Produce prescription programs tied to clinical gains in cardiometabolic health measures
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Key takeaways:
- Produce prescriptions increased fruit and vegetable intake and decreased food insecurity for adults and children.
- Researchers observed clinically relevant drops in HbA1c, BP and BMI in adults.
An analysis of 22 produce prescription programs throughout the U.S. suggests that the interventions improve fruit and vegetable intake, reduce food insecurity and are tied to clinically significant gains in cardiometabolic health measures.
“The state of produce prescription research prior to starting this study was rather small studies, generally, with most looking only at fruit and vegetable intake and the impact on food insecurity,” Kurt Hager, PhD, MS, an instructor at UMass Chan Medical School in Worcester, Massachusetts, told Healio. “The studies looking at fruit and vegetable intake and food insecurity have consistently shown beneficial impacts on those outcomes, even if from often smaller studies. Our study built on this and advanced our understanding of these programs by pooling data on produce prescriptions programs operated in 12 states in different regions of the U.S. with nearly 4,000 participants, with a wide range of clinical partners.”
Referrals for at-risk adults, families
Hager and colleagues analyzed data from 22 produce prescription locations operated by Wholesome Wave in 12 states from 2014 to 2020; none of the programs was previously evaluated. The study included 3,881 participants, including 2,064 adults and 1,817 children aged 2 to 17 years, all with or at risk for poor cardiometabolic health and recruited from clinics serving low-income neighborhoods.
“In order to be included in our study, there had to be a direct referral from a health care provider that had a relationship with Wholesome Wave,” Hager said during an interview. “That is important for clinicians to understand. This was not giving patients a brochure and saying, ‘If you get a chance, call this number.’ This was giving the organization the [patient’s] name and contact information. So, a warm handoff. That increases the probability that someone will be ultimately enrolled. Most patients were identified because they were explicitly food insecure or were a patient at a clinic targeting a low-income neighborhood. Most frequently, these [clinics] were referring patients who had overweight, obesity or type 2 diabetes.”
The programs provided financial incentives to purchase fruits and vegetables at grocery stores or farmers markets (median, $63 per month; duration, 4 to 10 months). The participants received an electronic card or paper vouchers that would allow access to free fruits and vegetables at farmers markets or grocery stores; the programs also allowed for frozen or canned produce. Participants completed surveys assessing fruit and vegetable intake, food security and self-reported health. Researchers measured HbA1c, BP, BMI and BMI z score at clinics. Models accounted for clustering by program.
The findings were published in Circulation: Cardiovascular Quality and Outcomes.
Decreases in HbA1c, BP, BMI
After median participation of 6 months, fruit and vegetable intake increased by 0.85 (95% CI, 0.68-1.02) cups per day among adults and 0.26 (95% CI, 0.06-0.45) cups per day among children. The odds of being food insecure dropped by one-third (OR = 0.63; 95% CI, 0.52-0.76) and odds of improving one level in self-reported health status increased for adults (OR = 1.62; 95% CI, 1.3-2.02) and children (OR = 2.37; 95% CI, 1.7-3.31).
Among adults with an HbA1c of 6.5% or greater, HbA1c declined by 0.29% age points (95% CI, 0.42 to 0.16); among adults with hypertension, systolic BP declined by 8.38 mm Hg (95% CI, 10.13 to 6.62) and diastolic BP declined by 4.94 mm Hg (95% CI, 5.96 to 3.92). Among adults with overweight or obesity, BMI decreased by 0.36 kg/m2 (95% CI, 0.64 to 0.09). Child BMI z score did not change at 0.01 (95% CI, 0.06 to 0.04).
“This study did not have a comparison group, so we do not know if observations like improvements in BP are strictly attributable to the intervention or if the physician enrolled a given participant and perhaps also changed their medication and referred them to other lifestyle interventions,” Hager told Healio. “We do not know. My key takeaway is these data are encouraging and offer a strong proof of concept and excellent rationale to continue investment in more robust studies and randomized controlled trials and expand these programs.”
Hager said prescriptions are not a routine part of clinical care; for most patients with food insecurity, such programs are not an option outside of grant-funded initiatives or clinical studies. Clinicians interested in launching such a program should look into local groups willing to fund a produce initiative and look to what may be covered under Medicare and Medicaid in their state as a “food as medicine” program.
“For better or worse, these programs are becoming known as ‘food as medicine,” Hager told Healio. “If we take the analogy of medication for hypertension, many people need to maintain that medication in order to maintain a reduction in BP. For some people, these programs might provide short-term support during an acute health crisis or family emergency. However, others may need longer-term services to maintain health benefits. Ideally, physicians should have the choice in which they can have access to a longer-term program. This is research that has important policy implications.”
‘Prescription’ to address food insecurity
In a related editorial, Candice A. Myers, PhD, director of the Social Determinants and Health Disparities Laboratory at Pennington Biomedical Research Center, wrote that the findings hold implications for policymakers, who should translate the data into an action plan. Myers noted that Hager and colleagues partnered with Wholesome Wave, the organization that designed and operated the produce prescription programs, to formally test hypotheses and effectively evaluate the health impact of the produce prescription programs via statistical analyses and testing that “otherwise may have been unattainable without this partnership.”
“More specifically, investment in food-based nutrition programs and interventions, such as produce prescription programs, that provide for the purchase and intake of healthy foods, such as fruits and vegetables, holds potential to address food insecurity and improve downstream health outcomes, especially in health disparate populations at greatest risk of poor nutrition,” Myers wrote.
References:
- Myers CA. Circ Cardiovasc Qual Outcomes. 2023;doi:10.1161/CIRCOUTCOMES.123.010319.
- Prescription for fruits, vegetables linked to better heart health, food security. https://newsroom.heart.org/news/prescription-for-fruits-vegetables-linked-to-better-heart-health-food-security. Published Aug. 29, 2023. Accessed Sept. 14, 2023.
For more information:
Kurt Hager, PhD, MS, can be reached at kurt.hager1@umassmed.edu.
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