From original Machine Learning research to grassroots community service.
We utilize original Machine Learning (ML) research to pinpoint chronic health and obesity gaps across the Peninsula, South Bay and other regions.
Depression, smoking, and housing insecurity predict obesity better than race, income, or education, even when both sets of factors are given to the model together. Mental health is an obesity intervention, not a separate concern.
SHAP Analysis · Random ForestAn east/west fault line runs through the county, with roughly a 5× gap in composite risk scores between the highest and lowest burden areas, where structural disadvantage compounds the cycle of chronic stress and poor health outcomes.
Composite Risk Score · 500+ TractsTracts with the highest obesity have the lowest checkup and cholesterol screening rates. The communities that need preventive care most are getting it least, a critical equity finding with direct policy implications.
Care Gap · Equity FindingA note on the model: The Random Forest model behind these findings (Test R² = 0.96) was built by comparing health-only, demographics-only, and combined predictor sets, which is how we know behavioral health factors outperform demographics even when both are available to the model. Because the underlying CDC PLACES estimates are themselves modeled figures, not directly measured ones, we treat tract scores as a tool for prioritizing outreach, not a diagnosis of any individual neighborhood.
Obesity affects up to 34% of residents in Santa Clara County's highest-burden neighborhoods - driving diabetes, cardiovascular disease, and depression, while compounding barriers to education and employment in communities already under structural stress.
Based on modeled estimates, not direct measurement; see methodology below.
Source: CDC PLACES (2025); U.S. Census Bureau, ACS (2019–2023); Random Forest Model (Test R² = 0.96)
New: Our tool now includes San Mateo County data →
We offer food ingredient nutrition and benefits info, no-cook and low-cook recipe kits, and nutrition tips pamphlets, available in English and Spanish. These are distributed via ongoing food boxes and emails, addressing a key challenge to eating healthy faced by unhoused and low-income community members.
Kits teach children and youth healthy eating, naming your feelings, and breathing techniques, with materials available in English, Spanish, Vietnamese, and Chinese. Each kit also includes fitness challenge cards and stress-relief exercise toys.
We teach youth mental health workshops, including a "Listen, Validate, Connect" peer-support session at Lead Beyond (ACDS). We also offer mindful art kits for adults and children, available in multiple languages.
Beyond these three focus areas, we design custom interventions matched to each neighborhood's specific risk profile. In Alum Rock, for example, a high-burden area spanning 3 census tracts with a composite risk score of 63.2/100, our recommended focus combines culturally-competent Medi-Cal enrollment through community health workers and bilingual access to county social services, alongside peer navigation to address depression (19.3% prevalence), the leading driver of risk there.
Sample focus areas: Mental health · Preventive care · Housing stability · Smoking cessation
3 census tracts · sample project
Estimated unmet need vs. availability
Data sources
Gap score method
need_percentile − resource_percentile. Need = percentile rank of indicator value in the SCC distribution. Resource = percentile rank of 2-mile facility count. Range ≈ −100 to +100. Positive values mean need exceeds resources.
Distance measurement
Straight-line (haversine) distance from census tract centroid, not walking or driving distance. May overstate access in hillside tracts with large area.
Limitations
Data last updated: 2026-05-02
We shared our research findings on chronic health and obesity trends with Senator Dave Cortese's district staff, and have been invited to table at the Senator's next Unhoused Health Fair.
Read more →We brought nutrition resources, exercise kits, and mental health leaflets to families through EHP's National Night Out and 20th Annual Blockfest events, alongside EHP's food boxes.
Read more →Henri co-led a "Listen, Validate, Connect" youth mental health workshop at Lead Beyond, as part of Sacred Heart Community Service's delegation to the Almaden Country Day School event.
Read more →Whether you're a community organization, a policymaker, a researcher, or simply someone who cares about health equity in Northern California, we'd love to hear from you.
Fill out this form or reach us directly at hsmit@healthysantaclara.com.