was asked to
share observations they made regarding patient behaviors associated with stretching their food
budget, use of community resources, and general nutrition knowledge. Lastly, the dietitian was
asked to identify the characteristics of ND that they felt positively and negatively impacted the
clinical outcomes of their patients. The interview questions for the patients and the dietitians are
found in Appendix A.
Data Collection Procedures
The primary researcher conducted qualitative face-to-face interviews using open-ended
semi-structured questions. The patients were invited to share their ideas, experiences, and
opinions on the topic of receiving medically tailored meals and nutrition therapy. The aim of the
study was to understand the perspectives of the participants and the impact medically tailored
meals had on this population (Merriam & Tisdell, 2016). This approach matches with the
research questions, specifically, what are the knowledge and motivational influences related to
low socioeconomic status patients with chronic diseases and how they meet their hunger needs?
The vantage point of the dietitian interview provided two benefits: first it created an
opportunity to validate the comprehension of the participants in regard to their ability to make
healthy food choices by a nutrition professional, and it provided a different frame to observe the
strategies and behaviors of this population. In addition to understanding the impact and role of
this service on the food insecure, chronically ill person, the interview protocol supports the

51
conceptual framework that explores the different roles each system (microsystem, mesosystem,
macrosystem, and exosystem) plays regarding the problem of practice.
The patient interviews were conducted first, followed by the dietitian interviews. This
design was used to increase the triangulation of the data and the validity of the information
obtained from the patients. The interviews took place in the fall semester of 2020. The patient
interviews took 30-50 minutes. The dietitian interviews took approximately 30 minutes. The
patients were selected with the assistance of the ND staff in a random manner. All dietitians
working at ND were invited to participate in the study. The interviews were conducted by video
conferencing or telephone. The interviews commenced with interviewees being ask for
permission to record the interview. The interviewees were each coded with a numerical
pseudonym to protect their identity. The list of the numerical pseudonyms with the actual
identify of the patients and dietitians was placed in a separate compartment that was locked,
secured, and suitable for the reliable storage of valuables. The recordings were transcribed with
the use of an online transcription service, such as Rev.com. The researcher took field notes
during the interviews. Throughout the interviews and immediately following the completion of
the interview, the researcher coded their notes and then reviewed and coded the transcript of the
interview to identify themes and concepts. The patients were given a $25 gift card for
participating in the research study interview.
Data Analysis
The data analysis took place as the data was being collected. The review of the first
interview transcript informed subsequent interviews (Merriam & Tisdell, 2016). The researcher
utilized observer’s notes throughout the interview process to capture ideas and themes that arose
during the interviews of both the patents and the dietitians. The interview questions and

52
formatting were adjusted based on previous interviews and observer notes. Additionally, the
researcher regularly looked back to the original research questions and the interrelationship to
the conceptual framework to ensure alignment. Interviews were conducted until a point of
saturation was achieved within the allotted time period of the study. Throughout the data
collection, the researcher utilized the act of coding to begin conceptualizing the answers to the
research questions through inductive and deductive reasoning (Merriam & Tisdell, 2016). This
process yielded data units that were analyzed in relation to the research questions and in
comparison, to each other. The data analysis was supported with a qualitative software program
to enhance the coding process. The use of winnowing of the data was applied to aggregate the
findings into themes, allowing the management of the dense, rich content that the interviews
yielded (Creswell & Creswell, 2018).
Method 1—Simultaneous Procedures
The researcher utilized the previous interview to inform future interviews. This included
taking notes or memos during and after an interview to be used as part of the final analysis
(Creswell & Creswell, 2018).
Method 2—Coding of Data
The researcher organized the data into themes or categories. The themes were identified
during the active interview and then fine-tuned as part of the data analysis process. Coding was
done both manually and supported with the use of the qualitative software program, Atlas.ti.com.
Method 3—Winnowing
The researcher determined the number of themes needed to best aggregate the data
obtained after the coding was completed. The winnowing process involved a review of the code
frequencies and the associated themes. The codes with the lowest number of frequencies were

53
disregarded to provide a greater opportunity to focus on the research questions (Creswell &
Creswell, 2018).
Method 4 —Qualitative Narrative
The themes and descriptions were presented through narrative passages to include
frequency data. The passages included quotes from the participants, observations from both the
patients and the dietitians, and any interconnected concepts that emerged (Creswell & Creswell,
2018).
Validity and Reliability
Interviewing both the recipients of ND services and the clinical staff that provided the
nutrition therapy of the recipients was part of the study, designed to increase the validity and
reliability. The use of rich, thick descriptions of the patients interviewed, with bias clarification,
was an additional part of the validity strategy that aimed to increase transferability (Creswell,
2018, Merriam & Tisdell, 2016). The third validity strategy was the researcher’s positionality,
through critical self-reflection, to include assumptions, worldviews, and technical knowledge.
The use of the two different interview groups provided a way to increase the consistency
between the results obtained and the information collected (Merriam & Tisdell, 2016).
The above outlined approach aligned with the research questions’ goals of understanding
strategies, attitudes, and behaviors of food insecure, chronically ill patients and the role food and
nutrition therapy play in their overall healthcare plan. The concept of establishing a working
hypothesis based on the specific situations observed by the researcher allowed for extrapolation
of ideas to inform future decisions (Merriam & Tisdell, 2016). The current approach supported
the conceptual framework outlined by seeking to understand the recipients of the service through
both their perspective and through the frame of the clinical professional. These different

54
perspectives reflected the inter-relationship of the different systems at play between the
microsystem, mesosytem, exosystem, and macrosystem (Gardiner,2018).
The Researcher
The positionality of the researcher was critical to understanding the underlying ethics of
this study (Creswell & Creswell, 2016). As a dietitian with a strong interest in food insecurity
and significant experience within the field of study, a certain amount of bias was present during
the process. As the interviewer, it was critical to establish a rapport with the interviewee, as well
as maintaining neutrality to the responses obtained (Merriam & Tisdell, 2016). The research
served several different interest levels, starting with Nutrition Delivered as a non-profit
organization, and the outcomes helped their board of directors to promote the mission of the
organization. The outcomes served the ND staff to understand the impact of their services on this
population. ND may be harmed if the outcomes do not support the mission of the organization. It
is hoped that the outcomes will serve the larger community of hunger workers such as Feeding
America and Food Research and Action Center (FRAC) to highlight the impact of medically
tailored meal delivery in this population. The researcher’s interest as a student and nutrition
professional was served by completing this study to obtain a doctoral degree, to increase the
knowledge of food insecurity, and to continue work to reduce food insecurity.
Ethics
In developing the information sheet for the study, a disclosure regarding the purpose of
the study was included to clearly inform the participants of the voluntary nature of their
participation, the intent of the research, permission to record the interview, and outline the
confidentiality of the data collected. The researcher used a cloud service provider to store all
personal data, which is accessible on a fingerprint-enabled laptop. The product used was

55
Microsoft OneDrive with a personal vault enabled, utilizing a two-step verification. As noted in
the data collection portion, the numerical pseudonyms list was stored separately from the
electronic storage of the dissertation documents in a locked and secured storage unit suitable for
valuables. An ethical code of conduct was utilized during the study to ensure professionalism
within the context of the interviews and contact with the patients and the staff of ND (Creswell
& Creswell, 2016). The code stressed the importance of respecting the cultural, religious, gender,
or other norms of the participants, while not pressuring them to participate. The researcher was
not connected to ND as an employee or donor; as a student, the researcher’s role should not
suggest any power or influence over the participants both patients and dietitians (Merriam &
Tisdell, 2016).

56
Chapter Four: Findings
The purpose of this study is to understand the relationship and impact of home-delivered
medically tailored meals to seriously ill, food insecure patients, in conjunction with
individualized nutrition therapy on the food insecurity cycle. For this study qualitative data was
collected through interviews using open-ended semi-structured questions, inviting the
participants to share their ideas, experiences, and opinions on the topic of receiving medically
tailored meals and nutrition therapy. The qualitative nature of the interview allowed the
interviewer to explore emerging ideas based on the respondents’ answers (Merriam & Tisdell,
2016). The findings were viewed through the theoretical framework of the socio-ecological
model. The findings were then organized by observed themes and categorized by the conceptual
framework to include the recipient of medically tailored meals (microsystem), the knowledge to
impact change and disease management (mesosystem), access to resources (exosystem), and
environmental, governmental, and societal norms (macrosystem). The results and findings were
reported using the four sections of the socio-ecological model and linking them to the four
research questions
Multiple interviews were conducted of recipients of MTM and the dietitians who
supported the program, informing the researcher about strategies, attitudes, and behaviors of the
individuals interviewed, including the impact and role of this service on the food insecure,
chronically ill person. The recipients of MTM were interviewed first to allow the researcher to
gain insights into theme development and evolve the interview questions as necessary, followed
by the dietitian interviews. A total of 25 clients were called by phone, 12 clients did not answer,
three clients indicated they were not interested in participating and 10 clients agreed to be
interviewed. All interviewees were offered their choice of using Zoom or the telephone for their

57
interview due to COVID-19 pandemic restrictions on face-to-face interactions. The interviews
lasted anywhere from 30-50 minutes.
Participating Stakeholders
The ten patients interviewed were randomly selected recipients of MTM for a minimum
of six months, English-speaking, and included nine women and one man. Their ages ranged from
61 to 87 years old, with the mean age being 69.8, the median age of 74, and the mode was 64
years old. The study population is older than the overall demographic of ND’s population,
specifically noted as 87% being over the age of 50. When the patients were asked to identify
their race, 70% indicated Caucasian, 20% stated African American, and 10% said Native
American. The entire sample indicated their work status as “not working.” When asked if they
received SNAP benefits, 60% indicated they did receive SNAP, while 40% did not receive
SNAP benefits at the time of the interview. Patients were asked the number of people they live
with: the mean response was 1, the median was 3, while the mode was 0. There was a range of 0-
5, with one patient living with five other people. The patients were asked to share their medical
history, which included AIDS, asthma, cancer, cardiac conditions, chronic obstructive
pulmonary disease (COPD), diabetes, hypertension, multiple sclerosis (MS), overweight/obesity,
and renal failure (dialysis). The majority (60%) of the patients had hypertension, followed by
50% of the patients having diabetes. A full 100% of the patients indicated having more than one
diagnosis. All the diagnosis of the study group are reflected in the overall demographics of ND’s
clients. Nine of the interviews were conducted over the telephone and one patient requested a
video conference using Zoom. All participants agreed to their interviews being recorded, as well
as answering all questions asked.

58
Nutrition Delivered employed six registered dietitians who worked to support the MTM
program at the time of the study. All six RDs were offered and agreed to be interviewed.
Demographic information was not obtained specific to the RDs. All RD interviews were
conducted using video conferencing (Zoom).
Determination of Themes
A total of sixteen interviews were conducted, representing ten patients and six dietitians.
Saturation was determined when greater than 85% of the respondents discussed similar topics,
leading to five major themes, as seen in Table 2. The themes were determined using open and a
priori coding, followed by the use of axial or second level coding. The five categories or
emerging themes were: access to resources, connection of healthy food to recovery from illness,
connection of MTM and nutrition therapy, education’s effect on food choices, and the effect of
the RD on food choices and health. The use of the two interview cohorts allowed for the
triangulation of responses to similar questions. A total of 17 codes were identified as part of the
data analysis process and can be found in Appendix B.

59
Table 2
Topics Discussed by Patients and Dietitians Leading to Themes
Interviewee Access to
Resources
Connection
of Healthy
Food to
Recovery
Connection
of MTM &
Nutrition
Therapy
Education
Effect on
Food Choices
Effect of RD
on Food
Choices,
Health
Patient 1 X X X
Patient 2 X X X X X
Patient 3 X X X X X
Patient 4 X X X X
Patient 5 X X X X X
Patient 6 X X X X X
Patient 7 X X X X X
Patient 8 X X X X
Patient 9 X X X X X
Patient 10 X X X X X
Dietitian 1 X X X X X
Dietitian 2 X X X
Dietitian 3 X X X X X
Dietitian 4 X X X X X
Dietitian 5 X X X X X
Dietitian 6 X X X X X

Results and Findings for Microsystem Causes
The first section reviews the findings and themes related to microsystems and includes
the food insecure person with a chronic disease. Limited access to healthy food influenced the

60
individual patients interviewed. Their access was limited because of funding, awareness of
resources, mobility, and physical proximity to food stores
Financial Resources
The patients and the dietitians shared the barriers encountered to buying healthy food as it
related to having enough money as a way of life. The challenge of limited financial resources
was reflected in nine of the ten patients interviewed, and five of the six dietitians identified it as a
barrier for their clients. Patient 5’s responses captured the difficulty encountered when asked,
“How would shopping make you feel? ”
It was hard because I always had to add up everything as I went to make sure I didn't go
over the money I had. But that’s, like, second nature to me. So, it’s in a sense, it’s hard
because you can’t get everything you want or need, but I’m used to it. I mean, you get
used to it after a while and you just - it - it becomes part of your life, and you just accept
it, and either you’re gonna be miserable or you’re gonna enjoy what you can do.
Patient 5 shared how they decide what food to buy: “Basically need. We don’t have a lot of want.
So, it’s, it’s more need. It’s what’s gonna get us through as inexpensively as possible and still
have good quality.”
The effect of limited financial resources impacts food choices, including the ability to
purchase the food they want in lieu of the food they need. The knowledge to meet one’s
nutritional needs with limited resources is a gap that the dietitian fills. The individualized
nutrition therapy provides the opportunity for the patient to learn how to stretch their food budget
while increasing the amount of healthy food in the home. This finding led to the theme of
awareness of resources.

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Awareness
In addition to limited financial resources, awareness was highlighted by all six dietitians
as another contributing factor to meeting the hunger needs of their patients. Dietitian 4 shared her
observations, which outlined an opportunity as an RD to fill an identified knowledge gap.
I think most of the patients that we have, a big barrier for them is financial income is
generally not enough for them to meet nutrition needs, or at least that is what they think.
We have a question we always ask our patients is, do you eat enough fruits and
vegetables daily? And some of them just say, ‘No, I can’t eat fruits and vegetables daily
because I just can’t afford it.’ And a lot of them don’t know, and it’s also lack of
education because then we come in and we say, ‘Well, maybe you could start buying
frozen fruits and vegetables that are typically more affordable, and you would be able to
reach that daily intake of fruits and vegetables.’
This observation was repeated by the other dietitians; simply put, the consensus was that
getting food into the home is a big challenge. The ability to influence the patients’ shopping is
seen by Patient 5’s response to, “What types of food do you typically buy?” She demonstrated
the idea of purchasing frozen versus fresh foods as noted by Dietitian 4, “Frozen vegetables
because they keep. Some fresh vegetables, but not a lot ‘cause they don’t keep.”
Dietitian 4’s observation regarding knowledge versus awareness was significant in
appreciating the importance of understanding where the food insecure, chronically ill person and
their readiness or ability to accept nutrition education was:
As you know, our clients shop and cook for themselves. That’s a huge limitation to
meeting your nutritional needs. Knowledge can be another one. Lack of awareness is
connected, but it’s not exactly the same. Sometimes with my clients, the only room that I

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see for change is bringing up the awareness, right? Not even the knowledge, just the
awareness.
The dietitians’ relationship with the patients is significant. The dietitians’ ability to assess
their patients’ nutritional needs and the patients’ readiness and ability to accept education,
comprehend it, and demonstrate the ability to implement education into their lifestyles represent
a core component of the MTM program. In addition to funding and awareness, mobility is noted
in contributing to getting food into the home.
Mobility
The impact of mobility cannot be underestimated. The challenges of getting to the food
store were outlined as a struggle by all ten patients interviewed. The population interviewed lives
within a large Northeast urban setting. Walking is the most common way to get to the store. The
transporting of food from the store to the home is noted by all as a barrier or hurdle to accessing
healthy food. Patient 6 shared how they transport their food.
Well, I’m using my walker, and I’m limited to what I can pick up, because I have to
make choices where, if I want certain things in say one store, I can’t pick up much in the
other because, the walker ain’t that big, and unless I got somebody with a wagon, or one
of those I call them wheelies where you put stuff, and it’s like a canvas bag. I can’t pick
up much of anything. I only go out once a day if I’m going shopping. I come back, and
then I’ll do whatever the next day. I can’t seem to do too much in one day anymore, not
like I used to years ago.
The struggle to get the desired food from the store back to the home while managing mobility
challenges was described by all ten patients interviewed. Patient 9 summarized a common

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feeling shared by many of the patients. “I do the best I can, right. I have a cart. I have the bags; I
do the best I can.”
The difficulty in getting food affected how some patients felt about shopping. This barrier
affected the emotions the patients had surrounding eating healthy food. The idea that eating
healthy is too hard or too expensive was impacted by the RD. The role of the dietitian to help
reduce this barrier is seen as a positive asset to this program, in addition to the delivery of
nutritious meals to the patients’ homes, reducing the amount of shopping needed while on the
program. Patient 2 shares her feelings about food shopping:
Oh well, I used to like going food shopping, now I don’t. It just takes me a long time
because I take, I look at how much sodium it got in it and how much sugar it got in it. So
it takes me a while to shop and right now it’s hard for me with the walker and the
distance.
Many of the patients interviewed live alone and due to their illness may have an aide. The
presence of an aide is noted often as it relates to getting food into the home. For the patient with
significant limitations on their ability to move/walk, the aide did the food shopping. This
presents as an asset and a challenge. The benefit is that that someone is shopping for the patient
and getting food into the home. The challenge is the disconnect between what the patient wants
and what the aide buys. Many patients explained making a list of the basics for the aide to
purchase. The patients shared the inability to see what is on sale or something that is new that
they may have wanted to try as a frustration. The patients were limited by what the aide can
transport, since the aide is walking to the nearest store. In all cases of those interviewed, the
patient or the aides are shopping in grocery stores or supermarkets. Patient 10 shared her
response when asked if there are barriers to getting food:

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Are there barriers? I mean, the aides are only able to get so much stuff. Pick up 12 items,
so that’s... bread and eggs, just those regular things. You can’t get anything big. You
can’t get something for the freezer to make yourself a meal.
Frustration and resignation are noted in the patients with aides doing their shopping. The ability
to get the basic food items into the home is important to them and allows a balance between the
emotions. For the patient that had previously enjoyed shopping and cooking, it is a loss. Patient 5
shared her feelings about cooking in the past:
Well, I don’t prepare it anymore because I have problems with my eyes. I used to be the
cook in the house and I always enjoyed cooking for everybody. And I enjoyed giving it to
them and seeing the smiles and seeing them reach for it. It made me very happy.
Physical Proximity
The location of affordable food was discussed by several patients, as well as being
identified as a barrier by the dietitians. The concept of a food desert was not described
specifically. All of the patients interviewed (10/10) indicated they shopped in a supermarket and
seldom had to rely on small local stores like bodegas. The major barrier noted was the distance to
an affordable supermarket, and, keeping in mind they all live within a city, the challenge of
transporting their groceries was noted, even if mobility issues were not indicated. This barrier or
challenge could be an inherent challenge of city life; however, it seemed magnified for a
chronically ill patient with limited funding. Patient 5 shared their thoughts when asked where she
goes to use her SNAP benefits.
In the neighborhood, which, in this neighborhood, there aren’t very many supermarkets.
There are only two. And they’re very expensive. We don’t have the resources to go
uptown where it’s cheaper. So, we shop in the neighborhood.

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Another patient noted the challenge of getting to a supermarket because he acknowledged that
although it was cheaper to go uptown, he could get more food for his money.
I take the bus, I do, I take the train. But you never know if there’s someone that’s going
to help me bring that basket up the stairs. So, I decided to stop doing that. I’ll take the bus
and then the bus can pick me back, I take the train out, and get a transfer to take the bus
back. It’s in the perfect place for that.
Lastly, the majority of the dietitians validated what the patients interviewed expressed
regarding the challenge of being both food insecure and without physical proximity to
affordable, healthy food. Dietitian 4 shared the following when asked to describe the impact food
insecurity had on their patients.
A lot of them sometimes just say, ‘I eat what I get and it’s generally not what I want to
eat.’ So, this morning, for example, I just had a client that said, ‘I don’t have enough
money, and I just find myself eating chips and salsa as my meal for the day. It’s not
having enough money to buy food, but it’s also not having food in your proximity. So,
this was also something that she was having issues with because of course she has
mobility issues, probably not a car to go to a grocery store nearby, she would have to
walk there or take public transportation. And especially now during these times, where a
lot of our patients are immune-compromised, they don’t want to go out and they don’t
want to take the train to go get food.
When assessing the problem through the lens of the microsystem, specifically the patient,
the answer begins to form to research question one, “What is the relationship between medically
tailored meal recipients, food insecurity and chronic disease in conjunction with individualized
medical nutrition therapy?” The relationship of the patient and the management of their chronic

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disease is impacted by the barriers they encounter individually. The intersection of MTM with
this population is minimizing the barriers by reducing the effect that funding, awareness of
resources, mobility, and physical proximity to food stores has on the individual. The answer is
also forming to research question two< “What are the knowledge and motivational influences
related to low socioeconomic status patients with chronic diseases and how they meet their
hunger needs?” The data showed that a lack of access to healthy food and awareness surrounding
nutrition is a recurring observation with the interviewed population and was validated by the
dietitians’ observations. Future focus on knowledge of access and nutrition, as well as the
motivation to meet their health needs, will prove valuable based on the data.
Results and Findings for Mesosystem Causes
The data viewed through the mesosystem incudes looking at the interpersonal
relationships of the individual who is food insecure with a chronic disease. These relationships
are seen through the impact of knowledge to impact change regarding their disease management.
The findings focus on the relationship of the patient to ND and the services provided, as well as
their prior ability to connect healthy food to recovery from illness.
Connection of Health to Recovery from Illness
All ten of the patients interviewed agreed there was a connection between food and
health. This consensus was seen in quotes such as the following to the question, “Some people
would say having the right type of food can increase your recovery from being sick; what would
you say?”
Patient 1: “I absolutely know that that’s absolutely the case.”

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Patient 2: “I believe that 100% really because some food you shouldn’t be eating to start
with and keep eating the wrong things and sometimes turn around and do the right things
you will feel better.”
Patient 5: “I would say that’s true.”
Patient 6: “Better diet, better health!”
Patient 8: “I’d say having the right food keeps me in a good frame of mind.”
Patient 9: “Having the right type of food can help your recovery from being sick by
50,000 times.” When asked to confirm they agree with the statement, the patient
responded, “Yes. 50,000 times over!”
This connection is a positive finding in relation to their knowledge of the value of MTM
over other meal delivery services. Many of the patients interviewed acknowledged they had
received Meals on Wheels in the past. The inclusion of nutrition therapy in the MTM model is
supported by a patient cohort that understands and values the importance of nutrition. This is
seen in the responses to questions about the effect both the dietitian and the MTM program had
had on them. Patient 8 clearly connected the concepts together, sharing that what she eats and her
health are interchangeable. “It is my health. What I feed my body contributes to my well-being.
I’m very aware of that, and I make those decisions thoughtfully. I always make sure I have more
fruits than I do anything else.” When Patient 8 was asked if she felt different physically since
receiving the meals from ND, she confirmed, “from the day I first got them, I started feeling
better.” This was a familiar response by the majority of the patients. In addition to the positive
finding of the food-to-health connection, an overwhelming finding is the sense of gratitude from
the patients.

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Gratefulness
The idea of gratefulness is seen when patients are asked about their feelings associated
with receiving the meals compared to before they received the meals. The overwhelming
response was that of being thankful and grateful, specifically, nine out of the ten patients
interviewed. Many equated the receiving of these meals to God’s work, and it provided them
with peace of mind. This was a significant positive finding in respect to the patient’s relationship
to the organization, leading to the organization’s ability to impact change through knowledge of
their population. Patient 1 shared her thoughts: “The organization is just - I think they’re
incredible. They really, really are. They’re amazing.” A similar feeling was shared by Patient 6,
who stated her thankfulness this way: “I have reduced stress, I know that I’m getting good food
and that my nutrition is complete, which leads to meeting my health needs.” The sentiment of
being thankful because of a reduction of stress was echoed by Patient 8 in this way, “I worry a
lot less with Nutrition Delivered because it’s something I have to put my head to and think about,
am I getting proper nutrition? I know I am. And that’s a good feeling.”
The feeling of contentment was again seen in Patient 10 when asked about feelings they
had now that they didn’t have prior to receiving MTM.
I feel that in my mind, I don’t have to get stressed out trying to figure out what to get and
how much of each thing. I just don’t need that. I felt relieved that this is just there, I can
just know that I’m going to have that.
The idea of gratefulness was prominent within the population interviewed. The dietitians shared
that they encounter a variety of opinions within the patients they treat. Dietitian 5 shared the
following: It’s always so funny, like two people might get the same thing and they just look at it

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so differently. But sometimes people are very, very, very grateful and then sometimes people
treat it as an entitlement.”
The idea of cooking for thousands of clients is an enormous task. Meeting both the
nutritional needs, as well as making food that pleases everyone, is a tall order. The effect that
flavor has on the compliance of patients is the next cause within the lens of the mesosystem.
Flavor/Taste on Compliance of Patients
When working within the field of food and nutrition, the challenge is often to find the
right amount of flavor and taste while meeting the nutritional restrictions of specific diets like
low sodium and low cholesterol cardiac diets. When certain fats and salt are restricted, it
becomes challenging to ensure that taste will be universally achieved. The use of spices can be
very effective and also controversial based on personal preference. Most of the patients
interviewed acknowledged that they have given certain meals away because they do not like
them. Following are some patient thoughts specifically about soups and vegetables and patient
satisfaction. Patient 5 said:
I mean, their soups are divine. They always give a lot of vegetables. The only thing they
should do is cook the vegetables more, because they’re too hard for older people. You
have to stick them back in the microwave and really cook it to death. They give it to you
almost hard, like, it’s not cooked. They should cook them a little softer because I know
there’s some older people that won’t bother doing that.
Patient 6 shared the same concern regarding the vegetables while having the opposite opinion of
the soup:
In my case, some of the vegetables that come with the meal, I ain’t crazy about. I says it’s
either, it’s really not hard, but I ain’t crazy about it. Certain things I don’t like eating, and

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that’s like kale burger. I’ll leave there. A real hamburger, I’ll have. I don't know what it is
but ND’s food changed from last year where I got a little bit more of what I liked.
Basically, I mean the food is okay. Like I said, I don't eat much of the soup. Generally, I
give that away. And they said, when I first got it, if you don’t want it, it’s all right for me
to give it to somebody else that will eat it, and I did find somebody who would eat the
soup. But I do like the whole wheat rolls that I get. So, I use that when I eat dinner,
Dietitian 1 shared:
There are folks with individual taste preferences and some people we try to broaden a
range of cultural diversity in the food. We try to add some curries and Caribbean flavors,
and some people appreciate it and then some people don’t because they’re not used to
curry.
As a result of the COVID-19 pandemic, menus were streamlined over the summer of
2020 as reported by the dietitians. Some of the patients interviewed noted a change in the food
they received since the summer. The process for modifying the menus based on the patient’s
preference was noted by some of the patients and most of the dietitians as a barrier or challenge
of the program. Dietitian 1 shared some of the operational steps that are faced in trying to meet
the patient’s individual preferences:
Well, we used to have a way of removing it for those people who didn’t really like it, and
then we would have a conversation about making sure they get enough vegetables you
know, fiber in their diet. Since we had to streamline our menus, and you may hear a lot of
that from clients that we had a lot of repetition over the summer, we had to really
streamline our menu. So, we've incorporated some more options now. So, the method that
we had to remove the veggie burger doesn’t work right now, so we found another way.

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In addition to the way flavor may influence the outcome of the MTM program, the ability for
knowledge to effect change is a strong principle within the MTM model.
Education’s Effect on Food Choices, Awareness
The MTM program provided patients with exposure to a healthy diet. The delivered
meals provided variety of foods, especially vegetables, to a population that may not have eaten
or been aware of what a well-balanced meal looked like. The MTM program provided an
excellent example of portion sizes, beyond the use of the paper educational material often
utilized by dietitians; having real food provided on a regular basis served as a positive reference
and teaching tool. In response to the question, “Do you think about nutrition differently now that
you’ve been getting these meals? Patient 9 replied, “Oh yeah, it helped me to try what I didn’t
want to try.” Patient 9 went on to share that not only has he learned what healthy food looks like,
“I use the meals I receive to teach my grandchildren how to eat healthy. I show them my meals
and talk to them about eating vegetables and fruit.”
The use of the meals by a patient to take the knowledge they have gained and then use
that information to help someone else represented a bonus benefit of the program. The program’s
benefits have the potential to reach beyond the intended patients they serve. The ability for
knowledge to impact change through the relationships of the dietitian, the food, and the patient is
a significant finding. This finding addresses the third research question, “Following the receipt of
medically tailored meal delivery services, how do patient attitudes and behaviors impact their
relationships, social interactions, support groups, and cultural context?” Additionally, the themes
of gratefulness and the connection of health and good food support the positive benefit seen by
the recipients of MTM.

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Results and Findings for Exosystem Causes
The exosystem represents the third layer from the individual and involves how the
individual interacts with their environment. This interaction may be indirect, for example, it may
include access to healthcare, as well as access to resources, which may include SNAP, not-for-
profits, insurance, community groups, churches, etc. The exosystem reflects a contrast in
responses between the patients and the dietitians, specifically regarding the patients’ interactions
with their community in respect to their nutritional needs. Synergy is seen regarding the role ND
plays in access to resources and knowledge. The effect that MTM has on the recipients is seen as
positively influencing their interactions with their communities.
Interaction with the Community
Seven out of ten of the patients indicated that their community did not play a role in
meeting their nutrition needs. Community in this context could be defined as one’s family,
friends, church, community center, neighbors, etc. The patients’ responses were clear and brief
when responding to the query, “What role does your community play in meeting your nutrition
needs?” Below are a few quotes to demonstrate the tone of the patients’ responses.
Patient 2: “With my community, nothing!”
Patient 4: “Not really.”
Patient 8: “No they do not.”
Patient 10: “No, not at all.”
When a similar question was asked of the dietitians, the majority of them indicated that
their patients utilize community resources, sharing that the most common resource was family,
followed by churches, food pantries, and of course ND. This finding represented the greatest
divide among responses between patients and dietitians. Below represents a sample of the

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dietitians’ responses when asked, “What have you observed are ways your patients use
community resources to meet their nutritional needs?
Dietitian 1: “Many clients are utilizing friends and church contacts. They’ll reach out to
family, of course there is a heavy reliance on family.”
Dietitian 6: “Definitely a lot of them lean on family members and neighbors. It just shows
how goodhearted some people are. I've spoken to some clients whose neighbors are just
shopping for them, paying for their food. So a lot of clients don’t have this resource, but
definitely the people around them is probably the biggest one. Dedicated home health
aides, home nurses. I would say the biggest one is family, the second one is of course
meal services like us. I’d say those two are the biggest ones.”
This gap represented an opportunity and potential need within the MTM program.
Patients receiving MTM showed improved interaction with their community as a result of
the service. Many of the patients shared they interact with their community in a more positive
manner because of their participation with ND. Patient 9 said:
Because I get the food and I feel like it helps me keep my weight on and maintains my
energy, I’m able to interact with my community by my words and by actions and how
people see me moving around, at my age and how I'm moving around and everything.
When asked, “Tell me if you feel you interact with your community differently because of the
services that you receive,” Patient 5 said, “Yes, absolutely. I think we’re all stronger because of
it.” Patient 4 simply shared that now that she receives MTM, “I’m able to go to church twice a
month!”

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ND’s Access to Resources
Nutrition Delivered provided its patients with access to food and education. The delivery
of medically tailored meals is the primary function, but the provision of education is significant
and is represented by the connection of the dietitian to the patient. Eight of the ten patients
interviewed reported contact with the dietitian from ND. Of the eight with contact, four indicated
significant improvement as a result of their working with the RD, while three indicated that the
dietitian provided complementary information, describing them as fine. The response to the
dietitian maybe influenced by the amount of contact the patient had with the dietitian, which is
prescribed by the organization. Patient 5 shared,
She (the dietitian) was very helpful, and they’re always available, and they’re always
there to answer your questions, which I think is wonderful. And, they seemed to care a lot
about, about serving the people that they serve and they want the best for them, which I
think is really beautiful.
Patient 9 expressed his enthusiasm associated with his work with the dietitian, “I've been able to
conform. I’ve learned, it’s taught me, especially the nutritionist, definitely the nutritionist!”
In addition to the patients, the dietitians shared their feelings about how they affect the
patients they work with. All the dietitians felt that the addition of nutrition education and
medically tailored meals made a real difference in the health of the clients they served. Dietitian
6 explained it this way:
Some of them, they keep a close relationship with their dietitian where they're calling and
making sure that this food is right, are you sure I can have this? A lot of them are taking
advantage of it, more than not. They’re very conscious of it and appreciative of it and
they’re taking charge to ask questions. So I definitely think the fact that, we have the

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option to make it low salt, low potassium, all these different things is helping and they’re
responding well overall.
Dietitian 4 shared similar feelings about the value of nutrition as a resource providing added
value beyond the actual food.
So, I actually had a client the other day, and he’s like, ‘After getting these meals, I know
what a balanced meal actually looks like now. I know that I need my protein, I need my
vegetable, I need my carbohydrate.’ And I think our meals really helped them understand
that because that’s our whole focus. I mean, of course vegetable filled, lean protein,
healthy carbohydrates, that really helps them understand so that they can start building
balanced meals on their own.
Nutrition education is the primary role of the dietitian, and this education is seen in the
form of individual nutrition therapy and webinars on a variety of health-related topics. The
process at the time of the study did not factor the patient’s acuity or need for nutritional therapy.
The dietitians interviewed expressed mixed opinions on the current model, but all acknowledged
the organization’s desire to reach as many patients in need as possible. Dietitian 2 shared her
thoughts and some frustration,
We lack the ability of being able to prioritize their health risk. So whether they’re high
risk, moderate risk, or low risk, I wish there was a way that we could flag the high risk
clients and prioritize them and the low risk client being able to follow up, but have softer
touch points than the high risk, if that makes sense.
Dietitian 5 did not agree with the concern about risk; she shared:
The truth is that I don’t agree because if there is somebody that I need to speak to more
frequently, and that’s where the barrier would come in, I would just speak with them.

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Right. So no, I feel and know that that isn’t a barrier because if I feel like a client needs to
speak with me, then I will just do a quicker follow-up.
The findings of the exosystem support the answer to research question number four,
“How do organizational influences impact low socioeconomic status patients with chronic
diseases meet their nutritional needs?” Nutrition Delivered influenced its clients’ interactions
with their communities through the provision of medically tailored meals and nutrition
education. The influences were seen in increased attendance at church and the patients’
perceptions that they are stronger, allowing them to participate in more activities outside of their
home.
Results and Findings for Macrosystem Causes
The last system to review for findings is the macrosystem. This layer represents all the
knowledge, values, and principles of the different levels the patient lives in. The macrosystem
layer provides the foundation for the norms of behavior for the environment. The positive
organizational culture ND provides is an overwhelming benefit to both the patients and the staff
dietitians.
Organizational Culture
A good organizational culture outweighs any noted barrier within the program, resulting
in strong patient satisfaction and employee loyalty. The positive culture was experienced by the
patients though their interaction with the staff of ND, which is clearly demonstrated by patient 5
as she shared her thoughts about working with her dietitian:
They’re always available, they’re always there to answer your questions, which I think is
wonderful. They seem to care a lot about serving the people that they serve and they want
the best for them, which I think is beautiful.

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Patient 2 shared how she feels she can always call ND and they will take care of her; they make
her feel like family.
If I need something I’ll call and I’ll ask for Betty (alias) but all of them that I speak to,
they always help me out and I tell them something I don’t like, what can they do to help
me? They always, ND treats me like family they are good to me.
This finding was repeated by most of the patients, especially during the current COVID
19 pandemic which limited the patients’ interactions outside their homes. The effect of this
organization on the clients they serve was seen as comfort, security, and love. The feeling of
service and doing good for others was strongly embedded in the organization, as voiced by the
dietitians. The culture of the organization has affected how the dietitians view their role and
purpose beyond meeting the mission of the organization. Dietitian 6 shared:
I think ND as an organization, it stands out. It’s like a small family, so the inter
department communication is always ongoing. It’s very strong, it’s like a small family.
So, everything outside, leading up to the nutrition assessment and after the nutritional
assessment, the whole cycle, is taken care of very well and there’s communication. So,
everyone is open to suggestions on improving the intake process and onboarding process
and follow-up process, that just makes our job easier and influences everything for the
better.
Dietitian 4 shared how the organization improved her listening, as well as her understanding
about the struggles of low socioeconomic status people she was unaware of prior to her work at
ND.
I think it’s definitely made me a great listener and it has opened my eyes to a lot of the
issues that people in the world are facing. And now I understand sometimes when clients

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mention to me, ‘Well, I just don’t have enough to eat every day.’ Before for me it was
just when I was giving nutrition education in a private practice, I was just telling patients,
this is what you have to buy for breakfast, and all these foods are expensive. It has helped
me, it’s opened my eyes, and now when I go to the grocery store I am pretty conscious
about that and I see what recommendations I can give to these clients that obviously
won’t break their bank because it’s the biggest issue that our clients face is financial
complications for access to food. So, I think that has been a positive outcome with
working at Nutrition Delivered.
Dietitian 4 clearly explained the impact of the organization on their work and the positive impact
it has. She connected the dots from the way she was treated as an employee, feeling supported
and valued, and this inspired her to treat her clients the same way, with kindness and love.
I think the culture of the organization, you are very well treated in terms of there’s good
energy, there’s good human resource. The human resource, it’s amazing. It’s nothing that
I have seen anywhere. To me, that’s very important to work with a team who is aligned to
do good. That’s what we do, simplified. That’s one thing. To be part of a bigger effort to
do good. Then, the resources. We have good resources to work. We have good
educational materials. We have the computers that we need. We have the resources that
we need to do our job, and that that’s very important. There’s team spirit and there’s good
leadership. That’s also very important and there’s recognition and there’s always
education around, and lots of examples around compassion and human values. When
you’re treated that way at the office, then you also want to treat other people, in this case,
clients the same way. Right? There are examples of that, so that you can imitate that. I
think it’s the overall philosophy. Yeah, that helps a lot. Those are the positives, and the

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freedom. There’s freedom also in decision-making, in doing things better, in giving
opinions, which I think it leads to growth. It’s good, individual and group.”
The norms and behaviors of both clients and staff are impacted by the culture of the
organization. This culture frames the interactions of the staff and clients beyond that of a
medically tailored meal delivery service, making this a significant asset of the organization. This
finding further provides insight into research question 3, concerning how patients’ attitudes and
behaviors impact their relationships and social interactions in a cultural context. When the MTM
organizational culture is positive, it can affect the patients beyond improving their physical
health.
Summary
In review of the results, framed by the research questions, the following major findings
emerged. Question one looked at the relationship between the chronically ill patient receiving
MTM and the management of their disease. The relationship is defined by the barriers
experienced by the individual patient. The major barriers within the population studied included
funding, awareness of resources, mobility, and physical proximity to food stores. The MTM
program provided an opportunity to minimize the barriers for the recipients of the service
through access to healthy food and education.
The second research question asked what the knowledge and motivational influences of
low SES status patients with chronic diseases were and how they met their hunger needs. The
findings indicated awareness about nutrition and access to healthy food are the major gaps in
knowledge identified by both the patients and the dietitians. Motivational influences were not as
easily identified. The patients shared their intent to do the best they could within the barriers they
experienced. All patients interviewed clearly identified the connection between food and health.

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The third research question focused on how the MTM services affect the patients’
attitudes and behaviors regarding relationships, social interactions, support groups, and cultural
context. The most significant finding was that of the patient using the knowledge they gained to
teach their family about eating healthy. This finding is beyond the expected scope of the
program; the MTM program is impacting the next layer of society, once removed from the
patient. This demonstrated both the effect of education on the patient and the effect it had on
their knowledge and motivation to share the importance of food as it relates to good health
beyond themselves. The second significant finding was that of gratefulness. The majority of
patients’ attitudes reflected their feelings about the MTM program and their thankfulness for the
services they received. The third finding is seen with the positive organizational culture of ND.
Both patients and staff of ND were affected by the positive culture of the organization. This
outcome may result in improvements in the patients beyond their physical health and has
impacted the staff, empowering them beyond the mission of the organization.
The fourth research question addressed the organizational influences’ impact on low SES
patients with a chronic disease meeting their nutritional needs. The study found the provision of
medically tailored meals and nutrition education positively influenced the recipients. This was
demonstrated by increased interaction with their community, seen through increased attendance
at church, feeling stronger and their ability to maintain their desired weight, and leading to
increased participation in activities outside their home.
The findings aligned with the conceptual framework of the SES model allow a clear
outline of the interconnecting relationship and how each impact on the other. The nesting circles
represent the different layers of the framework, while illustrating the overall intersections of the
findings to create the broad sweeping concepts effecting the concept of food as medicine in the

81
form of an MTM program. Figure 6 illustrates the relationship of the findings and the conceptual
framework.

82
Figure 6
Relationship of findings and conceptual framework
Micro
Resources
Awareness
Mobility
Physical proximity
Meso
Connection of health to recovery
Gratefulness
Flavor/taste on compliance
Education s effect on
food choices,
awareness
Exo
Interaction with the community
ND access to resources
Macro
Organizational culture

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Chapter Five: Recommendations and Discussion
This chapter includes a summary of the findings as they relate to the literature reviewed
in Chapter 2. Specifically, five major results were reflected in the literature: the importance and
impact of social determinants of health, access to supermarkets, individual motivation behind
food choices, nutrition therapy, and the effect of medically tailored meals on the patients
receiving the service. Following the review of pertinent literature to findings, recommendations
for practice are made for specific results or findings. A review of the limitations and
delimitations of the study is covered, which is then followed by a discussion of recommendations
for future research.
Discussion of Findings and Results
Five major themes emerged from the literature that aligned directly with the findings of
the research. The connection of social determinants of health and the risk of developing certain
types of health diagnosis, the effect of nutrition therapy and the dietary guidelines, followed by
the effect that access to supermarkets had on low SES patients. The alignment to the literature
continues to be seen regarding the motivation of the patients in their food choices and its
connection to healthy choices, followed by the effect that medically tailored meals had on the
recipients physically and mentally.
Alignment of Social Determinants of Health
The cohort of patients that participated in the research reflected the findings in the
literature, specifically, that hypertension, cardiac disease, diabetes and anxiety are seen more
frequently in the food insecure demographic (Health Research & Educational Trust, 2017). This
finding aligned with the idea of social influences affecting the well-being of a population’s
physical and mental health (O’Brien, 2019; Cohen et al. (2019). The findings of the study

84
showed the majority (60%) of the patients had hypertension, followed by 50% of the patients
having diabetes; 100% of the patients indicated having more than one diagnosis, while 90% of
the patients interviewed indicated a sense of anxiety over having food prior to receiving MTM
delivery services. The findings aligned with the importance of population health practices to
minimize chronic disease risks in this population by reducing food insecurity.
Alignment of Nutrition Therapy and Dietary Guidelines
The connection between eating healthy food and its effect on recovery from illness was
expressed by all ten patients interviewed. The nutrition therapy received as part of the MTM
program increased the patient’s ability to meet the Dietary Guidelines by increasing their
consumption of fruits and vegetables. In addition, the medically tailored meals themselves served
as an excellent teaching tool to reinforce the principles taught by the dietitian. Aligning with the
literature, the value of nutrition therapy with the chronically ill food insecure population and the
effect nutrition had on modifying chronic disease outcomes were supported (Drewnowski et al.
2004;Lenior-Wijnkoop, 2012; societyhealth.vcu, 2015). Mullen et al. (2016) and Johnson et al.
(2018) posited that meeting Dietary Guidelines has been shown to increase positive health
outcomes and reduce the risk of chronic diseases, complementing the study outcomes of both the
patients (ten out of ten) and the dietitians (six out of six) expressing improved health as a result
of MTM.
Access to Supermarkets
All patients interviewed expressed difficulty in the location of affordable supermarkets
and their frustration with getting healthy food into their households. This concept aligned with
the literature, which outlined transportation barriers and the location of supermarkets as critical
to supporting the food security status of underserved communities (Chrisinger, 2016; Hossefeld

85
et al. 2017Ma et al., 2018). The regular availability of healthy food positively affected the
management of chronic diseases like diabetes in the low SES population (Seligman et al., 2010).
This finding was mirrored in the study participants, with six out of six dietitians reporting
improved clinical outcomes of their patients.
Motivation of Food Choices
Motivation associated with food choices was an important factor in understanding the
individual readiness of the patient to make positive health changes, as well as providing insight
into public health policy development. The literature aligned with the research findings, which
indicated that ten out of ten of the patients made food choices based on health reasons. Of the ten
patients in the study, nine were women. Renner et al. (2012) shared that women regularly were
motivated to make food selections based on health. Cummins et al. (2014) showed that when a
new supermarket in a food desert provided educational interventions to its customers,
improvement in selecting fruits and vegetables increased. Improvement in awareness and food
choices was seen in all patients interviewed in the study and observed by all six of the dietitians
interviewed, suggesting that health is a strong motivator for this population.
Effect that Medically Tailored Meals Had on Recipients Physically and Mentally
Recipients of MTM have shown increased improvements clinically, physically, mentally,
nutritionally, and socially, as noted in the literature and observed in this study (Berkowitz, et al.,
2019; Palar et al., 2017). Palar et al. (2017) found clinical outcomes such as improved BMI and
laboratory results in diabetic patients, and decreased depressive symptoms were noted in
recipients of MTM. Both findings were observed by the clinical staff interviewed for this study,
mirroring the benefits of a food-as-medicine model from the literature. Cohn and Waters (2103)
outlined the importance of medical nutrition therapy and its link to the MTM model. The

86
inclusion of the dietitian and nutrition education in this study bridged the gap between a food
program like Meals on Wheels, with no nutrition education, and the benefits noted by the
patients in this study, leading to improved outcomes. The improvements were demonstrated by
the patients sharing their increased strength, decreased anxiety, and increased activities outside
the home.
Recommendations for Practice
Recommendation 1: Develop Educational Materials for Patients Regarding Online Food
Shopping and Provide Access to Local Food and Financial Resources, Both Electronically
and Hardcopy
As noted in Chapter 4, the findings associated with research question one identified the
major barriers to managing a chronic illness to include funding, awareness of resources,
mobility, and physical proximity to food stores. The majority of the patients indicated that their
community did not support their nutritional needs, sharing the struggle they encountered in
getting healthy food into their home. The inclusion of an educational program to address how to
shop for food online, including home delivery, would help minimize the above noted barriers.
This education could be provided in the form of a webinar and reinforced by the dietitian at the
time of the first encounter. A shopping online webinar can reinforce the nutritional concepts
shared by the dietitian to support the individualized nutrition therapy. To support the inclusion of
the webinar, it is suggested that nudge theory be applied to the implementation of the program.
Kosters and Van der Heijden (2015) explained the use of a nudge to help alter the choice of an
individual in a particular direction. This can be accomplished in a variety of ways, for example,
with the use of an auto-fill response on a computerized application. It is recommended that a
proactive approach be used when designing the system to facilitate the attendance of the webinar

87
for new recipients of MTM. For example, this webinar should be part of the onboarding of a new
patient into the program and only removed if the patient specifically choses to be removed from
the webinar option.
In addition to the online shopping webinar, a resource page should be developed to direct
patients to local and national resources associated with food and finances. This resource should
be available both electronically through a link on ND’s webpage and as a hard copy version that
is provided with the first food delivery, and reviewed by a staff member of ND with the patient
either in person or by telephone.
This recommendation addresses the major barriers mentioned, i.e., the online shopping
impacts patients with mobility issues and the proximity of affordable supermarkets. The resource
list addresses the gap in knowledge identified in the study regarding community resources
available for food and financial assistance. The use of both resources can supplement the current
nutrition education provided and fill an identified gap. This finding and recommendation impact
the mesosystem of the individual suffering from a chronic illness and food insecurity. The
mesosystem represents the next layer from the individual within the SES model and has potential
for valuable impact to the patient directly (Gardiner, 2018). Within this layer of the conceptual
framework, the aim was to impact the ability to manage the patient’s disease through the
knowledge to impact change. This recommendation is well aligned with both the conceptual
framework and the application of nudge theory as a change management approach.
Recommendation 2: Increase the Flexibility of Current Menu to Allow for Greater
Customization
The second recommendation addresses the finding of gratefulness of the recipients
associated with research question number three which asked, “Following the receipt of medically

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tailored meal delivery services, how do patient attitudes and behaviors impact their relationships,
social interactions, support groups, and cultural context?” The finding was that of gratefulness
and a positive organizational culture. Focusing on the thankfulness of the recipients of MTM and
how it has affected their lives, the study showed their willingness to accept the recent negative
changes to variety and quality of the food they received. The limiting factor of the COVID 19
pandemic and the software system used to manage and produce the current menus warrants a
review to evaluate the ability to change the current process and evaluate the affordability of
increasing the dietitian’s opportunity to customize the menus of the patients to a greater degree.
The use of the Burke-Litwin change model fits well with this recommendation and Nutrition
Delivered as an organization (Burke, 2018). The top-down process of the model can build on the
model’s different factors, starting with the external transformational factors influencing the
change, which included customer satisfaction and changing technology (Burke, 2018). The
positive organizational culture provided an excellent environment to work through the
operational levers outlined within the Burke-Litwin model. The arrangement of the operational
functions can build on the assets in place and facilitate the potential for positive impact for
change while maintaining fiscal responsibility.
This recommendation focuses on the mesosystem of the conceptual framework. Like
recommendation one, it impacts the second level from the individual patient, allowing this
change to have a direct effect on the lives of the person in receipt of MTM. This
recommendation was built off the positive organizational factors currently in place at ND, seen
through the gratefulness of the patients and the employee satisfaction of the staff, providing a
strong foundation for success as outlined by Burke-Litwin and the importance that the work unit
climate has on the levers needed to impact organizational change (Burke, 2018).

89
Recommendation 3: Increase Diversity of Registered Dietitian Staff at ND
Nutrition Delivered is a nonprofit organization, which means they are established to
operate for the overall purpose of benefiting society (Suykens et al., 2017). Along that line, the
importance of diversity, equity, and inclusion (DEI) is critically important to this type of
organization, knowing the value it brings to overall performance, financial success, managerial,
and leadership decision-making (Teitsworth, 2018). Teitsworth (2018) continued that
organizations reflect the communities they serve and are at the heart of understanding the
importance and relevance of DEI. The current staff of dietitians at ND does not reflect the
population of the city in which they work. As a large northeast metropolitan city, the latest
census data indicates the city demographics are 32.1% White, 29.1% Hispanic, 24.3% Black, and
14.1% Asian (census.gov). This recommendation was made for future consideration for staff
recruitment of registered dietitians for ND. This action impacts the macrosystem level of the
conceptual framework by impacting the norms and behaviors the organization functions within
and the society that the patient receiving MTM lives in. The recommendation’s impact was more
complex as it related to the individual with a chronic disease and food insecurity because of the
intersection of its effect with the other layers of the SES model (Gardiner, 2018).
As with the prior recommendation, the use of the Burke-Litwin change model when
working on DEI activities is well suited for ND as an organization. Burke (2018) outlined the
top-down driven nature of the model, the strong organizational culture currently demonstrated
through the findings of the study, and the mission of the organization to improve the health and
well-being of those with serious illnesses by alleviating hunger and malnutrition sets up the
organization for a positive outcome in its DEI efforts. The setting of goals for the organization

90
moving forward to achieve certain percentages of a diverse workforce is a good first step toward
achieving equity among the current clinical staff.
Recommendation 4: Increase Efforts to Impact Policy Associated with Insurance Coverage
for MTM and the Chronically Ill Patient
The answer to the fourth research question led to the final recommendation. The finding
was the provision of medically tailored meals and nutrition education positively influenced the
recipients. The recommendation is to build on the strong organizational culture of ND and the
benefits observed in the study to impact policy associated with insurance coverage to support the
provision of medically tailored meals, much like coverage for pharmaceuticals. The concept that
food is medicine and the associated benefits to the individual recipients have been noted in the
literature and by this study (FIMcoalition.org; Berkowitz et al., 2019). Using the Burke-Litwin
organizational change model, a key lever for change is a strong organizational culture, and the
findings of the study showed a strong organizational culture within ND. The finding provides a
significant positive factor to support change.
The recommendation supports leveraging the power of the current organization to
continue its advocacy for financial support of MTM. The recommendation is linked to the
mission of the organization and the role it plays in advocating for social justice. Prilleltensky
(2012) explained the effect health has on people at all different levels within the socio-ecological
continuum, supporting the benefit of MTM. The recommendation aligns with the literature that
posits the idea that food insecurity in a major health crisis in the United States due to the
negative outcomes related to overall health and healthcare costs (Gundersen & Ziliak, 2018).
Advocating for policy changes addresses the macrosystem level of the conceptual framework by
impacting the environment and government that the induvial with a chronic illness lives within.

91
The impact of this recommendation has a broad effect on the individual in receipt of MTM.
Positive policy changes could provide for services to more patients, while not changing the
current service of someone receiving MTM today. A policy change has the potential to impact
the environment through changes in healthcare costs and health outcomes for the better.
A summary of the relationships between the themes identified, the recommendations
made, and the conceptual framework are outlined in Figure 7.

Figure 7
Relationship Summary
Meso Mirco
Themes Recommendation
Connection of healthy food
to recovery
Impact Policy associated with
insurance coverage for MTM
Educations effect on food
choices
Training for financial and
community resources
Effect of RD on food choices
Increase diversity of RD staff
Connection of MTM and
nutrition therapy
Increase flexibility of menu to
allow for greater
custominzation
Access to resources
Education for online
shopping & delivery services
Meso
Exo
Macro

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Limitations and Delimitations
The study design had potential weaknesses or limitations out of the control of the
researcher and are outlined below. The study delimitations, which are within the control of the
researcher, are also outlined below. The interconnection of the researcher’s objectivity and
subjectivity played an important role in setting the views and conclusions drawn from this study
(www.dissertationrecipe.com).
The use of interviews assumed the trustworthiness of the respondents and created a
limitation. The interviewees were aware that the reason for the interviews were to support
research surrounding ND. Both the patients’ and the dietitians’ responses could have been
impacted by their honesty and their social and professional desirability to meet the expectations
of the researcher. The dietitian’s positionality as an employee and a key factor within the
research questions may have caused a limitation in the responses due to their underlying desire to
provide outcomes that themselves and their work in the best light, thereby causing a potential
limitation in the accuracy of their responses. The impact of the COVID-19 pandemic may have
caused a limitation in the perceptions of the patients and their views on healthcare, their
community, and the services offered to support food insecurity. The sample was 90% female,
which maybe a limitation in the responses of the patients based on their gender and potentially
impacting the transferability of the results to more diverse groups.
The first delimitation of the study was the impact the patient’s knowledge or ability to
understand the questions as they were asked had on their response. An additional delimitation of
the study was the geographic location of the participants. The study took place in a large
northeast urban setting, and the behaviors, experiences, and strategies may not be transferable to
rural or suburban settings. In response to the COVID-19 pandemic, the study design was altered

93
from in-person interviews to either telephone or video conferencing. This change minimized the
researcher’s ability to note non-verbal cues and gestures associated with the patient and
dietitian’s responses.
Recommendations for Future Research
Future research on the idea that food is medicine is warranted to address the following
two topics: specifically, food production systems to support greater customization while ensuring
fiscal responsibility for nonprofit organizations and the impact of greater frequency of nutrition
intervention beyond that of the current model investigated at ND. The model studied provided
tailored meals based on a rotating menu for overall diet types, low sodium, low cholesterol,
diabetic, etc. The ND model did not afford the dietitian a broad scope to customize the menu
based on food allergies or patient preference. The inability to customize to preferences and
allergies resulted in delivered food being given away by the recipients. This reduced the number
of well-balanced meals the patient consumed and may have impacted the benefits obtained from
the program.
Nutrition education is a key component to the success of the MTM model. Additional
research to determine the amount and type of education provided to the patient is warranted
based on the findings of this study. Additional research could investigate if there is continued or
increased benefit of the MTM program when additional encounters with the RD or other
educational encounters are offered. This research would support the financial evaluation of an
MTM program that would increase the available knowledge for healthcare administrators in
evaluating the development of a food is medicine program for their healthcare system.

94
Conclusion
The behavioral, social, and environmental significance of social determinants of health
remains a key factor to keeping people healthy and served as the focus of this study. The
alignment of food insecurity and health outcomes impacted the environment, known as the
healthcare system, systemically (Garcia et al., 2018). The study focused on the organizational
practices, relationships, and barriers that related to patient outcomes as they are related to the
receipt of MTM. This study was important because when good nutrition is not present, chronic
diseases worsen (Health Research & Education Trust, 2017). When good nutrition, coupled with
education, is available, patients with chronic diseases demonstrated improved ability to interact
with their community and advocate for the benefit and value of nutrition to their contacts. Good
nutrition and education together demonstrated a value beyond the microsystem level of the SES
model, expanding to the macrosystem level, and connecting the community and its norms and
values with the program outcomes.
Public health issues are associated with poor clinical outcomes and increased healthcare
costs (Gurvey et al., 2013; Health Research & Educational Trust, 2017). When healthy food and
education on how food connects with health is available, positive outcomes are observed,
impacting the public beyond the single individual receiving the service. Organizational culture is
a significant factor in driving positive change (Burke,2018). Nutrition Delivered as an
organization reflected the positive outcomes associated with a strong organizational culture to
effect change. The positive culture was demonstrated through positive customer feedback in the
form of gratefulness. Positive employee outcomes were demonstrated by their desire to impact
good outside their role as a dietitian because of the way their organization treated them and the
patients they serve. The study observations aligned with the conceptual framework, allowing the

95
researcher to provide insight, and understanding through a layered approach surrounding the
overall concept that food is medicine. The study complements the current research supporting the
benefits of MTM programs, while identifying barriers experienced by the patients at the different
socio-ecological levels, as outlined by the conceptual framework. Lastly, the study supported the
value of the registered dietitian’s role in impacting change with this patient demographic at the
microsystem, mesosytem, and exosystem level. This resulted in change beyond the individual
patient; the RD was the advocate and instrument for translating the concept of food is medicine.

96
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Appendix A: Interview Questions
Research Questions:
1. What is the relationship between medically tailored meal recipients, food insecurity and
chronic disease in conjunction with individualized medical nutrition therapy?
2. What are the knowledge and motivational influences related to low socioeconomic status
patients with chronic diseases and how they meet their hunger needs?
3. Following the receipt of medically tailored meal delivery services, how do patient attitudes
and behaviors impact their relationships, social interactions, support groups, and cultural
context?
4. How do organizational influences impact low socioeconomic status patients with chronic
diseases meet their nutritional needs?
Demographic Questions for Participants:
1. What is your age? Select the range: 18-29 years, 30-39 years, 40-49 years, 50-59 years, 60-
69 years, 70-79 years, older than 80 years
2. How do you identify your race?
3. Can you share your medical history?
4. How many people live with you?
5. What is relationship to the people in your household?
6. Do you work?
a. If yes, what is your job?
b. Is your work full time or part time?

107
c. Do you have more than one job?
7. Are you eligible for SNAP benefits?
If yes, do you receive SNAP benefits?
8. How did you learn about Nutrition Delivered?
Interview Questions:
1. Before receiving services from ND, tell me how you got food to eat? (RQ1)
(Microsystem)
2. How did you feel about having the right amount and type of food prior to receiving the
services of ND? (RQ2) (Microsystem)
3. Do you believe you had any impacts associated with not always having enough food?
(RQ2) (Mesosystem)
4. What role does your community play in meeting your nutrition needs? (Your community
could be your family, friends, church, etc.) (RQ3) (Exosystem)
5. Some people would say that having the right type of food can increase your recovery from
surgery or being sick. What would you say? (RQ1) (Macrosystem)
6. Do you shop for food? If yes, what type of store do you shop in? (RQ2) (Exosystem)
7. Tell me about any barriers you may experience regarding access to food. (RQ2)
(Macrosystem)
8. Share with me how food shopping makes you feel. (RQ2) (Microsystem)
9. What types of food do you typically buy? (RQ2) (Microsystem)
10. How do you decide what food to buy? RQ2) (Microsystem)
11. How does your food budget impact your food selections? (RQ1) (Mesosystem)
12. How do you stretch your food budget? (RQ2) (Mesosystem)

108
13. How does preparing food make you feel? (RQ2) (Microsystem)
14. Tell me about a time you were too ill to shop or prepare food. (RQ1) (Microsystem)
15. How, if at all, does food impact your health? (RQ1) (Mesosystem)
16. To what extent do you choose food based on your medical condition? (RQ2) (Exosystem)
17. How has receiving medically tailored meals influenced your ideas about nutrition? (RQ3)
(Mesosystem)
18. What impact did the dietitian from ND have on how you think about food? (RQ4)
(Mesosystem)
19. Tell me how you feel physically since you have been receiving medically tailored meals?
(RQ3) (Mesosystem)
20. Have you noticed any difference in your health since receiving medically tailored meals?
21. If yes, what have you noticed? (RQ4) (Exosystem)
22. Tell me if you feel you interact with your community differently because of the services
you received from ND? (RQ3) (Exosystem)
23. Explain to me how your experience food shopping has changed as a result of the services
you have received from ND? (RQ3) (Mesosystem)
24. How do you feel now compared to before you received the meals at home? (RQ4)
(Microsystem
25. Why do you think you feel that way? (RQ4) (Mesosystem)
Interview Questions for the Dietitians:
1. Tell me about the barriers you see patients experience in meeting their nutritional needs.
(RQ1) (Mesosystem)

109
2. Can you describe the impact that food insecurity has had on your patients? (RQ1)
(Microsystem)
3. What are some strategies you have observed patients use to stretch their food budget?
(RQ2) (Exosystem)
4. What are some strategies patients have used when they are too ill to purchase food? (RQ2)
(exosystem)
5. What are some strategies patients have used when they are too ill to prepare food? (RQ2)
(Exosystem)
6. What have you observed are ways your patients use community resources to meet their
nutritional needs? (RQ3) (Exosystem)
7. How do patients respond to receiving customized food to meet their medical needs? (RQ3)
(Mesosytem)
8. What impact do you see from the nutritional education provided? (RQ3) Mesosystem)
9. Can you describe situations when MTM impacted the patient’s ability to improve their
health? (RQ3) (Exosystem)
10. Can you describe situations when MTM impacted the patient’s knowledge of nutrition?
(RQ3) (Mesosystem)
11. Tell me about a time that the medically tailored meals being delivered impacted the
patient’s food security status (RQ1) (Microsystem)
12. Share with me organizational barriers you have observed to improving clinical outcomes.
(RQ4) (Macrosystem)
13. Describe to me the characteristics of ND that you feel positively and negatively impact
you as a dietitian to improve the clinical outcomes of your patients? (RQ4) (Macrosystem)

110
Appendix B: Code List

Code Frequency of use
Access to resources 32
Awareness of resources-knowledge gap 19
Connection of healthy food to recovery from illness 40
Connection of MTM & nutrition therapy 44
Connection to community 27
Education’s effect on food choices-awareness 40
Effect flavor/taste has on compliance 16
Effect of MTM on interaction with community 6
Effect of RD on food choices/health 32
Emotional/attitude associated with receiving MTM 25
Gratefulness-gratitude 26
Impact of standard menu 19
Limitations of program 21
Motivation of food choices 26
Organizational culture 11
Positive impact of program 26
Potential program improvements 18
Preferences/like food that is delivered 10
Relationship to cooking/shopping prior to illness 28
Strategies used to stretch food 27

Abstract (if available)

Abstract The high prevalence of food insecurity in patients with low socioeconomic status (SES) with chronic diseases represents a significant health risk. The relationship of income and reported poor health is five times greater for people living below the poverty level. Low SES Americans have increased rates of chronic diseases, including heart disease, diabetes, stroke, and other chronic disorders, compared to wealthier Americans. This problem of practice is important to address because the relationship between food insecurity and health outcomes impacts the overall healthcare system. Research linked food insecurity with high healthcare expenditures, demonstrated by increased admissions, readmissions, and pharmaceutical needs. As part of the resources available through a variety of nonprofit organizations, medically tailored meals represent a unique approach to improving healthcare outcomes utilizing the concept that food is medicine. The purpose of this study is to understand the relationship and impact of home-delivered medically tailored meals to seriously ill, food insecure patients, in conjunction with individualized nutrition therapy on the food insecurity cycle. A qualitative approach was used, with semi-structured interviews of patients and the dietitians who treated them. The findings were viewed through the theoretical framework of the socio-ecological model. Five categories or emerging themes were identified. The findings showed the majority of the patients had hypertension, followed by diabetes

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Asset Metadata

Creator Going, Christine (author)

Core Title Food is medicine: the intersection of food insecurity and chronic disease management

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/28/2021

Defense Date 03/24/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag food insecurity,food is medicine,medically tailored meals,Nutrition education,OAI-PMH Harvest,organizational culture,role of the dietitian,socio-ecological model

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Adibe, Bryant (committee chair), Lynch, Douglas (committee member), Utech, Anne (committee member)

Creator Email christine.going@va.gov,going@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-454320

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Legacy Identifier etd-GoingChris-9566.pdf

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Document Type Dissertation

Rights Going, Christine

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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