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Veggies as Medicine: Food Prescriptions to Improve Health, Address Inequities

“The last time I looked in my textbook, the specific therapy for malnutrition is food.” – Jack Geiger, founding member of Physicians for Human Rights

When Adrienne Dove’s doctor suggested a prescription of fresh vegetables to fight high blood pressure, an iron deficiency and a worrying sugar level, Ms. Dove, 44, first said “huh?” and then, enthusiastically, “yes!”

“I love vegetables,” says Ms. Dove, who lives in Washington, D.C.’s Ward 8. “I definitely love kale. I love spinach because that’s high in iron…I love green peppers, I love mushrooms, I love carrots and I love collard greens, but only in a certain way I fix them…And then I love broccoli.”

With the unusual treatment, health benefits weren’t far behind: in less than a year, Ms. Dove no longer has to take iron supplements; her sugar level and weight are both down, and her doctor is weening her off her blood pressure medicine. Known side effects? She is exercising more, has more energy, and her family—73-year-old mother, 17-year-old son and 23-year-old daughter—are also eating better.

Ms. Dove is the beneficiary of a produce prescription program in which health care providers distribute vouchers for free or discounted vegetables to address diet-related health conditions, such as diabetes, prediabetes or hypertension.

And she’s become a major champion of the program her neighborhood, comprised of 80,550 residents who are 92 percent Black, with a poverty rate of about 30.7 percent, compared with 13.5 for the rest of the city. “I thank God for this program and I’ve convinced more than 50 people to discuss it with their doctors,” she says, “It can really save your life.”

An Equity Intervention That Improves Health Outcomes

Some 32.5 million Americans, including 5.3 million children, live in food-insecure households, which the U.S. Department of Agriculture (USDA) defines as lack of consistent access to enough food for an active, healthy life.

Food insecurity is closely associated with chronic disease such as diabetes and high blood pressure. The pandemic has shone a harsh light on the toll of food insecurity and poor health: individuals with an underling condition, the majority of which are diet-related, account for 76 percent of Covid-19 deaths.

According to USDA data, 19.1 percent of Black households and 15.6 percent of Latin(x) households experienced food insecurity in 2019. White Americans fell below the national average, with 7.9 percent experiencing food insecurity.

Produce prescription programs were pioneered in 2010 by Wholesome Wave, a non-profit fighting nutritional insecurity across the U.S. Though widely viewed as a powerful nutritional intervention with the ability to change diets and behavior, improve health outcomes and reduce healthcare costs, currently programs reach a fraction of those who could benefit. DC Greens, the program that reached Ms. Dove, serves about 650 people with vouchers to the sole full-service grocery store in Ward 8.

Across the country, some 10,000-15,000 are served through community-based organizations and a small number more through integrated healthcare systems.

With the goal of scaling up access to produce prescriptions to support greater equity and improve nutrition security for high-need groups across the country, The Rockefeller Foundation is supporting both DC Greens and Reinvestment Partners in North Carolina.

The Foundation is also supporting research by three leading academic institutions to quantify participant outcomes—which diseases are most impacted by which “doses” of fruits and vegetables—as well as partnering with the Center for Health Law and Policy Innovation at Harvard Law School to create a comprehensive advocacy strategy.

  • Expanding produce prescription programs and integrating them into existing health and food policies are critical steps toward building a more nourishing and equitable food system.
    Devon Klatell
    Managing Director of the Food Initiative at The Rockefeller Foundation

Covid-19: A Turning Point for Produce Prescriptions?

“We should resolve now that the health of this nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the nation.” – Harry S. Truman, 33rd U.S. President

Adrienne Dove talks to local grocery store nutritionist

“We know logically that if you give people more healthy food, they will be healthier. But we need a data-driven approach,” agrees Lauren Biel, executive director of DC Greens, which is running its own outcomes evaluation through the end of the year to determine the impact of produce prescriptions on patient utilization of healthcare, including emergency room and doctors’ visits.

“I call myself a pragmatic utopian,” Biel says. “If we collectively can show that these programs bring down overall healthcare costs, we can make a strong case for bringing them to scale.”

Biel credits the data around Covid-19 with helping policymakers come face-to-face with the intertwining of poor health and food insecurity. “But the truth is, those health and mortality inequities have been there all along,” she says.

For instance, “there is a 17-year life expectancy difference between folks living in Ward 8 and those living in Ward 3, an affluent white community, and four of the five leading causes of death are diet-linked,” she notes. That is not a condition that developed just since the pandemic. One indicator of the food inequity is the existence of only that single full-service grocery store in Ward 8, compared with seven in Ward 3, which has a slightly smaller population at 72,775.

“There is a kind of persistent myth that folks living on limited incomes don’t want fruits and vegetables,” Biel says. “That’s a myth of convenience that allows for inaction.”

Programs Must Overcome Logistical and Legal Challenges

Even once the benefits of produce prescriptions are clearly documented, logistical hurdles remain. The program involves close collaboration between infrequent partners: non-profits, health care providers, insurance companies and grocery stores or farmers markets. On top of integrating complex and diverse workflows, there are legal barriers given the stringent requirements around the privacy of health data.

DC Greens launched its targeted produce prescription work in March of 2019 after two years of planning and the involvement of multiple lawyers.

Reinvestment Partners began its statewide program, SuperSNAP, in 2018 in North Carolina, where food insecurity impacts one in seven people. The program serves about 2,500 produce prescription patients throughout the state through partnerships with federally qualified health clinics. Research results have shown that participants on the program purchase two times as many fruits and vegetables as they did before the program.

With the Covid-19 crisis, Reinvestment Partners recognized that programs promoting fruit and vegetable consumption were more important than ever. They used CARES Act funding to expand SuperSNAP to serve over 37,000 people. The program provides $40 per month on the client’s grocery store loyalty card that can be used at any of the 498 Food Lions across North Carolina. In part due to the use of technology, administering the program is inexpensive, so 95 percent of the funds they receive go directly to food.

“This emergency produce prescription program demonstrates that our work is scalable,” notes Peter Skillern, Executive Director of Reinvestment Partners. “If there is funding, we can serve thousands of families across the state with greater efficiency.”

Beckie Brooks, Director of Drivers of Health Strategy of the Durham-based Blue Cross Blue Shield North Carolina, is beginning a pilot program to partner with Reinvestment Partners. “We’ve identified a specific population of our membership who has Type 2 diabetes and screens for food insecurity,” she says. “We are looking to conduct rigorous monitoring and evaluation so we can contribute to the evidence of what food interventions work and at what dose and duration.”

She notes legal complications around referring members to the program but adds, “in ten years, I think we will look back and wonder why we didn’t do this sooner.”

From A Diet of Few Vegetables to a “Wow, Thank You”

“No disease that can be treated by diet should be treated with any other means.” Maimonides, 12th Century philosopher

Ella Stephens of Gastonia, N.C., enrolled in SuperSNAP about a year ago as a prescription for her high blood pressure, thyroid issues and borderline diabetes.

“I rarely ate fresh vegetables—maybe collard greens on special occasions, but otherwise, canned,” says Ms. Stephens, 61, who works at a Salvation Army homeless shelter. “I couldn’t afford them, and I wasn’t raised that way.”

She began the program about a year ago, and two weeks ago, she got a call from her doctor about the results of her medical tests. “She said Ella, your tests came back way better. You are much more healthy now. I was shocked. I said wow, thank you.”