Opinion: What if doctors prescribed produce?

Bonita Evans holds a bowl of spinach salad that was prepared with a recipe provided by HEALing Community Center at their home in College Park. Lavern Evans and his wife, Bonita, who suffer from obesity, diabetes and hypertension, live in one of Georgia's 35 food deserts, which experts say weigh heavily on the state's chronic disease burden, costing it billions of dollars annually in diabetes care, treatment and management alone.

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Bonita Evans holds a bowl of spinach salad that was prepared with a recipe provided by HEALing Community Center at their home in College Park. Lavern Evans and his wife, Bonita, who suffer from obesity, diabetes and hypertension, live in one of Georgia's 35 food deserts, which experts say weigh heavily on the state's chronic disease burden, costing it billions of dollars annually in diabetes care, treatment and management alone.

SOLUTIONS: In some states, healthy food becomes part of healthcare.

THE ISSUE:

We all know we should eat more fruits and vegetables to live a healthy life. But for some, finding fresh produce isn’t easy, particularly for low-income Americans.

ONE SOLUTION:

To address the issue of poor health and food insecurity across the country, doctors are trying a new approach – produce prescription programs, known as PPRs. It allows clinicians to prescribe fresh produce to low-income patients with diet-related health risks or conditions.

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Lela Nargia

Credit: contributed

Lela Nargia

Credit: contributed

Combined ShapeCaption
Lela Nargia

Credit: contributed

Credit: contributed

The 61-year-old woman arrived at the health clinic in Alameda County, California, with high blood pressure, prediabetes and worries about kidney failure – a concern for prediabetics with insulin resistance.

She told the doctor, Steven Chen, that she wanted to learn to take care of her body, lose weight and eat right. He signed her up for a produce prescription that gave her free fresh, local fruits and vegetables, along with a suite of parallel interventions, like exercise.

In just four months, Chen said, the woman was no longer prediabetic. She saw a significant drop in her insulin levels, along with a huge improvement to her kidneys.

It seems like a straightforward proposition that Americans should eat more fruits and vegetables. But making this connection is easier said than done, especially because limited access to produce is often tied to food insecurity, which means low-income folks take the hardest hit.

One response to this call has been produce prescription programs, known as PPRs. They’re part of a broader “food as health” effort – including medically tailored meals and free distribution of local produce – meant to address the double-whammy of poor health and food insecurity across the country.

The concept envisions “an ecosystem in which healthy food becomes a part of healthcare because it’s such an important part of your health,” said Hilary Seligman, a professor of medicine at the University of California-San Francisco.

And it’s being met with optimism.

Understanding PPRs

In simplest terms, PPRs – which may alternatively be referred to as PPPs or Produce Rx – allow clinicians to prescribe fresh produce to low-income patients with diet-related health risks or conditions.

A person with diabetes might walk into a community health center, meet with a doctor or nurse practitioner who ask a series of targeted questions, receive a prescription and a voucher for, say, $10 worth of produce for the week, and then redeem the voucher at a participating grocery store or farmers’ market.

Some programs have additional components, such as exercise classes and training for medical staff. Ideally, a person’s health insurance provider pays for it all.

Since 2019, USDA’s Gus Schumacher Nutrition Incentive Program (GusNIP), which received funding for five years through the last farm bill, has been providing competitive grants for PPRs.

The vast majority of PPRs are funded primarily with private dollars, and the approaches vary widely: Some might provide only fruit and vegetables, while others allow for less-specific “healthier foods.”

However, anyone who receives a grant must have much-needed partnerships built into their program: a supermarket that accepts produce vouchers; clinicians working in the public health sector to do assessments and write prescriptions; and a health insurance provider who pays for the care. GusNIP grantees are also encouraged to offer nutrition education to patients.

The National Produce Prescription Collaborative estimates that there are 108 PPRs operating in 38 states, although Amy Yaroch, executive director of the Gretchen Swanson Center for Nutrition in Omaha, believes these numbers are higher.

Assisted by Seligman’s team at UCSF and other partners, the Gretchen Swanson Center will oversee GusNIP’s reporting and evaluation and analyze the long-term impact of these prescription programs.

So far, “self-reported health is trending in the right direction,” Yaroch said. But starting next year, when data from year 2 starts to roll in, “we’ll have more objective measures.”

A ‘three-ingredient’ approach

Chen is the chief medical officer at ALL IN Alameda County, a public health program that has covered a wide swath of the east side of the San Francisco Bay Area since 2014.

ALL IN is now also a GusNIP grantee for its PPR initiative. It has honed its practices over the years to what Chen calls a “three-ingredient” approach.

First, prescriptions are written for 16 weekly bags of produce for low-income participants who have any one of a number of cardio-metabolic or behavioral conditions. The prescriptions are filled for free and delivered by a local regenerative farm, which has the added benefit of reducing transportation barriers.

Second, through ALL IN’s “behavioral pharmacy,” patients take exercise and movement classes; learn healthful produce prep, stress reduction and mindfulness practices; and visit with a medical advisor to refine their recommended activities.

Finally, clinicians and clinic staff receive food-as-medicine training. They experience the behavioral pharmacy much as their patients do, with cooking demonstrations and meditation, among other activities.

They also learn to screen for food insecurity.

An economic benefit

ALL IN received seed money from the Alameda Alliance for Health – one of many insurance companies with a deep interest in learning how PPRs affect patient health.

In North Carolina, Blue Cross/Blue Shield is running its own privately funded PPR program pilot called Eat Well. It provides $40 worth of produce vouchers per week, for a year, to 5,000 people with hypertension and incomes between 100 and 250 percent of the federal poverty level. The vouchers can be redeemed at Food Lion grocery stores, which are ubiquitous across the state.

The difference in approaches among PPR programs, though, is a pain point for data collectors like Yaroch.

Even within GusNIP-funded programs, there’s a lack of coordination, which makes outcomes hard to measure, she said.

In an effort to get things standardized, the Gretchen Swanson Center created some shared metrics, hoping to make apples-to-apples comparisons among GusNIP-funded programs. The center is awaiting a batch of data so it can start measuring the impacts of produce consumption on things like hemoglobin A1C, which indicates blood sugar levels, and body mass index, a measure of body fat.

It is also hoping to eventually gain insights into metrics like “dosage” – how much produce is ideal for a patient to receive – and how many produce prescription refills are needed to make a difference in patients’ long-term health.

Meanwhile, Yaroch sees another big benefit to PPR programs: local economic impact. In its second year of operation, GusNIP’s PPR programs generated $1.1 million in sales for grocers, farmers’ markets and other local outlets.

Lela Nargia writes for Civil Eats, an independent, nonprofit digital news and commentary site about the American food system. This story is republished through the Solutions Journalism Network.

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