The Doctor Said to Eat Better, but With What? Presenters: Tori Makal, PhD Assistant Professor of Biochemistry Wendy Welch, PhD, MPH Executive Director, GMEC

1. Food Insecurity as a Catalyst for Medical
Mistrust in Appalachia
The Doctor Said to Eat Better, but With What?
Presenters: Tori Makal, PhD
Assistant Professor of Biochemistry
Wendy Welch, PhD, MPH
Executive Director, GMEC*
*Graduate Medical Education Consortium

2. A Long and Winding Road
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Food Insecurity
Medical Mistrust
Appalachian Health Disparities
Undergraduates in Action
Earning Trust
Nutritional Footprints
The Future
We are Here

3. “You are what you eat.”
• Interpretation:
• If you eat healthy food, then you will be a
healthy person.
• If you eat unhealthy or “junk” food, then you will
be an unhealthy person.
• Reality:
• You eat what you can afford.
• Affordability > nutritional value
• You eat what is available to you.
• Availability > nutritional value
• Food budgets must stretch the whole month.
• Shelf life > nutritional value
• Food deserts significantly limit what is available.
• Availability above all else
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4. Defining the Catalyst
• Applying scientific concepts
• Catalysts make reactions happen faster
• Reduces the amount of energy required to start
the reaction
• Reactions happen more easily
• Example: “The doctor said to eat better.”
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𝐂𝐚𝐭𝐚𝐥𝐲𝐳𝐞𝐝 𝐑𝐞𝐚𝐜𝐭𝐢𝐨𝐧: Vague Doctor Instructions + Limited Patient Resources Medical Mistrust
FOOD INSECURITY
𝐁𝐚𝐬𝐞𝐥𝐢𝐧𝐞 𝐑𝐞𝐚𝐜𝐭𝐢𝐨𝐧: Vague Doctor Instructions + Limited Patient Resources Medical Mistrust
Image Courtesy of Fuel Cell Store

5. Food Deserts Overlap with Health Professional
Shortage Areas (HPSA)
• Appalachian counties
• 89%  HPSA
• 90%  food desert
• Counties with above average children
in poverty
• 75%  HPSA
• 69%  food desert
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Source: https://www.ncahd.org/healthcare-workforce-research/

6. The Current Situation
• What does it mean for Appalachia?
• Higher mortality rates in 7 leading causes of death
• Dramatically higher in areas of economic distress
• Obesity, sedentary lifestyle, smoking, etc.
• Connecting the dots
• HPSAs overlap with areas of food insecurity
• Food insecurity has health implications
• Health implications can be managed with
preventative care
• Mistrust makes people less likely to seek care
• Lack of care results in health disparities
• Health disparities  confirmation bias
• “I see exactly what I expected to see.”
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https://www.arc.gov/report/virginia-health-disparities-and-bright-spots/

7. Identifying Research Questions
• Will community immersion and experiential learning at the undergraduate improve long-term
retention of heath professionals?
• How does community immersion impact nutritional curriculum development?
• Can community relationships and rates of preventative care be improved through experiential
learning at the undergraduate and graduate levels?
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8. Setting the Scene
• Graduate Medical Education Consortium
(SWVA-GMEC)
• Goal: get more medical professionals with
cultural competence to practice in Appalachia
• Problem: Medical residents have been
through medical school
• Have already formed opinions and biases
• Erosion of empathy (Hojat et a. 2009)
• Changes in moral development (Patenaude et al.
2003)
• Changes usually occur in MS3
• Before residency even begins (Newton et al., 2008)
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9. New Focus: Undergraduates
• The Baby Opossum Hypothesis
• Carry them for a while, and they will grow big
and strong
• UVA Wise Future Professionals
• Interdisciplinary group of undergraduate
students from all years
• Predominantly interested in pursuing careers in
medicine
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• Goal: use experiential learning to train students
• Circumvent and prevent erosion of empathy
• Understanding the lived experience of patients
• Get them to come back to Appalachia to practice
• Continuing to lead by example

10. Phase 1: Earning Trust Through Community Immersion
The Community Side of Things
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11. The Community at Inman Village
• Family low-income housing apartment
• Section 8 Project-Based Rental Assistance
• Demographics
• Single mothers with kids and the elderly
• Most families are on public assistance or social security
• Many villagers have disabilities
• 5-9% are working families
• Food desert
• 2 stores in Appalachia sell groceries
• Neither of them is an actual grocery store
• Inman Village is 3.5 miles from both
• 1 in 3 Inman Village residents owns a car
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12. Phase 1: Earning Trust
• Goal: Demonstrate how to cook reliably healthy
meals in food deserts.
• PPC prepares a healthy meal at each event
• Ingredients sourced from local discount store*
• Fresh produce provided through gleaning
• Give out recipe cards
• Collab with FoodShare SC & Feeding SWVA
• Engaging the community socially
• Spaces include community church or park
• Door knocking to recruit attendees
• Children’s seasonal craft at every event
• Meal deliveries for villagers with mobility restrictions or
disability
• Educational gaming for adults
• Exercising empathy and humility
• Food dump mishap
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13. Learning to Ask the Right Questions
• Collaboration with VCOM and ACP
• Students offered free medical and health services
• Blood pressure checks
• Medication reviews
• COVID testing
• Villagers did not use their services
• Why?
• Ask and learn vs. assume and alienate
• “Why doesn’t anyone want our help?”
• Implication: Villagers are ungrateful, lazy, and apathetic about
their own health.
• “What can we do to make people feel comfortable
accepting our help?”
• Implication: Our approach needs refinement
• Even failure is a learning experience.
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14. Phase 2: Developing a “Nutritional Footprint”
The Science Side of Things
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15. The Obesogen Hypothesis
• What are obesogens ?
• Chemical agents that increase susceptibility
to obesity
• Egusquiza and Blumberg, 2020
• Obesogens disrupt adipocyte
development
• Adipocytes increase in number
• Change in gene expression
• Alteration of microbiome
• Hormone signaling disruption
• What does it mean?
• Diet is more than just calories in vs calories
out
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16. Developing Science-based Nutritional Information
• Hypotheses
• Products available in food deserts contain higher levels of
obesogens.
• Scientifically-guided nutritional curriculum can encourage self-
selection of foods with reduced obesogen content.
• Constraints: limited time, budget, and resources
• Understanding the lived experience
• Goal: Identify the healthiest choices from the items we can
access.
• Footprint = what is available at local discount store to
individuals living in Inman Village
• Cross-list with items available through EBT/SNAP
• How will items be classified?
• pH testing
• Ingredient analysis
• Relative obesogen content
• HPLC and UV-VIS
• Sodium benzoate and potassium sorbate
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17. Ingredient Survey of Select Drinks at Hometown Variety Discount
Soft
Drinks
Name Calories Sodium Carbs Sugars Caffeine (12 oz.) Artificial Sweetener Sodium Benzoate
Sunkist Berry Lemonade 170 60 mg 44 g 43 g - - Y
Sunkist Cherry Limeade 170 60 mg 44 g 43 g - - Y
Sunkist Orange 160 65 mg 44 g 44 g 19 mg - Y
Simple 7Up 110 40 mg 28 g 28 g - Y -
RC Cola 160 40 mg 43 g 43 g 43 mg - -
7Up Zero Sugar - 45 mg - - - Y -
A&W Cream Soda 170 70 mg 46 g 46 g - - Y
Non-Soft
Drinks
Name Calories Sodium Carbs Sugars Caffeine (12 oz.) Artificial Sweetener Sodium Benzoate
Vitamin Water Fresh Squeezed - - 4 g - - Y -
Vitamin Water XXX - - 3 g - - Y -
Vitamin Water Rise - - 3 g - - Y -
Vitarain Zero Açaí Blueberry Pomegranate - - - - - Y -
Capri Sun Fruit Punch 90 25 mg 21 g 20 g - - -
Orgain Kids Protein Shake - Chocolate 180 130 mg 21 g 9 g - - -
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18. pH of Select Drinks at Hometown Variety Discount
3.05 3.18 3.22
2.90
2.50
3.55
3.97
3.16 3.13 2.93 2.80
3.57
6.86
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
pH
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19. Why start with pH testing?
• Acidic drinks erode dental enamel
• pH < 4.0 is associated with increased risk of
erosion (Reddy et al. 2015)
• Erosion = demineralization  tooth
decay
• Rates of unmet dental needs are higher in rural
populations (Martin et al. 2017)
• Increased risk of periodontal disease, cavities,
and tooth loss among adults
• Untreated dental disease can have systemic
consequences
• Implications: sodas are not the only culprits for
tooth erosion
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20. Victories
Progress happens one step at a time.
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21. Since October 2021…
• Addressing food insecurity in Inman
• Mobile Market collaboration
• Fresh produce = cost-effective and available
• Accepts SNAP/EBT
• Feeding Southwest Virginia Summer Meal Program
• Weekly: 5 breakfast, 5 lunch shelf-stable meals
• Each Inman Village child for the duration of the summer
• Program starts the day after schools stop and ends the
day before schools reopen.
• Recipe library collaboration with FoodShare SC
• Gaining Support
• Collaborations
• Appalachian College of Pharmacy
• Lincoln Memorial University – DeBusk COM
• Public involvement
• News articles
• Conference presentations
• Ukranian connection!
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22. Gratitude
• UVA Wise Pre-Professional Club
• President – Haley Sykes
• Vice President – Kaley Sykes
• Our amazing student volunteers!
• Graduate Medical Education Consortium of SWVA
• Wendy Welch, PhD, MPH
• Collaborators
• UVA Wise - Ryan Huish, PhD
• Feeding Southwest Virginia – Mobile Market
• FoodShare South Carolina
• Appalachian College of Pharmacy
• Lincoln Memorial University
• Marybeth Babos, PharmD
• Inman Baptist Chapel
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23. “
A hungry man can’t see right or wrong.
He just sees food.
- Pearl S. Buck
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24. Key Citations
• Feeding America, 2014. Hunger in America 2014 – National Report. Available online at: https://www.feedingamerica.org/research/hunger-in-america
• Seligman, H. K. and Shillinger, D. 2010. Hunger and Socioeconomic Disparities in Chronic Disease. The New England Journal of Medicine, 363:6-9. doi:10.1056/NEJMp1000072
• Laraia, B.A., Leak, T.M., Tester, J.M. and Leung, C.W., 2017. Biobehavioral factors that shape nutrition in low-income populations: a narrative review. American Journal of
Preventive Medicine. Vol 52(2:2), pp. S118-S126. https://doi.org/10.1016/j.amepre.2016.08.003
• Hadley, C., & Crooks, D. L. (2012). Coping and the biosocial consequences of food insecurity in the 21st century. American Journal of Physical Anthropology, 149(S55), 72-94.
https://doi.org/10.1002/ajpa.22161
• Berkowitz, S. A., Seligman, H. K., & Choudhry, N. K. (2014). Treat or eat: food insecurity, cost-related medication underuse, and unmet needs. The American journal of medicine,
127(4), 303-310.
• Shan, Linghan & Li, Ye & Wu, Qunhong & Liu, Chaojie & Jiao, Mingli & Hao, Yanhua & Han, Yuzhen & Gao, Lijun & Hao, Jiejing & Wang, Lan & Xu, Weilan & Ren, Jiaojiao. (2016).
Patient Satisfaction with Hospital Inpatient Care: Effects of Trust, Medical Insurance and Perceived Quality of Care. PLOS ONE. 11. 10.1371/journal.pone.0164366.
• Hojat M, Vergare MJ, Maxwell K, Brainard G, Herrine SK, Isenberg GA, Veloski J, Gonnella JS. The devil is in the third year: a longitudinal study of erosion of empathy in medical
school. Acad Med. 2009 Sep;84(9):1182-91. doi: 10.1097/ACM.0b013e3181b17e55. Erratum in: Acad Med. 2009 Nov;84(11):1616. PMID: 19707055.
• Patenaude J, Niyonsenga T, Fafard D. Changes in students' moral development during medical school: a cohort study. CMAJ. 2003 Apr 1;168(7):840-4. PMID: 12668541; PMCID:
PMC151989.
• Newton BW, Barber L, Clardy J, Cleveland E, O'Sullivan P. Is there hardening of the heart during medical school? Acad Med. 2008 Mar;83(3):244-9. doi:
10.1097/ACM.0b013e3181637837. PMID: 18316868.
• Griffith DM, Bergner EM, Fair AS, Wilkins CH. Using Mistrust, Distrust, and Low Trust Precisely in Medical Care and Medical Research Advances Health Equity. Am J Prev Med.
2021;60(3):442-445. doi:10.1016/j.amepre.2020.08.019
• Williamson LD, Bigman CA. A systematic review of medical mistrust measures. Patient Educ Couns. 2018 Oct;101(10):1786-1794. doi: 10.1016/j.pec.2018.05.007. Epub 2018 May
17. PMID: 29861339.
• Md. Sharif, Zatul Iranati & Mustapha, Alia & Jai, Junaidah & Noorsuhana, M.Y. & Md Zaki, Nurul Asyikin. (2017). Review on methods for preservation and natural preservatives for
extending the food longevity. Chemical Engineering Research Bulletin. 19. 145. 10.3329/cerb.v19i0.33809.
• Raquel Chamorro-Garcia, Almudena Veiga-Lopez. Chapter Twelve - The new kids on the block: Emerging obesogens, Advances in Pharmacology, Academic Press, Volume 92,
2021. Pages 457-484. https://doi.org/10.1016/bs.apha.2021.05.003.
• Riann Jenay Egusquiza, Bruce Blumberg, Environmental Obesogens and Their Impact on Susceptibility to Obesity: New Mechanisms and Chemicals, Endocrinology, Volume 161,
Issue 3, March 2020, bqaa024, https://doi.org/10.1210/endocr/bqaa024
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