The International Journal of Psychosocial Rehabilitation
Better Eating and Recovery:
 Addressing Food Insecurity at an urban Community Mental Health Center

 
Marydale DeBor JD
Lecturer, Yale School of Medicine, Department of Psychiatry

Chef Anne Gallagher
Consulting Chef, Connecticut Mental Health Center

Francine Blinten MS,
 Consulting Nutritionist, Connecticut Mental Health Center

Michael Sernyak MD
 Professor of Psychiatry, Yale University Department of Psychiatry and Chief Executive Officer, Connecticut Mental Health Center

Robert Cole MHSA
Lecturer, Yale University Department of Psychiatry and Chief Operating Officer, Connecticut Mental Health Center

Steve Olsen
 
Peer Facilitator, Connecticut Mental Health Center

Annie Harper PhD
 Associate Research Scientist, Yale University Department of Psychiatry




Citation:
Debor M, Gallagher A, Blinten F, Sernyak M, Cole R, Olsen S, & Harper A. (2016)
   Better Eating and Recovery: Addressing Food Insecurity at an urban Community Mental Health Center.
 
International Journal of Psychosocial Rehabilitation. Vol 20 (1) 78-87




Corresponding Author:
Annie Harper, annie.harper@yale.edu, 58 Anderson st, New Haven, CT 06511.

Acklowledgements: The authors wish to acknowledge the support of Ann Joy, Director of Out Patient Rehabilitation at CMHC whose department added occupational therapy expertise in curriculum development and pilot implementation. Research Associate Cara Donovan (MPH/MS candidate Yale School of Public Health/Yale School of Forestry and Environmental Science, 2017) assisted with documentation of the sessions and research support. Also contributing to the effort were Better Eaters Club alumnae and co- facilitators Serena Spruill and Robert Forlano.

Abstract
This article describes a pilot program to improve diet and nutrition among low-income clients of an urban mental health center, including efforts to transform the overall food delivery system and culture, and the ‘Better Eaters Club’, a recovery oriented, hands-on intervention directly targeting clients with group based and one-on-one nutritional counseling.  The article outlines the complexity involved in full-scale transformation of an institutional food delivery system and culture, and describes initial, promising results of the Better Eaters Club and one-on-one nutritional counseling, based on anecdotal reports from participants. This pilot project has laid an important foundation for a transformed food delivery system, and the institutionalization of a cooking and nutrition program designed specifically for low-income people with mental illness, including a finances and budgeting component. Future steps will incorporate more rigorous evaluation mechanisms tracking health indicators, knowledge of nutritional issues, cooking skills, and food security.

Keywords: Food Insecurity; Nutrition; Cooking; Chronic Disease and Mental Health


Introduction:
A recovery-oriented approach to mental illness is based on the premise that a good life with the illness is possible, rather than putting life on hold while attempting to recover from symptoms of the illness.  The essence of recovery is “a renewed sense of self as a whole person, despite or incorporating ones illness, along with a redefinition of one’s illness as only one aspect of a multidimensional self” (Davidson, 2003). Within this approach, person-centered services and supports that help people lead a good life where they are able to take maximum control over decisions that affect their life are essential, alongside efforts to reduce distressing psychiatric symptoms.  (Substance Abuse and Mental Health Services Administration, 2004).

Diet and nutrition are key building blocks for both good physical and mental health. People with mental illness often struggle to eat a healthy diet and are more likely than the general population to be obese and suffer from diabetes and other diet-sensitive diseases  (De Hert et al., 2011). This may in some cases be due to side effects of medications and/or sedentary lifestyles (Allison et al., 1999; Compton, Daumit, & Druss, 2006; Dipasquale et al., 2013; McCreadie & Scottish Schizophrenia Lifestyle Group, 2003). There is also evidence that there may be a causal relationship between poor nutrition and mental disorders including depression and anxiety (Melanson, 2007). In addition to the biological effects of an improved diet, the experience of taking control of one’s diet and taking care of one’s physical and mental health through that diet may support the recovery process; the development of self-efficacy – a sense of a competent and agentive self – has been shown to play a key role in recovery (Mancini, 2007).

Poverty and related food insecurity are also important factors in the connection between mental illness and poor diet (Compton & Shim, 2015; Compton et al., 2006) (Wunderlich & Norwood, 2006). People who are poor struggle to access and afford low energy density food that has a high content of vitamins and minerals, such as whole grains, lean meats, fish and fresh fruit and vegetables (Darmon & Drewnowski, 2008). People with mental illness are more likely than others to be poor and unemployed, with income from social security benefits for those unable to work leaving many recipients living below the federal poverty line  (McDonald, Conroy, Morris, & Jennings, 2015). A higher percentage of people with disabilities than those without are homeless, which compounds difficulties in maintaining a healthy diet (Folsom et al., 2005)

The Setting: Connecticut Mental Health Center, New Haven, CT.
Connecticut Mental Health Center (CMHC), founded in 1966, is one of the oldest community mental health centers in the United States. An enduring collaboration between the State of Connecticut Department of Mental Health & Addiction Services and the Yale University Department of Psychiatry, CMHC provides mental health services for 5,000 people in the Greater New Haven area each year. It is also a center for scientific advancement in the understanding and treatment of mental health and substance abuse disorders. CMHC, is a major training site for psychiatrists and psychologists from the Yale Department of Psychiatry and welcomes trainees from a variety of other disciplines including nursing, social work, and chaplaincy. Most if not all patients served live on low or very low incomes. CMHC aspires to follow a recovery-oriented model of care, and takes seriously the social determinants of health that affect many of its clients.

Recognizing the value of a healthy diet and the multiple barriers faced by people with mental illness in achieving a healthy diet particularly given poverty-related constraints, CMHC began in recent years to actively consider how to better incorporate diet and nutrition into care.  In 2010, CMHC leadership arranged for a farmers’ market to operate on site on a weekly basis between July and October. The market is made accessible to clients not simply through proximity and convenience, but also through an arrangement whereby SNAP benefits (food stamps) can be ‘doubled’ when purchasing produce ($2 of produce for every $1 of SNAP paid), and also through integrating distribution of farmers market vouchers into existing incentive programs at the Center.

Building on this first step in establishing its commitment to helping clients access healthy and affordable food and desiring to change its inpatient and retail cafeteria food service, CMHC leadership then hired a consulting firm, Fresh Advantage® LLC to develop an institutional food policy and a multi-faceted “master plan” to guide the change process. The master plan recommended redesign of the existing on-site retail cafeteria and dining space, including construction of a full scale commercial kitchen that would also be used for onsite preparation and serving of meals for the small inpatient unit (this unit had up until that point had meal service provided by the general hospital located across the street). The plan also provided for a competitive procurement process to bring a qualified food service management company to manage the entire operation.  The master plan also recommended providing educational, programmatic and clinical activities to address the nutritional needs of CMHC patients, including the creation of an onsite culinary garden and a community garden close to the center, with opportunities for patients to explore and learn in both spaces.

In 2013, after the plan had been finalized, members of the Fresh Advantage team, including a project leader, consulting chef and nutritionist, were hired to put the plan into practice. In order to promote the cultural change needed to fully realize the food systems transformation, the project team began by hosting a series of food tasting and educational activities on site for clients, staff and faculty. Symposia (e.g.,  “Hunger as a Health Issue”) and lectures by prominent authors were organized, including Michael Moss, author of Salt, Sugar, Fat (Moss, 2013); Daphne Miller MD, author of The Jungle Effect and Farmacology (Miller, 2009; Miller, 2013), and Drew Ramsey, MD, author of The Happiness Diet and 50 Shades of Kale (Drew, 2013; Graham & Drew, 2012).

In 2014, while construction and the procurement process were underway, work began on realizing CMHC’s long-term goal of providing individual nutritional counseling to every patient at CMHC who desired it. Given resource constraints CMHC leadership and the project team decided to pilot an individual nutritional counseling program as a service of the on-site “Wellness Center”  (a primary care clinic of a local federally qualified health center that CMHC clients may choose to use for co-occurring medical needs). While this decision limited the numbers of ambulatory patients who could participate in the pilot, it housed the service where clients were receiving their primary care, ensuring strong linkage to treatment for their physical health conditions and tracking of outcomes. Oversight by the supervising physician (boarded in internal medicine and psychiatry) provided additional support to the nutritionist and primary care provider. Once referral, medical records, logistical and other administrative systems were put place the project team nutritionist was able to coordinate client care with the APRN/primary care provider and supervising physician, and to access laboratory data and client medical records. The referral process enabled the primary care provider to identify patients with diet-sensitive medical conditions that could be better managed with nutritional counseling and improved diet and then offer the nutritional counseling to them.  Referral, screening and assessment forms were developed collaboratively with the primary care center staff, supervising physician-nutritionist and project leader, then submitted and approved to the medical records committee. The assessment forms include screening for food insecurity using two USDA validated questions. Cooking and food shopping habits along with food dairies were also assessed. Peer health navigators in the clinic supported clients with respect to scheduling and keeping of appointments with the nutritionist.

Within a short time, the nutritional counseling sessions revealed low to very low food security (as defined by the USDA), lack of basic cooking skills and equipment, erratic patterns of meal consumption and significant barriers to accessing nutritious and affordable foods due to poverty. This combination of features of life circumstances made it difficult, if not impossible, for clients receiving the counseling to act on the learning gained in their sessions. It also gave rise to the second additional component of the comprehensive food system initiative plan: the “Better Eaters Club.”

Better Eaters Club Program
The “Better Eaters Club” was designed consistent with the Community Support Programs (“CSP”) model originally developed in 1977 by the National Institute for Mental Health for individuals with persistent and serious psychiatric illness (Turner J, 1978). Consistent with the CSP principles of rehabilitation, recovery, and integration into the community, the curriculum was also informed by the prior experience of the consulting chef and Project Leader in developing food learning curricula for at risk youth and their families and cancer survivors who are also nutritionally deficient due to their specific life circumstances.  Importantly, as a skill-building program, the service is a Medicaid billable activity.

With the consulting chef taking the lead, a six-session curriculum was developed through an interdisciplinary process that included input from occupational therapists in the outpatient rehabilitation department at CMHC, a social anthropologist in the Department of Psychiatry with expertise in promoting financial health and skill building among CMHC clients living in poverty, and peers involved in the nutritional counseling program. The curriculum takes into account the environments in which people live, including local access to affordable, healthy food ingredients, income constraints, and access to cooking facilities and equipment. The Better Eaters club was piloted in early 2015 with a cohort of six clients who had been referred by the nutritionist and were receiving ongoing individual nutritional counseling from her.

The approach is highly interactive, offering a group learning experience with the goal of empowering clients living in the community to meet their basic nutritional needs and to experience the psycho-social benefits that can accompany preparation of and sharing meals.  The format of each session is consistent, with preparation and sharing of a recipe/meal forming the core of the session. Each session includes the following components: i) sign in/set up, including overview of session, tasks and “prep”, discussion of group and individual goals; ii) preparation of food item; teaching of culinary skills and the simple equipment necessary (knife, vegetable peeler, cutting board) to prepare the item; discussion of topic of the day using the food item prepared as a guide; and iii) debrief, the “take away” of the day, discussion of what was done best as a group, what can we improve, and establishing a goal for the next session. Many recipes prepared are taken from the Good and Cheap: Eat Well on $4 a Day cookbook by Leanne Brown (Brown, 2015). Each participant is provided with a copy of the cookbook, along with a backpack for food shopping, and notebooks for keeping handouts and notes.

The topic order of the six-week series is as follows, with each session being a complete learning experience in and of itself, not conditional upon participation at each preceding session although attendance at all is strongly encouraged and optimal:

Better Eaters Club 1.0 curriculum
Session One: The Best Snacks: Make simple to prepare, delicious and nutrient dense foods that are fulfilling and help counteract hunger surges associated with psychoactive medications.

Session Two: How to Build Your Pantry: What, how, when and where to buy key staple items to create multiple meals with a limited variety of high quality foods.

Session Three: Create your Food Budget: Use monthly income, benefits and community resources to meet dietary needs.

Session Four: Community Shopping Field Trip: Find the best places for quality foods at affordable prices, and recognize the value of a shopping list

Session Five: Food Safety: What labels and expiration dates really mean. Prepare a meal from the “mock pantry” to facilitate understanding of food safety practices for animal proteins, fish and dairy. Save scraps and avoid food waste.

Session Six: Celebratory meal:  Prepare and enjoy a meal together, with participants’ their choice of menu. Raffle of special culinary gift basket, an incentive announced at the outset of the series.

Better Eaters Club Experiences to Date
While the Better Eaters club as an element of the organization wide “food transformation initiative” is a work in progress, many benefits have already been observed. Participants were extremely enthusiastic and excited about the class, both in anticipation of what they would learn, and after learning it. As one client put it after one class, “you two [the chef and the nutritionist] were like a big sink of water and we were the sponges”.  She said of the chef – “Chef Anne didn’t just go to cooking school, she has a gift”. During the sessions, particularly when they were actively engaged in food preparation and cooking, the atmosphere was one of joy and serenity. The clients said that when they were engaged in the task at hand, their minds were at rest. One client said to the chef, as she chopped carrots “my voices are telling me that they like you”. There was a strong sense of community, of belonging, and of coming together on a joint endeavor.

The staff involved in the program not only teach cooking skills, but also help participants overcome fears or other anxieties associated with food and its preparation. During the sessions, participants expressed these doubts and fears. Some were nervous about using the knife, others expressed a lack of confidence about experimenting with recipes, and some were concerned about particular ingredients. When participants expressed their concerns, staff reassured them, and also took the opportunity to use the moment to discuss broader food issues.  For example, one participant expressed concern about the amount of salt she saw going into the food, worrying that it might be unhealthy.  The chef reassured her that she was using a healthy quantity of salt that would heighten the flavors of the dish, making it more balanced and delicious, and that they would feel more satisfied after they had finished eating. She then took the opportunity to start a conversation about fast food, explaining that the amount of salt she was adding was minimal compared to the amount of salt in processed or fast food, which surprised all the participants present.

Over time, clients noted that they were beginning to apply what they were learning at home – eating smaller portions, choosing healthier ingredients, and exercising more. The confidence they gained in the “teaching kitchen” was translated into their daily lives where they began to experiment with new foods and coached their peers in food matters. One participant said, “My eating habits have changed. Rather than a daily bagel I have only had 2 or 3 since I last met with [the nutritionist]”. Another explained “I eat when I’m hungry, more quality foods, and I always cook my food so I know what is in it”.  One participant said that he was not eating at night so frequently, a problem that had plagued him as a result of his medication. They also spoke of purchasing ingredients they had never bought before, based on what they had learned in class, starting to grow fresh herbs at home, and shopping at farmers’ markets. One client told us, “When I was working at Wendy’s, kale was just a decoration on the salad bar, a garnish. Now I can’t get enough of it”.  Yet another client exclaimed, “ I never knew something without meat could taste so good.”

The mix of facilitators was well received by participants. They appreciated the nutritionist’s detailed knowledge about the chemical make up of food, and the chef’s skill, carrying the lessons they learned from her to their own kitchens. As one participant put it, “I hear Chef Anne’s voice while I’m cooking, instructing me or telling me not to do something!” One participant said “You all bring your own perspective to the group, you are all very supportive”.

Integrating discussions about finances into the sessions was helpful, especially when coupled with use of the “mock pantry” so clients could learn how to get through the month using inexpensive kitchen staples. Participants were happy to share their own specific financial situations, and shared experiences and strategies that they used to afford groceries on very limited budgets.  The chef and the financial health specialist worked together to ensure that the recipes being taught were within the financial constraints of most participants (most rely on food stamps, a total of approximately $190 per month, or $6 a day). The need for food to be affordable was a theme running through all the sessions; in discussions about balanced meals, for example, the chef would explain that even a small portion of a high quality protein such as fish was worth preparing, alongside large portions of vegetables to fill the stomach.  During the shopping trip there was an emphasis on affordability, with participants comparing the cost of different items at different stores. Many were surprised that many items were cheaper at a health food store, rather than from the supermarket that they usually shopped at. One client said “I didn’t know I could eat healthy on my budget, now I know it’s possible”.

A number of participants organized one-on-one financial counseling sessions separately from the Better Eaters Club meetings upon hearing that the financial specialist offered such counseling, to follow up on financial issues discussed during the class. One participant took advantage of those financial counseling sessions to support her realization of a long-held dream of becoming a chef, by starting a savings plan to enroll in culinary school.

There is currently no process in place for formal evaluation of the Better Eaters Club, since the pilot was developed to first develop and test the organizational logistics associated with offering and sustaining the program within CMHC and the appeal and ease of delivery of the curriculum, given reliance on institutional resources (space, transportation to venues for certain sessions, peer support to facilitate attendance). However, all clients participating in the Better Eaters Club pilot to date are also participating in one-on-one counseling, and their health data is tracked as part of the counseling process. The profile below in figure one demonstrates the impact that the interventions in combination can have on individuals who are able to participate in both consistently.

Figure One: A Client Profile: Impact of Combined Individual Nutritional Counseling and the Better Eaters Club
Joe, a 49 year-old male client of the CMHC Wellness Center was referred in October 2014 by his primary care provider to the nutritionist with several conditions that could be improved with counseling, including:

•    GERD
•    Hyperlipidemia
•    Pre-diabetes
•    Sleep Apnea
•    Dermatitis

The nutritionist provided a ‘food prescription’ to the client including changes to his current diet, educated him regarding portion sizes and referred him to the Better Eaters Club. He was asked to revisit the nutritionist every 2 months, in addition to informal check-ins at the Better Eaters club (when the nutritionist was present at the sessions). The client continued to meet regularly with the nutritionist and over a period of nine months, lost 21 pounds and sustained reductions in his blood sugar non-fasting, cholesterol and A (1) C laboratory test values. He also reported improvements in his GERD sleep apnea and dermatitis symptoms

As the client put it, regarding his new diet – “Don’t call it a diet because that is something you go off; this is the way I am going to eat for the rest of my life”. He then went on to become a peer facilitator in the future sessions of the Better Eaters Club.

At the final celebratory session, the first cohort of clients themselves then insisted that a second six-week series be developed, entitled “Better Eaters Club 2.0”.  With their input, the consulting chef and team created a second curriculum and all clients who participated in the “1.0” series participated in six more sessions addressing the following topics:

Better Eaters Club 2.0 curriculum
Session One: The Five Tastes: Explore your palate, and understand why a balanced plate is important. Address cravings and achieve healthy satiety.

Session Two: Virtual Shopping Using the Mock Pantry: The importance of meal planning and preparation, using shopping lists, budgeting, and prioritizing nutritious foods.

Session Three: Recipe Reading: Improvise, find healthier alternatives, and how to use seasonings. Use recipes as suggestions.

Session Four: Food Myths and Common Misconceptions: Understand the difference between “good and bad” sugars, and the impact of sugar on physiology. Understand what “natural” foods are. Address personal food fears. Manage cholesterol and diabetes.

Session Five: Meal Planning and Shopping Trip: Plan and shop for meal to be Prepared Following Week. Review food storage, food safety, and product shelf life.

Session Six: Celebratory Community Lunch: Prepare and eat a meal together, with menu items reflective of all five tastes.

Challenges and Plans for Better Eaters Club Expansion
The Better Eaters club has not been without its challenges.  The ideal space for the class would be a teaching kitchen, but no such space existed in the Center. The chef brought portable burners with her to class, but it was not easy to find a space at the Center where these burners could be safely used. This situation will be remedied in 2016 since funds have now been secured to renovate an underutilized kitchen space on the transitional living patient floor into a full-scale teaching kitchen.

While the Better Eaters Club is targeted specifically at low-income people, limited finances remain a problem for some clients. As one client explained, when she was asked if she had ever eaten hummus (the class had prepared home-made hummus that day, using a food processor), “I don’t do all that cause I don’t got the machines.” The same client also mentioned that she did not currently have a working freezer at home, and needed to replace her refrigerator. Another client mentioned how exhausted she got carrying her grocery bags full of shopping to her home. Clients told use that they found the prices to be higher at grocery stores at the beginning of the month, right when they need to replenish their supplies (we have no evidence that this is indeed the case, but clients clearly find it difficult and stressful to afford to buy the ingredients they need).

Attendance became a problem when Better Eaters Club 1.0 was offered for the second time, to a new group of Wellness Center clients referred by the nutritionist. The initial group of students remained extremely enthusiastic, having advocated for Better Eaters Club 2.0, and taking on peer worker positions for the subsequent class series to support the facilitators. The second cohort was more difficult to recruit, partly due to a fairly onerous referral process, and an inadequate marketing strategy.  Those who did join the group did not always attend regularly. Recognizing the complex lives of many clients, the facilitators worked to support their regular attendance. A peer led reminder system was established, whereby a peer worker would call participants the day before to remind them about class and check that they planned to attend.

The Center is committed to continuing the classes, and is opening the Better Eaters Club to all CMHC ambulatory clients (not just those receiving care in the Wellness Center) by working directly with the clinical teams that provide mental health care and creating a simple referral process. The club is also developing a marketing and communications strategy with support from those CMHC departments to ensure that all clients and clinicians know about the benefits and enjoyment that can be gained from participation in the Better Eaters Club. An evaluation mechanism that builds upon the qualitative data gathered to date will be put in place, tracking not only participants’ health indicators (for those who agree to provide this information) but also their subjective perceptions of how participation in the club may have affected their knowledge of food issues, and their cooking and eating habits. As the program develops, we will continue to learn from our experiences, and adapt and innovate accordingly to ensure that we are reaching as wide a group of clients as possible with an effective and meaningful program.

Conclusion
We know that people with mental health problems struggle more than others to achieve good physical health, we know there is a connection between physical health and diet, and we know that people who are poor are more likely to have unhealthy diets.  The Better Eaters Club targets all of these inter-related problems, by providing low-income people with mental illness with hands-on education about nutrition and food preparation that takes into consideration the financial constraints within which they live.  Importantly, the changes that the Better Eaters Club aims to effect are supported by the wider clinical context in which the classes take place. Throughout CMHC there is a visible and explicit recognition of the importance of healthy food and nutrition, in the form of the well-appointed, professionally run cafeteria that serves healthy meal options, the weekly farmers’ market, the onsite culinary garden, and regular events relating to food, nutrition and the wider food system. All of these components of CMHC’s food transformation plan buttress one another, as part of the overall mission of providing truly holistic mental health care.

Funding and Support
The CMHC Food System Transformation initiative is funded by the State of Connecticut Department of Mental Health and Addiction Services  and the CMHC Foundation, which provides support for innovative pilot programs at CMHC. The Wellness Center at CMHC is funded by a grant from the Health and Human Services Administration/SAMHSA.



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