Chronic diseases (eg: heart disease, stroke, DM, kidney disease, cancer) account for 5 of the top 10 causes of death in our country. Obesity is a well-known risk factor for all these chronic diseases, and we have almost 40% of US adults and 20% of children obese in the US, and the COVID pandemic has only worsened these trends. We currently have outstanding innovations in the field of medicine that focus on medications, delivery methods, and surgeries, yet our communities continue to struggle with chronic disease management and increasing rates of obesity.

It couldn’t be emphasized enough that nutrition plays a major role in the prevention, risk reduction, and management of obesity and chronic diseases. Yet, healthcare models lack focus on it. My work is to highlight the power of nutrition in obesity and chronic disease prevention, risk reduction, and management in a model of integrated care.

The challenge was to create the nutrition-focused model in an FQHC (Federally Qualified Health Clinic) setting, with communities that are uninsured or underinsured, lack access to transportation, have limited means and income, rely on community health clinics for their comprehensive care, and all these barriers further muddled with insurance payment models failing to focus on prevention. The interviews with the stakeholders - patients and their caregivers, clinicians, leads from other departments, and healthcare leaders from other organizations to understand the needs of the community and the success/failures of previous efforts in this arena and community-based organizations - proved to be extremely vital in shaping the direction of this project.