Providing planetary health diet meals to low-income families in Baltimore City during the COVID-19 pandemic

The COVID-19 pandemic has increased food insecurity, especially among low-income Black and His¬panic families in the United States. Food insecurity is associated with poorer health and higher mortality in adults and greater risk of impaired cognitive development and behavioral problems in children. Pro-viding food for low-income families is an important priority of the COVID-19 response. Food That Connects Us All is a program that provides healthy meals to low-income Black and Hispanic families in Baltimore City. The meals follow guidelines for the planetary health diet, a reference diet developed by the EAT-Lancet Commission to optimize health and be sustainable within planetary boundaries. The planetary health diet consists largely of vegetables, fruit, whole grains, legumes, nuts, and unsaturated oils, with a low to moderate amount of seafood and poultry and with little or no red or processed meats, refined grains, starchy vegetables, and added sugar. In a food survey, participants showed a high level of satisfaction with the taste, appearance, and healthfulness of the meals. Food That Connects Us All is a direct approach to reducing health disparities and demonstrates the feasibility of providing an ideal reference diet to vulnerable low-income families at high risk for poor health outcomes during the pandemic.

amount, but many households with children are already at the maximum amount (Kinsey, Kinsey, & Rundle, 2020). Given the lack of federal guidelines, an uneven patchwork of support has emerged across the country, causing concerns that COVID-19 will exacerbate existing health disparities and have profound lasting negative impacts (Kinsey et al., 2020).

The Planetary Health Diet
In 2019, the EAT-Lancet Commission proposed an ideal diet known as the 'planetary health diet' (EAT-Lancet, 2020;Willett et al., 2019). The diet is based on the best nutritional evidence available for optimizing health (defined by the World Health Organization as a state of complete physical, mental, and social well-being, and not just absence of disease [Preamble to the Constitution of WHO, 1948]) without surpassing planetary boundaries. The planetary health diet is a universal healthy reference diet that consists largely of vegetables, fruit, whole grains, legumes, nuts, and unsaturated oils, with a low to moderate amount of seafood and poultry and with little or no red or processed meats, added sugar, refined grains, and starchy vegetables ( Table 1). The diet is sustainable within planetary boundaries for six environmental processes that include climate change, land-system change, freshwater use, biodiversity loss, and interference with the global nitrogen and phosphorus cycles (Willett et al., 2019).

Description of the Model Program
A program known as Food That Connects Us All has served more than 50,000 meals in Baltimore City, Maryland, since the beginning of the COVID-19 pandemic. Food That Connects Us All was founded in mid-March 2020 by Alkimiah, a collaboration between the catering business Mera Kitchen Collective and the restaurant Alma Cocina Latina. It was created to address food insecurity in response to the pandemic. Alkimiah has received funding and support from the World Central Kitchen, founded by Chef José Andrés. Fresh fruit and vegetables, dairy products, and chicken are sourced from local organic farms, as much as possible, or received as donations of excess fresh produce from farms in Maryland and Pennsylvania. Fish and meat are obtained from local purveyors. The coordinating chef plans the menu daily with five cooks in the kitchen of Alkimiah. The founding principles of Food That Connects Us All include providing healthy, sustainable diets to people in need. The meals generally follow guidelines for the planetary health diet (Table 1) (EAT-Lancet, 2020; Willett et al., 2019). Examples of meals include (1) salmon cakes with mixed seasonal vegetables, Israeli couscous, and creamy pesto sauce; (2) chicken salad with red peppers, green beans, mixed greens, caramelized onions, dried figs, quinoa, and fresh basil; (3) ground turkey chili with red kidney beans, polenta, local sweet corn, Latin coleslaw, and cilantro. The staff prepare approximately 500 meals per day in the early morning, and the meal boxes are distributed in the afternoon by distribution center volunteers. Food workers are paid a minimum of US$16/hour in the project. The food distribution has included over 15 schools, community centers, and senior homes in Baltimore City, Monday through Saturday, 1:00 to 4:00 PM. Some meals are delivered by volunteers directly to families that are unable to come to the distribution centers. Since the distribution of meals is community-based, most recipients walk a short distance to the distribution centers. This program supports primarily low-income Hispanic families in areas of Baltimore City that are highpriority food areas (sometimes known as food deserts) (Franco, Diez Roux, Glass, Caballero, & Brancati, 2008). In order to evaluate the recipients' satisfaction with the meals provided by Food That Connects Us All, a survey was conducted consisting of six questions: (1) How do you like the taste of the food? Delicious/good/so so/not good/bad; (2) How do like the appearance of the food? Beautiful/nice/so so/not nice/not beautiful; (3) How healthy is the food? Very healthy/healthy/not sure/unhealthy/very unhealthy; (4) What is your overall satisfaction with the food? Love it/like it/so so/don't like/really don't like; (5) Would you recommend this food to a friend? Yes/no; (6) What would you change about the meal? Check any: Nothing/bigger portions/more vegetables/more variety. The survey was given in both English and Spanish. Of the approximately 500 people who regularly receive their meal boxes, 242 completed the survey in the period of August 17-24, for a response rate of 48.4%. The results of the first four questions are shown in Figure 1. The responses were highly positive, such as 55.4% for delicious taste, 52.0% for beautiful appearance, 56.2% for very healthy, and for overall satisfaction, 55.8% love it. When asked "Would you recommend this food to a friend?" 96.2% responded yes and 3.8% responded no. When asked about changing anything about the meal, 36.8% would not change anything, 32.2% wanted bigger portions, 14.4% wanted more vegetables, and 9.0% wanted more variety.

Addressing Food Insecurity
The COVID-19 pandemic may increase health disparities among low-income minority families due to loss of livelihood and exacerbation of food insecurity (Kinsey et al., 2020). To our knowledge, Food That Connects Us All is a novel community program providing meals consistent with the planetary health diet to low-income families. This program attempts to overcome some of the limitations of other food assistance programs.
The largest program addressing food insecurity in the U.S. is SNAP, which cost US$60.3 billion in 2019 (Duffin, 2020). Retailers can accept SNAP funds for essentially any food product, including candy, chips, sodas, doughnuts, and other convenience foods; analyses from the National Health and Nutrition Examination Survey show that participants were likely to make food choices that have relatively poor dietary quality (Leung et al., 2012a). Among children 2 to 17 years old, SNAP recipients were more likely to consume sugar-sweetened beverages and to be overweight or obese compared to those who did not receive SNAP benefits (Twarog et al., 2020). SNAP participants have a higher consumption of sugarsweetened beverages compared to some SNAP-eligible nonparticipants (Nguyen & Powell, 2015). SNAP

Figure 1. Responses of 242 Participants in Food That Connects Us All to Four Questions in a Food Survey
has been implicated in increasing both diet and health disparities (Fang Zhang et al., 2018). SNAP participants are at higher risk of hypertension, cardiovascular disease, diabetes, and have higher risk of all cause, cardiovascular, and diabetes mortality compared with other American adults (Conrad, Rehm, Wilde, & Mozaffarian, 2017;Leung, Willett, & Ding, 2012b;Nguyen, Shuval, Bertmann, & Yaroch, 2015). In order to increase access to staple foods in high-priority food areas, SNAP was updated with standards to increase the "depth of stock" of healthier foods. In Baltimore City, however, the barriers to providing better foods in food deserts have included low customer demand and the potential for food spoilage (Ross, Krishnan, Ruggiero, Kerrigan, & Gittelsohn, 2018). Food banks, which were traditionally established to alleviate hunger, are another source of food for low-income families. Many food banks have difficulties providing fresh fruit and vegetables, and not all leaders of food banks consider their organizations to be agents for change to promote health and reduce chronic disease (Wetherill, White, & Seligman, 2019). Many food banks do not want to turn down food, even though it may not be considered healthy (Wetherill et al., 2019). Other challenges with food banks include limited hours and the availability of mostly poor-quality foods Ginsburg et al., 2019).
A strength of Food That Connects Us All is an innovative application of the planetary health diet in a vulnerable population at high risk for obesity (Flórez et al., 2019), diabetes (Aguayo-Mazzucato et al., 2019), and cardiovascular disease (Graham, 2015). The planetary health diet was formulated-based upon the strongest scientific evidence-as the reference diet for promoting health and longevity and staying within planetary boundaries (EAT-Lancet, 2020;Willett et al., 2019). The program in Baltimore shows the feasibility of applying this healthy reference diet in an urban setting. The responses to the survey showed a high rate of satisfaction with the food by the participants. According to one of the program directors, initially the meals were somewhat of a shock to some of the participants, who were accustomed to eating beef, pork, and highly processed foods and snacks (Irena Stein, personal communication, August 21, 2020). However, the participants expressed overall satisfaction with the meals.
The program provides meals on a daily basis, which allows for inclusion of fresh vegetables and fruit that have a limited shelf life. The program offered a reasonable working wage to cooks and personnel and supports locally sourced foods. The planetary health diet is sustainable for the planet; if the diet were adopted worldwide, there would be an estimated 23% reduction in agricultural global greenhouse gas emissions (Semba et al., 2020).
As noted above, meals are provided daily by the program. A more convenient alternative may be to supply a week's worth of food in one pickup; however, prepared fresh salads, fruit, vegetables, and dairy products may lose quality and appeal after storage in a refrigerator beyond a day or two. Nuts are not included in the meals because of concerns about nut allergies among the participants. The meals are relatively expensive, as the total cost of one meal, including food costs, food preparation, transport, and delivery, is US$10.00/meal, compared with US$1.40/meal provided by support from SNAP (Center for Budget and Policy Priorities, 2019). The long-term impact of these healthy meals on recipients' health outcomes is not known because the program was just recently initiated. The formulation of the planetary health diet is based on what is considered to be an ideal healthy reference diet that reduces risk of heart disease, diabetes, obesity, cancer, and mortality (EAT-Lancet, 2020; Willett et al., 2019). There may be long-term benefits in providing healthy food to high-risk, low-income families, such as reducing chronic diseases and the related health care costs (Jardim et al., 2019). Food That Connects Us All demonstrates the feasibility of providing an ideal reference diet during the COVID-19 pandemic to vulnerable, lowincome families who have a high risk for poor health outcomes.