From time to time, most strategic grant-making organizations review their programmatic priorities, assessing the needs and opportunities in a given area and figuring out what role a foundation could play in it. When the New York State Health Foundation’s (NYSHealth’s) board and staff began reviewing its strategic priorities in 2014, we grappled with how we could have the most impact given our modest resources. (Our annual grants and operations budget is approximately $15 million—a modest sum in a state expected, by 2020, to spend more than $300 billion annually on health care!)
One question for us was how best to tackle challenges outside of the medical care delivery system that have an impact on New Yorkers’ health. Doing so meant taking a hard look at our work to address the diabetes epidemic to see whether we were targeting the right populations to achieve the most impact.
An important priority for NYSHealth since our inception in 2006 had been reducing the toll of Type 2 diabetes in New York State. We singled out this type of diabetes (which primarily affects adults) for two key reasons: (1) its incidence and prevalence were increasing (while for some other chronic conditions, like asthma, rates were actually declining) and (2) it could be both prevented and managed, so we could use both community-based and clinical interventions.
Initially, we focused most of our attention on improving primary care and outcomes for patients with diabetes. By the end of 2013, we had helped more than 3,000 health care providers achieve National Committee for Quality Assurance (NCQA) recognition for excellent diabetes care and outcomes; these providers care for approximately 600,000 of the 1.8 million New Yorkers with diabetes.
We felt good about our clinical work, but we also saw needs and opportunities for the prevention—not just treatment—of diabetes. The need is great: more than 4 million New Yorkers have prediabetes, a condition that puts them at high risk for developing diabetes and its complications (including cardiovascular disease, kidney disease, nerve damage, and complications with their eyes and feet). And a key opportunity is to ensure that more New Yorkers with prediabetes have access to the National Diabetes Prevention Program (NDPP), a lifestyle modification program that has been shown to help participants lose 5–7 percent of their body weight and reduce their risk of developing diabetes by 50 percent.
In 2010, NYSHealth supported YMCAs in ten regions across New York State to deliver the NDPP, and in 2013 the foundation provided grants and technical assistance to twenty-five other community-based organizations to implement, expand, and secure the sustainability of the NDPP.
But we grew concerned that our investment would not be sufficient to reach a substantial number of New Yorkers with prediabetes. In addition, we wondered whether our approach was too narrow: by targeting those adults at highest risk for developing diabetes, were we missing an opportunity that could help a wider swath of New Yorkers of all ages to lead healthy lives and maintain a healthy weight?
Should we be thinking beyond diabetes, and beyond just those at highest risk?
As we often do, we looked to other leading health foundations to inform our thinking. Some of our peer foundations were focused more broadly on “healthy communities” (for example, the California Wellness Foundation’s Promoting Healthy and Safe Neighborhoods efforts include attention to environmental justice and violence prevention).
Other funders had chosen to focus at least some of their efforts on childhood obesity (for example, the Colorado Health Foundation’s Healthy Living priority area addresses opportunities for young people to eat healthy foods and engage in physical activity, and the Missouri Foundation for Health focuses primarily on childhood obesity in its Healthy Schools Healthy Communities initiative). And, of course, the Robert Wood Johnson Foundation has committed $1 billion in the area of childhood obesity as a key element of creating a “culture of health.”
It seemed logical that an exclusive focus on children could lead to enduring success. From a classic prevention perspective, if we can ensure healthy patterns of eating and exercise among children and keep them fit and healthy, it may be the best path to avoiding diseases like diabetes that are related to what we eat and how much physical activity we get every day of our lives.
But what about those adults at high risk of developing diabetes and other obesity-related conditions? Would we be swinging the pendulum too far if we focused only on kids?
A recent New York Times op-ed by Tom Farley, the former health commissioner of New York City, reminded me of the debates NYSHealth had internally as we grappled with these questions. Farley posits that investing in children alone is actually a risky bet in the battle against obesity and related conditions, because “[w]hile obese children tend to become obese adults, about 80 percent of obese adults were not obese as children, and more than half were not even overweight.”
These numbers suggest that investing in children very well could be worthwhile and should be part of the battle plan when it comes to tackling obesity and conditions like diabetes. But, addressing the problem only for children cannot be the entire battle plan.
A holistic approach that creates community environments encouraging healthy living for everyone, regardless of age, makes sense to me.
Ultimately, this is where NYSHealth has decided to focus its efforts. The main part of our battle plan, which we call Building Healthy Communities, is focused on changing community environments in six neighborhoods throughout New York State so that healthy foods and physical activity become easy choices for residents. We aim to improve the availability of affordable healthy foods, increase access to safe places to exercise, and encourage physical activity throughout every resident’s normal day. And, if these interventions lead to good outcomes, we hope other funders in our state step in to help us spread the idea to more communities.
This approach is not without its challenges—it will require years to achieve our ultimate goal: a meaningful impact on rates of physical activity and consumption of healthy foods in these communities. Although it is encouraging to see important progress (for example, the addition of farmers markets or improvements to local parks) being made more immediately, it will require much more time for those improvements to lead to actual changes in behavior.
And our support is only a small fraction of the investments happening in these areas; so, while we know we are contributing, how can we measure precisely what NYSHealth’s specific impact has been in the communities we fund? This comprehensive strategy, targeting all residents of vulnerable communities, is certainly more difficult to evaluate than our earlier work, in which we could simply count the number of health care providers delivering excellent diabetes care, was!
But philanthropy is often more art than science, and we feel confident that we will see palpable change in our targeted communities in the coming months and years.
“Project ECHO Is Awarded $6.4 Million Grant For Diabetes And Endocrinology Care To New Mexico Underserved,” by Tracy Gnadinger, GrantWatch section, Health Affairs Blog, July 23, 2014.
“New York State Health Foundation’s Diabetes Campaign Is Influencing Practices to Improve Care,” by Harris Meyer, GrantWatch Profile, Health Affairs, January 2012 issue.