David Hill: Lucia Leone learned early on what it meant to stretch the family's food dollars. Her mom had no car and rarely got to the supermarket, so Lucia had to get creative in between trips. Her go-to after school snack was a roll plucked from the freezer, dipped in red sauce. Occasionally, she'd get a pint of 99-cent rice from the Chinese place down the road, to which she'd sometimes add frozen peas and soy sauce.

Lucia Leone: Yeah, I remember complaining to my mom one time, “Why don't we have all the good snacks that my friends have?” And she said, “I don't buy food for snacks. I buy food to make meals.”

David Hill: Those words stuck with Leone, who today is an associate professor of community health and health behavior at UB and director of the Community Health Interventions Lab. Her work, a potent combination of research, community engagement and policy advocacy, focuses on interventions designed to give families in every neighborhood access to healthy foods along with the knowledge they need to prepare them.

Welcome to Driven to Discover, a University at Buffalo podcast that explores what inspires today's innovators. My name is David Hill, and in this episode, I'll be talking with Lucia Leone about closing the food gap.

Thank you for being here, Dr. Leone.

Lucia Leone: It's great to be here. Thanks for having me.

David Hill: How did your childhood influence your interest in nutrition?

Lucia Leone: Yeah, so when I was young, when I was over at my dad's house, we'd eat a lot of fast food, and then I'd come over to my mom's house, and she was concerned that I was eating all this junk. So she bought me a book called “How to Stay Alive and Well in the Fast Food Lane,” so that sparked my initial interest in nutrition, you know. And then as I got older and started to study nutrition and really learned about some of the disparities in people's access to healthy food, it really harkened back to what I saw in my childhood and what my mother went through—being reliant on some public assistance to get food and also not having a car and not being able to get to the grocery store. So she wasn't able to get fresh food a lot, and so we would have frozen foods and rely on our bread being frozen, our vegetables being frozen.

But what I did learn from my mom is that it was possible to make healthy food on a limited budget and be able to take what she could get at the grocery store, make meals, freeze things, save things and be able to get by. And I know that that's not necessarily everyone's capability when they don't have cooking skills, they might not have the utensils. So, you know, it really just helped me develop an empathy and understanding for the reasons why people maybe are not eating as healthy as they should. It's not always just not wanting to; it's a lot of times not being able to.

David Hill: And this was in Buffalo, correct, where you grew up?

Lucia Leone: Yeah, I'm originally from Buffalo. I grew up here through high school, went away for college for a little while and came back. But I grew up on the west side of Buffalo.

David Hill: So that actually leads to my next question, which is, you obtained your BA at Penn and then your PhD from the University of North Carolina at Chapel Hill, where you stayed for an additional three years as a postdoc and then a year as a faculty member. What was it that brought you back to Buffalo and UB?

Lucia Leone: The perfect job came up. It was to look at a cross between urban planning and community health, and so food access is right at the intersection of those two things. It was also a very ideal time. I actually interviewed for the job when I was three days out of the hospital with my first child, and the idea of being close to family was very enticing. I thought I might move around a little bit before moving back to Buffalo, but the combination of family and this perfect job for me really made that the time to come back.

David Hill: Now, before we get into your research, can you explain your use of the term nutrition security? Most people talk about food insecurity, what's important about this distinction?

Lucia Leone: I think our research has evolved a little bit over the past several years in terms of how we refer to it and how we talk about it. Nutrition security is a relatively new term that people have started using. And, you know, I was looking at food access, but with the goal of trying to increase fruit and vegetable consumption, which is really the central part of a healthy diet. And those two things together really are a perfect combination for describing what nutrition security is. Nutrition security is really the idea that you don't just have enough or a sufficient amount of food, but the food that you're eating is supporting a healthy, active lifestyle and helps reduce your risk of disease. And there's also, in the concept of nutrition security, really a focus on health equity as well—that food is culturally appropriate, that it's getting to people in an equal manner, regardless of your background, your race, where you come from, rural, urban, that type of thing.

David Hill: How big of a problem is nutrition security in the U.S.?

Lucia Leone: The food insecurity rates that we see are, on average, about 12% of people. We don't have a good measure for monitoring nutrition security specifically. Some of our own work has looked at the fact that, depending on the population, nutrition and food insecurity rates might actually be pretty similar, but that 12% food insecurity rate is not equally spread across everyone. Families with small children are likely to have some of the highest food insecurity rates. Lower income and minority groups, underrepresented groups, also have very high rates of food insecurity, more in the 20 and 30%. So a real focus of our work is trying to address those disparities, and why we see disparities for certain populations in their food security.

David Hill: What else is affected when somebody is experiencing food insecurity?

Lucia Leone: There are a lot of people who, you know, they may have money to buy food, but all the challenges around finding, buying, preparing healthy food can be barriers to being nutrition secure.

So a lot of my research actually focuses on how to make it easier for people who are receiving government assistance, like SNAP and WIC, to find, buy and prepare healthy foods. Because you think about, OK, maybe you're working two jobs, and your WIC benefits say that you can get a certain type of milk or a certain type of yogurt, but you go to your regular grocery store, and they don't have that certain type of milk or yogurt. So now you're jumping over to another grocery store and trying to find that food, and sometimes it gets to the point where it's like, “Well, what's the point? I'm just gonna not have the food.”

That mental load is just really taxing when you're trying to plan and prepare meals. There's a lot of executive function, a lot of thinking that goes into doing those things and being able to prepare food in a healthy way, being able to save money, being able to use your benefits effectively. I think I've only met one person in all of the focus groups that we've done with lower income families that said, “Hey, yeah, I get plenty of SNAP benefits. I don't have to worry about them running out at the end of the month.” And that was, you know, a stay-at-home mom who was able to cut coupons, go to multiple stores, plan her meals, do all those things, but not everybody has the bandwidth in their life to do those things. And I don't think that we should be expecting people with limited income to do all those things when the majority of us do not do all those things. And so that's why we have such a challenge with food security. Because even when we do have these safety net programs like SNAP, like WIC, getting enough food through those programs, getting enough benefits, and being able to use them can be really challenging to people.

David Hill: Now, much of your research is done in the community. One of those projects is the Veggie Van study. Can you tell us a little bit about that and what you've learned from that research?

Lucia Leone: Yeah, so Veggie Van is something I've been working on most of my career. It started when I was in grad school. I was in a business competition to start a healthy fast food restaurant that sold fresh, local, affordable food, but like healthy food at fast food prices. And we got a little money, we decided to start this nonprofit, but then we did a lot of focus groups and research with the people that we were trying to serve, which were lower income people in North Carolina, and they were like, “No, no, no, we don't go out to eat. We just need a place to get fresh, healthy food that actually looks decent, like that I want to actually eat.” You know, I would hear things like, “You have to go all the way into a wealthy neighborhood to get food that actually looks good to eat.”

So that really turned things around for me and so we started focusing on Veggie Van. Veggie Van is a mobile produce market that travels to lower income and underserved communities to sell fresh fruits and vegetables at prices generally below that of a supermarket. Focusing a lot on local food, offering nutrition education, using different behavioral economic techniques to try and encourage people to purchase more fruits and vegetables. Veggie Van also accepts SNAP and also offers incentives for people to buy more fruits and vegetables. So we tested out Veggie Van, it had a great impact on fruit and vegetable consumption in the communities that we worked with in North Carolina, so we decided to take this model and expand it nationwide.

And so that's the study that we just ended. That study is hopefully going to be published very soon, but interestingly, we did not see the exact same thing in the study on a nationwide basis. So what we did was work in 33 communities across the country. We saw that the Veggie Van users had greater improvements in food security compared to the non-users. And while we saw some trends towards greater fruit and vegetable intake in the people who were using Veggie Van, it wasn't as strong as when we did this work in North Carolina. And I think the biggest difference was, when we were running Veggie Van in North Carolina, we had a strong focus on nutrition and cooking education, and our partners across the country who were running Veggie Van in this newest study had a lot of challenges delivering cooking and nutrition education, especially in person, especially during COVID, especially even just right after COVID. So I think it really speaks to the fact that, you know, providing people access to food is necessary, but not sufficient for improving diet and improving nutrition security. They had the access, they improved their food security, but it really takes the nutrition and the cooking education to get them to be eating more fruits and vegetables, improving their nutrition security, not just their food security.

David Hill: You've also been collaborating with ECMC here in Buffalo on a “food is medicine” program for seniors, which is basically writing prescriptions for healthy foods. What have you discovered from that program?

Lucia Leone: This program was based on the premise that, you know, when you go to the doctor, they might tell you to eat healthier, but when you don't have the money to buy healthy food, or maybe even the knowledge to find, prepare, and maybe don't even like some of that healthy food, it is a challenging thing to do. So what ends up happening? People don't eat healthy. They don't get better. The doctor says, “OK, well, let me give you some medication instead.” But there's no step in there to really help facilitate them being able to get the food and eat healthier.

And so, the idea behind a food prescription is you get prescribed food instead of getting prescribed medicine, or maybe in addition to getting prescribed medicine. And so we actually focused on seniors who had some form of food insecurity. There is a lot of research that's happening that looks at, and focuses on, how does giving people healthy food improve diabetes, improve blood pressure, you know, improve X, Y and Z, cancer, any disease? Our focus was not on that. Our focus was on, how do we get people to use these food prescriptions? Because when you look in the literature, the rate of usage or redemption of the prescriptions, on average, ranges between like 9 and 18%. So you know, I'm a firm believer that if we can get people to eat the healthy food, they will be healthier. I don't think we need another research study to show that. But how do we get them to get that food prepared and eat it? How do we implement programs that people want to use?

And so, we looked at, well, what are the reasons people are not using food prescriptions? OK, so you give them a voucher or maybe a gift card to go to the grocery store and get some healthy food. I don't have a car, you know, how do I use my voucher? Or maybe you say you can go pick up the food at a food pantry. Well, I don't want to walk into a food pantry. That looks like a handout. I don't need a handout. You know, there's a lot of stigma surrounding free food, so we tried to address both of those things of transportation and stigma by doing home-delivered food to seniors. But also, not just addressing the issues of stigma and transportation, but also addressing other things that we know are so important to participants, quality being a huge one. We’re using food from local farmers, local meat and just really high quality products, because we know, more than any other group, people with limited income really value high quality food. The main reason behind that being is, if you go into a grocery store, you buy a bag of apples, you go to eat those apples in a couple days and they're bad, for some people, that's like a meal or two that they can't eat. So you don't want to buy food if you're concerned about the quality, and even when you're getting a food prescription, it's that dignity of having a high quality product and not feeling like I'm getting seconds or leftovers, right?

The second piece that we're trying to look at is the dignity of choice as well. So, a lot of programs, even if they do offer delivery, might just give you a box of a bunch of different foods. I've talked to some families, they say, “Well, you know, I got one of those boxes, but I had to give away half of it because it's not stuff my family would eat. I have kids with special needs, or I have dietary considerations or something. I can't eat that food.” So choice was a really important aspect, and, you know, I think we're one of the only programs in the country that was combining both delivery and choice, and I think that really made a difference. When we compared our redemption rates of our food prescriptions that we delivered to people's homes versus one where they got a voucher and could go pick up food at a mobile market, you're looking at a less than 20% redemption rate at the mobile market versus an 87% redemption rate for home delivery. So, you know, I think it just really speaks to the fact that when we make these programs easy to use, we're going to see a much higher impact.

David Hill: Can you tell us about some common nutrition security myths that are out there?

Lucia Leone: Yeah, I think something that we're seeing right now, which is really concerning, is that a lot of states are starting to limit what people can buy with their SNAP benefits. I heard the example on the radio the other day that in some states that are limiting sugary foods that you can buy with SNAP, that you can buy a granola bar if it has chocolate chips in it but you can't buy a granola bar that has a chocolate drizzle on it. These are the same exact things that we saw when we were working with the WIC program, that people just get so confused about what the guidelines are that they stop using their benefits to the full extent.

And I think that that idea that we have to limit what people are buying with SNAP dollars really comes from this idea that, “Oh, well, poor people are just going to spend their money on junk food.” It's this very paternalistic, like, “We need to tell them what they should be eating.” And you know, I always have come from a perspective that people generally know what's healthy and that they may just need the support, the education, the skills to be able to implement that. And I think that myth that poor people are spending their money on fast food is really not there. They don't have that money. They're cooking at home. They care about what's in their food. My current community advisory board that I'm working with is a lot of great women who have small children, and they're like, “I don't know what's in that food when I go out to eat. I don't trust what they're putting in it.” So, they're actually really concerned about what their family is eating.

David Hill: Is food insecurity a problem we can solve?

Lucia Leone: On a national level, and really on a social determinants of health level, the issue is economic, right? The biggest issue is people just can't afford enough healthy food. Yes, we need more education and those types of things. But that is not the core thing, right? We need jobs. Without having that, the next step is, OK, well then we need safety net programs. We have some of those safety net programs, but I think, as I was talking about before, most of them are not giving people the full amount of food and the full amount of benefits that they really need to be healthy. So, you know, advocating for changing those programs, but that's not where we are in our current political environment. Those programs are getting cut, not added to, so then it tends to fall more on the state and local actors, the food pantries, the food banks, to address food security by providing food.

In some ways, I like this trend of food as medicine, or this idea of getting a food prescription through your physician, because it does take away some of that stigma, but it's not a new thing. It's just a new way we're trying to get to people, and we're always just trying to come up with creative ways to get people fresh, healthy food and the education. And, you know, whether that's through Veggie Van, whether that's through food prescriptions, you know, just trying to come up with innovative ways to be able to basically provide a Band-Aid for the fact that at a larger societal level, we don't see food as a right, and we don't see a living wage as a right, and we don't see health care as a right.

David Hill: We've really covered a lot of ground today. Thank you so much for your time, Dr. Leone.

Lucia Leone: Yeah, thank you. It's been great to be here.