Prevention is the Best Cure

reprinted from Issue 19, Fall 2014 of Frontiers of Medicine (PDF)

"We have to start thinking about moving prevention outside traditional places where doctors work, and into places where our patients feel the most comfortable. Food pantries are a great place to do that...."
— Dr. Hilary Seligman, shown above (right) talking with Morgan C. Smith, diabetes wellness project lead at the Redwood Empire Food Bank in Santa Rosa. Seligman is piloting diabetes interventions at three food banks nationally.

As a new internist at San Francisco General Hospital (SFGH), Hilary Seligman, MD, remembers asking a pre-diabetic patient about his diet.

"Every day for lunch, he ate a piece of Spam between two cinnamon rolls," says Seligman (pronounced SELL-ig-man). "My jaw dropped – could that possibly taste good? He said he had a dollar a day to spend on food, and eating this ensured he wouldn't be hungry until the next morning. With this huge barrier, I realized it was going to be hard to help him not become diabetic."

That dilemma launched her research into the impact of hunger on health. Seligman has become a medical expert on food insecurity – which includes hunger as well as reduced quality, variety or desirability of diet because of limited finances. She is one of many Department of Medicine faculty members who are working to prevent disease before it occurs. Through innovative research, policy work, educational efforts and clinical care, these faculty members are pioneering ways to keep patients out of the hospital and helping them live longer, healthier lives.

Seligman is a core faculty member at the UCSF Center for Vulnerable Populations at SFGH, which is dedicated to improving health and reducing health disparities. She is particularly troubled by the ways that food insecurity contributes to the obesity epidemic and hurts diabetic patients' ability to manage their disease. Patients who take diabetes medication but can't afford to eat may develop hypoglycemia, or low blood sugar. The end of the month is particularly hard for patients who exhaust paychecks or food stamp benefits (now known as the Supplemental Nutrition Assistance Program, or SNAP), which in California average about $5 per person per day.

In a recent study published in Health Affairs, Seligman's team studied California hospital admissions over nine years. They found that the poorest patients experienced a 27 percent increase in hypoglycemia admissions during the last week of the month, compared to the first week of the month. By contrast, hypoglycemia admissions for higher income patients remained stable throughout the month.

"Only the most severe hypoglycemia cases get admitted," says Seligman. "Usually, you drink a cup of orange juice and you're fine. But what if you have nothing to eat?" She notes that for every hypoglycemia admission, there are probably many other patients who experience symptoms at home – along with complications that can eventually lead to loss of sight, amputation and kidney failure. "That is a huge cost to our medical system, and to patients' quality of life," says Seligman.

Dr. Hilary Seligman at the diabetes wellness project at Redwood Empire Food Bank in Santa Rosa.

Developing New Solutions

"These ‘Big Data' projects are important for creating motivation towards policy solutions, but we also need to develop interventions," says Seligman. One such endeavor is her collaboration with Feeding America, the country's largest domestic hunger relief organization, to pilot diabetes intervention programs at three food banks nationally. As the project's lead scientist, Seligman and her colleagues screen food bank recipients for diabetes, offer diabetes education onsite and provide weekly diabetes-appropriate food boxes.

"We have to start thinking about moving prevention outside traditional places where doctors work, and into places where our patients feel the most comfortable," says Seligman. "Food pantries are a great place to do that, because they are open at convenient hours, people are already going there every week, and we have this incredible opportunity to give food."

"Hilary's work demonstrates what can happen when you marry rigorous academic research with strong community partnerships and a dedicated commitment to policy and advocacy in such an important arena as food insecurity," says Kirsten Bibbins-Domingo, MD, PhD, MAS, director of the UCSF Center for Vulnerable Populations at SFGH and the Lee Goldman, MD Endowed Chair in Medicine. "She is poised to continue to make important contributions that will improve the health of some of our most vulnerable communities."

Seligman serves on the San Francisco Board of Supervisors' Food Security Task Force and the boards of the San Francisco-Marin Food Bank and California Food Policy Advocates. She also trains residents how to identify food insecurity in patients, how to adjust medications if consistent access to food is a challenge, and strategies for connecting patients with the hunger safety net.

"One in seven households in the US is at risk of going hungry because they can't afford food," says Seligman. "We as physicians need to step up as community leaders and say that SNAP benefits are not adequate, and that an apple and peanut butter should be no more expensive than a bag of Cheetos."

Seligman and the UCSF Center for Vulnerable Populations at SFGH recently received a lead gift from the Hellman Foundation to build EatSF. This initiative brings together community organizations, food vendors, the San Francisco Department of Public Health, other healthcare organizations and private philanthropy to develop a sustainable fruit and vegetable voucher delivery system in San Francisco. The goals are both to increase low-income residents' access to healthy food, and stimulate demand for these items – helping to avoid dietary tradeoffs in which people choose cheap calories over nutritious foods in order to reduce hunger.

"We are thrilled that the Hellman Foundation recognized Hilary's leadership in this area and have helped launch EatSF with this lead gift," said Bibbins-Domingo. "With additional support, this initiative could help improve access to healthy food for all San Franciscans."

Although overcoming food insecurity is no small challenge, Seligman says she is continuously inspired by the tobacco control movement – whose leaders also include many Department of Medicine faculty members. "Reducing smoking seemed equally impossible 20 years ago, and look how far we've come," says Seligman. "We can do it again – we've just got to keep working on it."

Sheri Lippman: Recipe for Change

"Biomedical tools and social interventions are complementary, and can be much more effective if done together."
— Sheri Lippman, PhD, MPH, partners with South Africa-based nonprofit Sonke Gender Justice to develop and test HIV interventions. Above, a community mural helps generate dialogue about HIV, which is often considered an individual problem even though more than 6 million people in South Africa are HIV+.

Street theater, murals and gender equality workshops are some of the innovative tools that Sheri A. Lippman, PhD, MPH, an epidemiologist at the Center for AIDS Prevention Studies in the Division of Prevention Science, is testing to improve HIV prevention in South Africa.

That nation currently has more than 6 million people living with HIV/AIDS. In some areas, residents have a 40 percent chance of becoming HIV+ by age 40. "My work looks at how you create cohesive communities so they can confront epidemics," says Lippman, who began her career by piloting social interventions among Brazilian sex workers to prevent HIV and other sexually transmitted infections.

Although there have been major biomedical advances in HIV treatment in recent years, significant social and logistical barriers to HIV prevention, testing and treatment remain. By analyzing literature from social movements, community development and related fields, Lippman and her collaborators identified key elements that support "community mobilization," or engaging groups to take action towards a common goal. These include having a shared concern, the ability to problem-solve together, mutual trust, leadership, organizations and social networks, and working together on collective activities such as meetings or rallies. "We're looking for a ‘recipe' – the key combination of things we need for change to occur," says Lippman. "Just like basic science requires a hypothesis and method, the same thing goes for social sciences – we need a recipe to guide mixing the basic ingredients."

Working in Mpumalanga, a rural area of South Africa with a particularly high prevalence of HIV, Lippman's team, which includes investigators from the University of North Carolina, the University of the Witwatersrand's Rural Public Health and Health Transitions Research Unit, and South Africa-based nonprofit Sonke Gender Justice, has designed and are testing a combination of culturally competent strategies to prevent HIV and gender-based violence, including:

  • Educational workshops:
  • Through its "One Man Can" project, Sonke Gender Justice conducts intensive two-day workshops for men ages 18 to 35 on topics including masculinity, alcohol abuse and intimate partner violence. "In many places, it's a sign of weakness to reach out for support, go to a clinic, or to let your girlfriend tell you that you need to use a condom," says Lippman. "These workshops help participants think about how they can be healthy men who feel good about who they are, and who aren't trying to exert power over others in a way that puts themselves or their partners at risk."

  • Street theater:
  • Sonke Gender Justice also trains community mobilizers who stage an "argument" on the street about a topic like condom use, drawing a crowd. The actors then facilitate an impromptu discussion about HIV, a topic that in South Africa is generally considered an individual rather than a community problem. "The stigma around HIV is remarkable, and has been a huge impediment to making progress with prevention," says Lippman. "There is a total communication breakdown when it comes to discussing sexuality. Just generating dialogue is a huge part of what the mobilizers are doing."

  • Educational murals:
  • The team has engaged community members to paint murals about various topics related to gender and supporting people with HIV, and trains them to engage passersby in discussions about the artwork.

  • Digital stories:
  • The team has produced videos about gender, HIV, alcohol abuse and making change occur. The mobilizers screen these videos and lead discussions about them.

Lippman and her collaborators have randomized 22 different communities, half of which are receiving the community mobilizing intervention, and are evaluating which elements appear to be most effective. "We're trying to improve the science amidst all of the excitement around community engagement," she says. "If we do effect change, we can show how we did it and offer the approach as a best practice to other groups."

"Just because we build it, doesn't mean people will come," says Marguerita Lightfoot, PhD, chief of the Division of Prevention Science. "Sheri's work addresses the crucial issues of getting our innovations to be suitable for and accepted by those who need them."

Lippman's next NIH-supported project will focus on treatment as HIV prevention – getting people diagnosed and on treatment earlier, which improves their prognosis and also greatly reduces transmission risk. She is also interested in ways that her community mobilization framework can be applied to other communities and issues, such as improving nutrition or reducing gun violence in the US.

"Biomedical tools and social interventions are complementary, and can be much more effective if done together," says Lippman. "When we succeed in combining these approaches for HIV prevention, I think we will see the change that we've been waiting for."

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