A pilot study of an online produce market combined with a fruit and vegetable prescription program for rural families

Changes to Fruit and Vegetable Intake and Waste When Households Receive Free Produce

Objective

The study evaluated changes in household food intake, the waste of fruits and vegetables (FV), and FV inventories after supplemental produce was provided free of charge and in response to a smart coaching intervention to reduce food waste and replace less nutritious foods with FV.

Design

Households measured food intake and waste for ≥3 days before and after intervention. Households were randomized to receive either an intervention to reduce food waste and replace less healthy foods with FV or a control intervention. Both groups received free FV and measured FV inventories before and after intervention.

Setting

Participants were from the Baton Rouge, Louisiana region and picked up FV at a central location.

Participants

46 adults and their household members.

Results

Treatment participants increased intake of fruits (0.33 servings/day, p=0.09) and vegetables (0.50 servings/day, p=0.01) compared to the control group. All participants reported a decrease in daily total caloric intake (133 kcal/day, p=0.04), an increase in the number (9.5 events/period, p<0.001) and average magnitude (100.5 g/event, p=0.005) of FV waste events, and an increase in fresh FV inventories (4.1 kg/household, p=0.001) after receiving free FVs. Compared to the control group, treatment participants reported less FV waste during eating occasions (22.2 g/day, p=0.09) and an increase in frozen FV inventories (1.8 kg/household, p=0.04).

Conclusions

Providing free FVs without additional intervention does not increase FV intake but does lead to more and larger FV waste events. When coupled with targeted information to improve diet quality and reduce waste, free FV provision can lead to increased FV intake with no significant increase in energy intake or plate waste and smaller increases in the number and magnitude of FV waste events, suggesting that pairing intensive intervention efforts with free FV provision is critical to translate program resources into improved nutrition without increasing waste.

Qualitative Analysis of a Home-Delivered Produce Prescription Intervention to Improve Food and Nutrition Security

Background/Objective: In total, 17.9% of households with children experienced food insecurity (FI) in 2023. Produce prescription interventions (PRx) are a viable intervention to address FI and improve diet quality. Few studies have explored home-delivered PRxs in children. The objective of this qualitative study is to explore the experience of a novel PRx among families with young children in households at risk of experiencing FI and diet-related chronic disease. Methods: Semi-structured interviews were conducted with caretakers after the completion of a 12-month PRx. Interviews were recorded, transcribed, and analyzed using thematic analysis to identify emergent themes. Univariate descriptive statistics were used to describe baseline demographics. Results: Twenty-five families were enrolled, from which eighteen completed the program and fifteen agreed to participate in an interview. All participants were African American women. The mean age was 30.2 (±6.4) years old, and the median household size was three. Qualitative data analysis revealed three major themes. (1) The produce delivery partially alleviated financial stress, contributing to increased produce consumption patterns; (2) the intervention positively shifted the nutrition- and cooking-related knowledge and behavior of families; and (3) familial and programmatic barriers affected participation and engagement. Conclusions: PRxs are a viable option to support families to lessen the burden of FI from financial hardship and build healthy dietary habits. These insights can inform future PRx program development, delivery, evaluation, and policy or funding decisions. Future research should examine the sustained impact of PRx on healthy eating, health outcomes among caregivers and their children, and the healthcare cost and utilization rates among PRx participants.

Grocery Delivery to Support Individuals With Type 2 Diabetes: Protocol for a Pilot Quality Improvement Program

BACKGROUND

People with low income are disproportionately affected by type 2 diabetes (T2D), and 17.6% of US adults with T2D experience food insecurity and low diet quality. Low-carbohydrate eating plans can improve glycemic control, promote weight loss, and are associated with improved cardiometabolic health and all-cause mortality. Little is known about supporting low-carbohydrate eating for people with T2D, although food-as-medicine interventions paired with nutrition education offer a promising solution.

OBJECTIVE

This program aims to support the initiation of dietary changes by using grocery delivery and low-carbohydrate education to increase the quality of low-carbohydrate nutrition among people with T2D and food insecurity.

METHODS

This program was a nonrandomized pilot conducted at 21 primary care practices in Michigan. Adults with T2D and food insecurity or low income were eligible to enroll. Patients were referred by primary care clinic staff. All participants received the 3-month program, which included monthly US $80 credits for healthy foods, free grocery delivery from Shipt, and low-carbohydrate nutrition education. Food credits were restricted to the purchase of healthy foods. Education materials, developed in collaboration with providers and patients, included print, digital, interactive web, and video formats. At enrollment, participants completed a survey including demographics, diabetes health, diet and physical activity, and diabetes management and knowledge. After the 3-month program, participants completed a survey with repeat assessments of diabetes health, diet and physical activity, and diabetes management and knowledge. Perspectives on participant experience and perceived program impact, food purchasing behaviors, and use of educational materials were also collected. Diabetes health information was supplemented with data from participant medical records. We plan to perform mixed methods analysis to assess program feasibility, acceptability, and impact. Primary quality improvement (QI) measures are the number of patients referred and enrolled, use of US $80 food credits, analysis of food purchasing behavior, participant experience with the program, and program costs. Secondary QI measures include changes in hemoglobin A1c, weight, medications, self-efficacy, diabetes and carbohydrate knowledge, and activity between baseline and follow-up.

RESULTS

This program started in October 2022. Data collection is expected to be concluded in June 2024. A total of 151 patients were referred to the program, and 83 (55%) were enrolled. The average age was 57 (SD 13; range 18-86) years, 72% (57/79) were female, 90% (70/78) were White, and 96% (74/77) were of non-Hispanic ethnicity. All participants successfully ordered grocery delivery during the program.

CONCLUSIONS

This pilot QI program aimed to improve diet quality among people with T2D and food insecurity by using grocery delivery and low-carbohydrate nutrition education. Our findings may help inform the implementation of future QI programs and research studies on food-as-medicine interventions that include grocery delivery and education for people with T2D.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54043.

Pediatric produce prescription initiatives in the U.S.: a scoping review

BACKGROUND

To describe pediatric Produce Prescription (PRx) interventions and their study designs, outcomes, and opportunities for future research.

METHODS

A scoping review framework was used to describe PRx interventions published between January 2000 and September 2023. Articles from online databases were uploaded into Covidence. Data on study characteristics, outcomes of interest (health, food insecurity (FI), nutritional and culinary efficacy, and fruit and vegetable (F/V) consumption), and feasibility were extracted. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment.

RESULTS

19 articles met inclusion criteria. Ten studies were quantitative, five were qualitative, and four used mixed-methods. Interventions included food vouchers (n = 14) or food box/pantries (n = 5). Four studies allowed food items in addition to F/Vs. Six studies measured changes in FI and five reported a statistically significant decrease. Seven studies measured changes in F/V consumption and five reported a statistically significant increase. One study reported a statistically significant reduction in child BMI z-score. Most studies reported high feasibility. Few studies used high-quality methods.

CONCLUSIONS

Pediatric PRx interventions show promising potential to reduce FI and improve diet quality and health-related outcomes. Future studies should utilize rigorous study designs and validated assessment tools to understand the impact of pediatric PRx on health.

IMPACT

This work offers a summary of programmatic outcomes including retention, redemption, incentives, nutrition education, study design and quality limitations to help inform future work. We found positive impacts of pediatric produce prescriptions (PRx) on FI, F/V consumption, and nutritional knowledge and culinary skills. More high-quality, rigorous studies are needed to understand the best delivery and design of PRx and their impact on child behavior and health outcomes. This work provides support for the need for rigorous studies and the potential for PRx to play a role in multi-pronged strategies that address pediatric FI and diet-related disease.

Evaluation of the reach and utilization of the American College of Lifestyle Medicine's Culinary Medicine Curriculum

Introduction

Despite the growing interest in "food as medicine," healthcare professionals have very limited exposure to nutrition as part of their training. Culinary medicine (CM), an evidence-based field integrating nutrition education with culinary knowledge and skills, offers one approach to fill this training gap. The American College of Lifestyle Medicine published a complimentary Culinary Medicine Curriculum (CMC) in 2019, and the objective of this study is to evaluate its reach and utilization, as well as to collect feedback from users.

Methods

Individuals who downloaded the CMC prior to March 1, 2022 (N = 6,162) were emailed an invitation to participate in an online, cross-sectional survey. The survey included both multiple choice and free-text questions about whether CM sessions were conducted, if and how the CMC was used, if and how it was modified for use, and additional requested resources. Free-text responses were inductively coded, and quantitative data was summarized using descriptive statistics.

Results

A total of 522 respondents provided consent, indicated that they had downloaded the curriculum, and completed the survey. Of the 522, 366 (70%) reported that they had not led or created any CM sessions. The top-reported reason for not leading a session was lack of time (29%). The remaining respondents who did create a CM session did so across various settings, including academic, clinical, coaching, and other settings, and a variety of professionals delivered the CMC sessions, including physicians (50%), registered dietitian nutritionists (30%), and chefs (25%). The majority of respondents (81%) modified the CMC in some way, with many using the curriculum for guidance or ideas only. Patient education materials (66%) and cooking technique instruction videos (59%) were among top requested resources.

Discussion

The CMC is a versatile resource that can be successfully adapted for use across various settings and by various types of health professionals and practitioners. Future research should investigate whether training in CM results in improved health outcomes for patients/clients. The curriculum will continue to grow to address the needs of users by expanding to include more digital content such as curriculum videos and cooking technique videos.

Narrative review: food as medicine across the pediatric age continuum

PURPOSE OF REVIEW

Poor diet and food insecurity contribute to the dramatic rise in diet-related chronic disease and increasing cost of healthcare. The Food as Medicine (FAM) framework describes food-based interventions designed to prevent, manage, and treat diet-related diseases. However, FAM interventions have not been widely implemented or evaluated in pediatric populations, so critical questions remain about their optimal delivery and design, efficacy, and funding opportunities. We have reviewed the recent literature and offer insights into potential funding and implementation strategies for pediatric healthcare providers.

RECENT FINDINGS

Data from adult and population-level interventions provide evidence that FAM interventions positively impact diet quality, food security, health outcomes, and healthcare utilization and cost in adults and households with children. Evidence from recent pediatric-based FAM interventions and population data from recent changes to federal nutrition programs support the use of food-based interventions to improve child diet quality, food insecurity, and potentially impact long-term health and healthcare utilization and cost.

SUMMARY

Applying the entire spectrum of evidence-based FAM interventions in pediatric settings from prenatal to adolescent stages will offer the greatest opportunity to ensure all children have access to enough healthful food so they can achieve their highest potential in life.

Implementing a Food Prescription Program during COVID-19: Benefits and Barriers

Food prescription programs (Food Rx) have the potential to improve management of diet-related chronic diseases or underlying conditions such as type 2 diabetes (T2D), hypertension, and high body mass index (BMI) among food-insecure patients. The purpose of this study was to examine the effectiveness of a Food Rx program implemented in two community-based clinics in Florida. Data were collected through researcher-administered surveys (food insecurity, demographics, and socio-economic variables) and biometric data (HbA1c, blood pressure, and BMI). Key results include the following: (1) Hispanic patients are more likely to utilize the program than their Black and White counterparts (p < 0.001); (2) older patients (≥50 years) have a higher food redemption rate when compared to younger patients (36-49.9 years); (3) food redemption rate is negatively associated with food security scores indicating improvements in food security status over time (r2 = -0.184, p = 0.036); (4) diabetic patients with higher baseline HbA1c (>9%) have significant reductions in glycated hemoglobin (p = 0.011) over time as compared to patients with lower baseline values (<7%); and (5) patients enrolled in the program for at least 6 months have a significant reduction in systolic blood pressure (p = 0.051). Changes in BMI were not significantly associated with redemption rates. This study is significant as it offers insights into the potential benefits and challenges of implementing Food Rx programs to address diet-related chronic diseases among underserved populations.

Impact of a Pediatric Produce Prescription Intervention on Food Security and Perceived Nutrition-Related Behaviors: A Mixed-Methods Study

OBJECTIVES

Poor Food security (FS) is associated with risk of diet-related diseases and rising healthcare costs. Produce Prescription Interventions (PRx) are emerging clinical tools to improve FS and diet quality, but their impact in families with children is not well established. This study evaluates the impact of a pediatric PRx on FS and nutrition-related behaviors.

METHODS

Adult caregivers of children (0-18) were enrolled within a 6-month produce delivery and nutrition education intervention. A validated food security survey was administered pre/post intervention to determine FS scores and "Food Secure" status. Statistical analyses tested pre-post differences in FS scores and proportion of scores within the "Food Secure" range. Semi-structured interviews were performed post-intervention to explore families' experiences with low FS and healthy behaviors and were thematically analyzed.

RESULTS

Between October 2021 and December 2022, 82 families were enrolled, 65 completed FS survey at baseline and 54 completed it at post-intervention. FS scores improved post-intervention (P < .05) and a greater proportion of household- and child-level scores fell within the "Food Secure" range post-intervention (P < .05). Twenty-eight interviews were analyzed. Three salient themes were identified: (1) value of healthcare-based screening and intervention, (2) food and education motivate behavior change, and (3) perceptions of post-intervention lifestyle sustainability.

CONCLUSIONS

Participation in the PRx was associated with improvements in FS and nutrition-related attitudes and behaviors. PRx can be implemented by health systems to improve FS and health behaviors associated with risk for diet-related diseases. Longer-term support may be needed to maintain healthy behavior changes associated with PRx participation.

Participation in the Georgia Food for Health programme and CVD risk factors: a longitudinal observational study

OBJECTIVE

To assess the relationship between programme attendance in a produce prescription (PRx) programme and changes in cardiovascular risk factors.

DESIGN

The Georgia Food for Health (GF4H) programme provided six monthly nutrition education sessions, six weekly cooking classes and weekly produce vouchers. Participants became programme graduates attending at least 4 of the 6 of both the weekly cooking classes and monthly education sessions. We used a longitudinal, single-arm approach to estimate the association between the number of monthly programme visits attended and changes in health indicators.

SETTING

GF4H was implemented in partnership with a large safety-net health system in Atlanta, GA.

PARTICIPANTS

Three hundred thirty-one participants living with or at-risk of chronic disease and food insecurity were recruited from primary care clinics. Over three years, 282 participants graduated from the programme.

RESULTS

After adjusting for programme site, year, participant sex, age, race and ethnicity, Supplemental Nutrition Assistance Program participation and household size, we estimated that each additional programme visit attended beyond four visits was associated with a 0·06 kg/m2 reduction in BMI (95 % CI -0·12, -0·01; P = 0·02), a 0·37 inch reduction in waist circumference (95 % CI -0·48, -0·27; P < 0·001), a 1·01 mmHg reduction in systolic blood pressure (95 % CI -1·45, -0·57; P < 0·001) and a 0·43 mmHg reduction in diastolic blood pressure (95 % CI -0·69, -0·17; P = 0·001).

CONCLUSIONS

Each additional cooking and nutrition education visit attended beyond the graduation threshold was associated with modest but significant improvements in CVD risk factors, suggesting that increased engagement in educational components of a PRx programme improves health outcomes.

Food as Medicine Clinic: Early Results and Lessons Learned

INTRODUCTION

Hospital-based food pantries are commonly used to address food insecurity. However, few studies have examined the impact of these food pantries on patients with chronic health conditions. In this study, we sought to assess the effect of a hospital-based food pantry clinic on self-reported dietary changes, health outcomes, and resource utilization.

METHODS

This study included food insecure participants with suboptimally controlled congestive heart failure, hypertension, or diabetes who visited a Food as Medicine (FAM) clinic at an academic healthcare system between October 2018 and November 2019. The clinic provided a three-day supply of food for participants and their families up to two times per month for up to 12 months. Baseline, three-month, and six-month surveys were used to assess dietary behaviors, and electronic health record (EHR) data were used to assess health outcomes and utilization. Multivariable Poisson regression was used to explore variables associated with FAM clinic use.

RESULTS

At three months, participants self-reported improved dietary behaviors, including increased consumption of fruits and vegetables as snacks and an increased variety of fruits and vegetables consumed. There were no statistically significant changes in clinical or healthcare utilization measures, despite small absolute improvements in systolic blood pressure (SBP), hospitalizations, and emergency department (ED) visits. There was a weak association between FAM clinic visit frequency and changes in dietary behaviors.

CONCLUSION

Among patients with chronic diseases, the use of the FAM clinic was associated with improved self-reported dietary behaviors and a nonsignificant improvement in health outcomes and resource utilization.

The effect of food prescription programs on chronic disease management in primarily low-income populations: A systematic review and meta-analysis

Background: Having low-income limits one's ability to purchase foods that are high in nutritional value (e.g. vegetables and fruits (V/F)). Higher V/F intake is associated with less diet-related chronic disease. Food pharmacy programs are potential solutions to providing V/F to low-income populations with or at-risk for chronic disease. Aim: This systematic review aimed to determine the effect of food pharmacy programs, including interventions targeting populations at-risk for chronic disease. Methods: We searched Pubmed and Google Scholar databases for studies reporting on food pharmacy interventions and outcomes (hemoglobin A1c, body mass index (BMI), V/F intake, and blood pressure). We calculated pooled mean differences using a random-effects model. Seventeen studies met our inclusion criteria; 13 studies used a pre/post study design, three used a randomized controlled trial, and one was a post-survey only. Results: We found that the pooled mean daily servings of V/F (0.77; 95% CI: 0.30 to 1.24) was higher and BMI (-0.40; 95% CI: -0.50 to -0.31) was lower with food pharmacy interventions We did not find any differences in the pooled mean differences for hemoglobin A1c or systolic blood pressure. Conclusion: Findings posit that food pharmacy programs delivered to primarily low-income individuals with comorbidities may be a promising solution to improving V/F intake and possibly overall diet in these populations.

Feasibility of a Home-Delivery Produce Prescription Program to Address Food Insecurity and Diet Quality in Adults and Children

Produce prescription programs aim to improve food insecurity (FI) and nutrition but their effectiveness is unclear. We conducted a pilot study to demonstrate the feasibility and explore the potential impact of a family-based, home-delivery produce prescription and nutrition education program. We measured enrollment, satisfaction, participation, and retention as measure of feasibility. Adult participants answered pre-post self-report questionnaires assessing FI, child and adult fruit and vegetable intake, and culinary literacy and self-efficacy. To understand participants' lived experiences, qualitative interviews were conducted at the 6-month time point. Twenty-five families were enrolled. Feasibility measures indicate participants were generally satisfied with the program but there were important barriers to participation. Qualitative data revealed themes around reduced food hardship, healthy eating, budget flexibility, and family bonding. Fruit and vegetable consumption increased in a small subgroup of children, but post-intervention intake remained below recommended levels, particularly for vegetables. FI scores were not significantly different post-intervention, but qualitative findings indicated improved access and reliability of food. This is the first intervention of its kind to be evaluated for feasibility and our results suggest the intervention is well-received and supportive. However, further study, with a larger sample size, is needed to understand factors influencing participation and assess effectiveness.

Online Pilot Grocery Intervention among Rural and Urban Residents Aimed to Improve Purchasing Habits

Online grocery shopping has the potential to improve access to food, particularly among low-income households located in urban food deserts and rural communities. The primary aim of this pilot intervention was to test whether a three-armed online grocery trial improved fruit and vegetable (F&V) purchases. Rural and urban adults across seven counties in Kentucky, Maryland, and North Carolina were recruited to participate in an 8-week intervention in fall 2021. A total of 184 adults were enrolled into the following groups: (1) brick-and-mortar "BM" (control participants only received reminders to submit weekly grocery shopping receipts); (2) online-only with no support "O" (participants received weekly reminders to grocery shop online and to submit itemized receipts); and (3) online shopping with intervention nudges "O+I" (participants received nudges three times per week to grocery shop online, meal ideas, recipes, Facebook group support, and weekly reminders to shop online and to submit itemized receipts). On average, reported food spending on F/V by the O+I participants was USD 6.84 more compared to the BM arm. Online shopping with behavioral nudges and nutrition information shows great promise for helping customers in diverse locations to navigate the increasing presence of online grocery shopping platforms and to improve F&V purchases.

OUP accepted manuscript

Context

Online grocery services are an emerging component of the food system with the potential to address disparities in access to healthy food.

Objective

We assessed the barriers and facilitators of equitable access to healthy foods in the online grocery environment, and the psychosocial, purchasing, and dietary behaviors related to its use among low-income, diverse populations.

Data Sources

Four electronic databases were searched to identify relevant literature; 16 studies were identified.

Results

Barriers to equitable access to healthy food included cost and limited availability of online grocery services in food deserts and rural areas. The expansion of online grocery services and the ability to use nutrition assistance benefits online were equity-promoting factors. Perceived low control over food selection was a psychosocial factor that discouraged online grocery use, whereas convenience and lower perceived stress were facilitators. Findings were mixed regarding healthfulness of foods purchased online. Although few studies assessed diet, healthy food consumption was associated with online grocery use.

Conclusion

Researchers should assess the impact of online grocery shopping on low-income families’ food purchases and diet.

Systematic Review Registration

PROSPERO registration no. CRD: 42021240277

Strategies and Challenges: Qualitative Lessons Learned From Georgia Produce Prescription Programs

Produce prescription programs (PPPs) have grown in numbers in the past decade, empowering health care providers to promote health by issuing subsidies for produce to vulnerable patients. However, little research has been conducted on the facilitators that make it easier for PPPs to succeed or the barriers that programs face, which could provide guidance on how to improve future PPP design and implementation. The study sought to identify the facilitators and barriers affecting positive outcomes in Georgia PPPs called Fruit and Vegetable Prescription (FVRx) Programs. A process evaluation with a qualitative comparative case study approach was conducted. Fifteen FVRx providers, ranging from nutrition educators to farmers market managers, were interviewed in a focus group interview or on the phone between 2016 and 2017. Two nutrition education classes and an FVRx best practices meeting were observed, and program documents were collected. Interview transcripts, field notes from observations, and documents were then thematically analyzed. Four overall themes were determined regarding facilitators and barriers experienced by FVRx programs: (1) creating accessible programming may encourage FVRx participation, (2) provider dedication to the program is important, (3) participants' challenging life circumstances can make participation difficult, and (4) the sustainability of the program is a concern. The findings of this study suggest helpful strategies and challenges for providers to consider when developing and implementing PPPs in Georgia and beyond. Research on the long-term program impact is needed, and policy options for sustainable, scaling up of PPPs should be explored.

The Influence of Rurality on Fruit and Vegetable Intake and BMI: Findings in Mississippi Are Not Consistent with Those at the National Level

Sixty percent of Americans have at least one chronic disease that is both diet-related and preventable. Those living in rural areas often experience a greater burden of disease than those who live near a city center. The purpose of this study is to determine the influence of rurality on fruit and vegetable (FV) consumption and BMI. Additionally, the study compares national results to those in Mississippi, a state with an aging population, and high rates of poverty, rurality, poor diet, and obesity. Data utilized were from the 2017 Behavioral Risk Factor Surveillance System. One-way analyses of covariance were performed to determine impact of rurality on nutritional intake and BMI, while controlling for age, income, education, race, and the presence of children in the home. At the national level, rurality had a significant impact on BMI, and the daily intake of fruit juice, fruits, dark green vegetables, French fries, potatoes, other vegetables, and total daily vegetable intake. BMI and nutritional intake of those living in Mississippi was significantly poorer than those living in other states. More research is needed to determine how to best facilitate access to healthy FVs for those living in rural communities.

An exploration of key barriers to healthcare providers' use of food prescription (FRx) interventions in the rural South

OBJECTIVE

The purpose of this exploratory study was to examine the attitude towards food prescriptions (FRx) interventions among clinicians and identify potential barriers to their use in clinical practice.

DESIGN

The current study employed an exploratory research design using in-depth semi-structured interviews. Research participants were selected from primary care facilities, family practice offices and obesity clinics located in Mississippi and Louisiana.

SETTING

Providers selected for participation in the current study serve predominantly rural, low-income communities in the US South.

PARTICIPANTS

From an original population of fifty healthcare providers that included physicians, registered dieticians and nurse practitioners, from Oxford, Tupelo, Batesville, Jackson, and Charleston, MS and New Orleans, LA. Fifteen healthcare providers agreed to participate, including three physicians, four registered dieticians, three nurses and three nurse practitioners.

RESULTS

The current study found that while healthcare providers expressed a desire to use FRx interventions, there was a universal lack of understanding by healthcare providers of what FRx interventions were, how they were implemented and what outcomes they were likely to influence.

CONCLUSIONS

The current study identified key bottlenecks in the use of FRx interventions at the clinic level and data provided evidence for two key recommendations: (1) development and validation of a screening tool to be used by clinicians for enrolling patients in such interventions and (2) implementation of nutrition education in primary professional training, as well as in continuing education.