Healthy Food Prescription Programs and their Impact on Dietary Behavior and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis

Federally Qualified Health Center-Based Food is Medicine Intervention Associated With Improved Health and Nutritional Outcomes

OBJECTIVE

To evaluate health outcomes associated with a Food is Medicine (FIM) intervention.

DESIGN

Single group prepost design.

PARTICIPANTS

Patients with food insecurity at a Federally Qualified Health Center who had a nutrition-related health condition (n = 134).

INTERVENTION

Nine-month FIM program which provided medically tailored grocery boxes and one-on-one nutrition coaching.

MAIN OUTCOME MEASURES

Hemoglobin A1C, body mass index, blood pressure, fruit and vegetable consumption, food insecurity, medication adherence, and overall health status.

ANALYSIS

Generalized estimating equations estimated the association between outcomes and program participation.

RESULTS

Mean hemoglobin A1C decreased from 7.4% to 7.0% (P = 0.001), body mass index declined from 40.5 to 39.6 (P < 0.01), fruit and vegetable intake increased from 10.0 to 14.6 times/wk (P < 0.001), and food insecurity decreased from 89.6% to 36.1% (P < 0.001). Medication adherence (P = 0.002) and overall health status (P < 0.001) also significantly improved post program.

CONCLUSION AND IMPLICATIONS

Participation in a FIM intervention was associated with significant improvements in patient health outcomes, food security, and diet behaviors. Findings show potential for FIM interventions implemented in partnership between food banks and safety net providers to alleviate food insecurity and improve patients' health outcomes.

Community-Engaged Codesign and Piloting of the FOOD4MOMS Produce Prescription Program for Pregnant Latina Women

Background

Eating plenty of fruit and vegetables is key for maternal-child food and nutrition security. In the United States, fruit and vegetable consumption is lower among low-income families. Produce prescription programs (PRx) provide monetary benefits to low-income individuals to buy fresh produce or directly provide the produce itself to improve their food and nutrition security.

Objective

To codesign the FOOD4MOMS PRx (F4M) program for low-income Hispanic pregnant mothers and to test its feasibility through a pilot study using the Program Impact Pathway framework.

Methods

The participants for the codesign phase and the feasibility phase were recruited from the Hispanic Health Council Maternal Health Programs and the Special Supplemental Nutrition Program for Women, Infants and Children program. Listening sessions (LSs) with adult Hispanic pregnant and nonpregnant women with children aged <3 y were conducted and transcribed for thematic analysis to inform the F4M codesign. The pilot feasibility study only included adult pregnant women enrolled during the first 2 pregnancy trimesters.

Results

The 3 codesign LSs (n = 21 participants) showed that participants thought good nutrition was very important during pregnancy and were very interested in having skill-building nutrition classes as part of the PRx. Most participants preferred receiving incentives through the Fresh Connect card to allow them to choose their produce. They also recognized that some participants with limited transportation options may benefit from a produce box delivered at home. All pilot study participants chose the electronic benefit transfer card as their incentive redemption channel. The redemption rate of benefits by pilot participants was 70% and they felt that F4M helped them and their families consume more produce. Pilot participants reported high levels of satisfaction with F4M.

Conclusion

The community-engaged codesign approach likely explains the successful piloting of the feasibility of F4M and the strong satisfaction of the clients participating in it.

The Effectiveness of Recipe4Health: A Quasi-Experimental Evaluation

INTRODUCTION

Food as Medicine is increasingly recognized as an important strategy for addressing the related challenges of food insecurity and nutrition-related chronic conditions. Food as Medicine refers to integration of food-based nutrition interventions into healthcare to prevent and treat disease. However, there is limited evidence to understand the effectiveness of Food as Medicine.

METHODS

Recipe4Health (R4H), a comprehensive Food as Medicine program, was implemented in 4 Federally Qualified Health Centers in California for patients with food insecurity and/or nutrition-related chronic conditions. Patients were referred by a healthcare provider to a "Food Farmacy" (16 weekly produce home deliveries) alone or in combination with a "Behavioral Pharmacy" (16 weekly group visits). A quasi-experimental study with pre/post surveys (4 months) and propensity score matched controls for Electronic Health Record outcomes over 12 months was conducted. Participants were 2,643 R4H patients and 2,643 controls identified from 1/2020 to 12/2022; data were analyzed from 2023 to 2024.

RESULTS

There was a significant increase in produce consumption from baseline to 4 months (0.41 servings/day [0.11, 0.72], p=0.007) in the Food Farmacy in combination with Behavioral Pharmacy. Compared to controls, there were improvements in non-HDL cholesterol for the Food Farmacy alone (-17.1 mg/dL [-26.9, -7.2], p<0.001) and in combination with Behavioral Pharmacy (-17 mg/dL [-28.3, -5.8], p=0.003) at 12 months. Compared to controls, HbA1c significantly decreased in the Food Farmacy alone at 12 months (-0.37%, 95% CI [-0.65, -0.08]; p=0.01), but not the Food Farmacy with Behavioral Pharmacy.

CONCLUSIONS

R4H resulted in improvements in diet and multiple clinical health outcomes, such as non-HDL cholesterol and HbA1c.

Food as medicine through the lenses of Food Access, Justice, and Sovereignty

PURPOSE OF REVIEW

Food as Medicine (FAM) and supplemental nutrition programs like supplemental nutrition assistance program (SNAP), women, infants, and children (WIC), and school meals aim to combat rising diet-related chronic diseases and healthcare costs by addressing poor diet and food insecurity. However, their effectiveness is limited by a lack of community integration in planning, implementation, and evaluation. We introduce the Food Access, Justice, and Sovereignty (FAJS) framework, which expands FAM efforts to address acute food disparity through community-based strategies grounded in justice and sovereignty.

RECENT FINDINGS

FAM interventions on adult populations have demonstrated a positive impact on food insecurity and its related chronic illness and shows promise for pediatric populations. However, community-driven solutions are essential for shifting power toward greater integration of the lived experiences of community, which can enhance positive behavioral changes needed for greater prevention and management of chronic illness.

SUMMARY

Using community driven approaches through the lens of access, justice, and sovereignty address the effects of food insecurity and diet-related chronic diseases for adults and pediatric populations. Through the FAJS Framework, interventionalists can develop sustainable nutrition programs that engender community health, control, and lasting impact.

A Prescription Produce Program integrating lifestyle behavior counseling and health education: A program description and evaluation

Prescription Produce Programs (PPPs) are increasingly being used to address food insecurity and healthy diets. Yet, limited evidence exists on the effectiveness of integrating lifestyle counseling within a PPP to promote dietary and health behaviors. To describe the implementation of a 6- or 12-week PPP integrating lifestyle counseling to low-income adults. The PPP was implemented as part of a wellness and care coordination program and included: (i) a screening for social needs, (ii) PPP health education and lifestyle counseling visits, and (iii) distribution of produce. We conducted a pre- and post-descriptive analysis. We also reported a case study illustrating the PPP implementation and a Strengths/Weaknesses/Opportunities/Threats analysis. Fifty-three participants (85% Black American, 64% female, mean age: 66 years) completed the PPP. Food insecurity scores significantly decreased between pre- and post-enrollment in the PPP (P = .002). Compared with pre-enrollment, participants who completed the PPP reported an increase in the frequency of fruits and vegetables intake (χ2 = 12.6, P = .006). A majority of the participants (77%) reported setting and achieving at least one health-related goal by the end of the program. A strength of the PPP included the long-standing relationship with community partners. Weaknesses included the survey burden, the need for additional personnel, and the need for a sustained funding source. Integrating lifestyle counseling within a PPP can promote food security and a healthy diet. Future research is warranted using rigorous research methods, including randomization and a comparison group.

A Systematic Review of Interventions for Obesity Among Adults With Food Insecurity

OBJECTIVE

Food insecurity is associated with reduced dietary quality and excess weight gain. However, interventions that are effective for obesity among individuals with food insecurity are unclear. The purpose of this systematic review was to synthesize studies in which authors examined interventions for obesity among adults with food insecurity.

METHODS

PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to October 2022. Studies were included if their authors reported on nonpharmacological and nonsurgical interventions that focused on adults with food insecurity and overweight/obesity and reported weight loss.

RESULTS

A total of 1360 titles were reviewed during the electronic search, and only 5 studies met inclusion criteria. There were 2 primary types of interventions that have been tested: first, behavioral weight loss counseling with or without tailoring for individuals with food insecurity and, second, subsidies for food. Findings of the benefits of one type of intervention over another are mixed.

CONCLUSIONS

This systematic review highlights that the current evidence for interventions that address food insecurity and obesity is mixed and limited in scope. There is a need for rigorous controlled trials to examine the effectiveness and cost-effectiveness of interventions for weight management among individuals with food insecurity and obesity while considering sustainability.

Association between youth blood pressure and exposure to pediatric fruit and vegetable prescriptions

BACKGROUND

Health impacts of pediatric fruit and vegetable prescription programs (FVPPs) are unclear. This study assessed whether exposure to an FVPP that provided $15 produce prescriptions during pediatric visits was associated with differences in child diet, food security, physical activity, weight status, and blood pressure.

METHODS

This cross-sectional analysis included data from caregiver-child dyads with varying levels of exposure to the FVPP. Dyads completed surveys at pediatric offices. Trained research assistants measured height and weight of children and recorded blood pressure through chart review. Causal inference analyses using propensity score adjustments compared outcomes of exposure groups.

RESULTS

680 dyads enrolled. Youth who received ≥1 prescription (exposed) reported greater physical activity compared to youth who received no prescriptions (unexposed). Blood pressure percentiles were lower among exposed when compared to unexposed youth (63.273 versus 75.060 for SBP; 71.472 versus 77.548 for DBP); and fewer exposed children recorded elevated blood pressure when compared to unexposed (0.141 versus 0.343 for SBP; 0.199 versus 0.344 for DBP; and 0.286 versus 0.531 overall). Similar findings were obtained using duration as a measure of exposure.

CONCLUSION

Youth exposed to the FVPP experienced greater physical activity and healthier blood pressure. Findings may indicate novel health-promoting effects of pediatric FVPPs.

IMPACT

When compared to youth with no exposure, youth exposed to a pediatric fruit and vegetable prescription program recorded greater physical activity and healthier blood pressure. Youth with high exposure (≥24 months) to the fruit and vegetable prescription program experienced greater physical activity and healthier blood pressure when compared to youth with low exposure (<24 months). This extends evaluation of pediatric fruit and vegetable prescription programs beyond feasibility and preliminary effectiveness to indicate potential of such programs in positively influencing physical activity and blood pressure of participating youth. Findings indicate novel health-promoting effects of pediatric fruit and vegetable prescription programs.

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.

Addressing Dietary-Related Health Disparities in Underserved Communities: Outcomes From a 24-Month Pilot, Subsidized Food Prescription Program in the Mississippi Delta

Background: This study examines the outcomes of the 24-months Charleston FoodRx food prescription program implemented in rural Mississippi to address dietary-related health disparities.Purpose: Examine changes in participant produce consumption, food seccurity, and anthropometrics over a 24-month period.Research Design: A one-group, repeated measures design, was utilized to assess changes in produce consumption, food security, and anthropometric data from baseline.Study Sample: A total of 55 households completed the study.Data analyses: longitudinal and regression analyses were conducted to identify significant change over time.Results: Results indicated an increase in weekly produce consumption, and a decrease in the prevalence of food insecurity over the follow-up periods. Among adults, statistically significant reductions in weight, body mass index (BMI), waist circumference, and triglyceride levels were observed at the 24-month endpoint.Conclusions: These outcomes support the efficacy of food prescription programs in promoting healthier dietary behaviors and improving health-related outcomes. The study provides valuable insights into the impact of such interventions on dietary-related health disparities in underserved communities. However, more robust research is needed to maximize the potential of these interventions.

Will a Programmatic Framework Integrating Food Is Medicine Achieve Value on Investment?

Diet-related chronic diseases account for seven out of the ten leading causes of death in the USA. Food is Medicine (FIM) interventions can be effective adjuncts to standard medical care to address this cost burden. While the Food is Medicine Pyramid recommends some culinary skill development when integrating FIM into healthcare, the emphasis is on medically tailored meals and food provision. Hence, there is a practice gap to ensure patients develop the necessary skills to apply nutrition recommendations into improved food behaviors to achieve positive long-term health outcomes. This paper presents a theoretical framework for optimizing existing clinical services to provide FIM interventions, tracking associated improvements in patient outcomes, and identifying healthcare cost saving/revenue generation that can lead to a net value on investment. It describes how these interventions can and have been used in a clinical setting as adjuncts to clinical care. While there is published evidence for each modality individually, the literature lacks evidence of the value of an integrated approach. The framework therefore provides a roadmap to both identify best practices and evaluate outcomes that will inform viable financial models.

Family meals on prescription as treatment for childhood obesity-a randomized controlled trial

The aim with the present study was to evaluate the effects and tolerability of Family Meals on Prescription, a 3-month intensive dietary intervention with a participatory approach on body mass index (BMI) and metabolic health in children living with obesity. In this prospective randomized controlled trial, children aged 5-15 years were included from the Pediatric Obesity outpatient Clinics in Halland, Sweden. Participants were randomly assigned to receive lifestyle treatment with or without Family Meals on Prescription (FMP) consisting of a subsidized prepacked grocery bag including recipes and provisions for five Family Meals per week for 3 months. The primary endpoint was changed in BMIz after 3, 12 and 18-24 months and secondary endpoints included to assess tolerability of FMP and effects on metabolic biomarker and frequency of shared meals. Eighty-nine children (51.7% female) entered the study, 54 patients in the intervention group and 35 in the control group. There were no significant differences between the groups concerning gender, age or level of obesity at baseline. The Family Meal on Prescription intervention combined with lifestyle treatment led to a significantly greater reduction in BMIz than lifestyle treatment alone after the 3-month long intervention (- 0.17 vs + 0.01, p < 0.01); however, this difference was not sustained throughout the study period, and in fact, the control group had a greater reduction in BMIz after 18-24 months.A subsidized prepacked grocery bag may be a novel, well-tolerated and effective tool in the treatment of childhood obesity. The fact that the BMIz reduction shown at the end of the intervention did not persist over time emphasized the need of long-term treatment. Registered at clinicaltrals.gov 27 Nov 2020, retrospectively registered: clinicaltrials.gov number 19002468. https://clinicaltrials.gov/study/NCT05225350 What is Known: • Swedish data shows that lifestyle treatment alone is not sufficient for many families undergoing treatment for childhood obesity. • Regular family meals and mealtime routines have been shown to be important for nutritional health and dietary patterns in children and adolescents. What is New: • This intervention with a participatory approach involving prepacked family meals was well tolerated and led to a significant reduction in BMIz during the intervention. • That fact that these results were not sustained over time indicates a need to evaluate longer interventions, and that childhood obesity is a chronic and complex disease which requires long-time treatments.

Examining Food Security, Fruit and Vegetable Intake, and Cardiovascular Disease Risk Outcomes of Produce Prescription (PPR) Programs: A Systematic Review

OBJECTIVE

Outcomes from produce prescription (PPR) programs, an exemplar of a Food is Medicine intervention, have not been synthesized. The objective of this study was to conduct a systematic review to examine the impact of PPR programs on food security, fruit and vegetable (FV) intake, and/or cardiovascular risk factors (HbA1c, blood pressure, and blood lipids).

DESIGN

Searches were conducted across three databases (PubMed, CINAHL, and Web of Science). Eligible studies were published between August 2012 and April 2023, conducted in the US in child/family, or adult populations, written in English and had a PPR program as an exposure.

OUTCOMES VARIABLES MEASURED

Food security, FV intake, and/or cardiovascular risk factors.

RESULTS

Twenty studies ranging from a duration of between 6 weeks to 24 months were included. Of the 5 studies (3 in child/family and 4 in adult populations) that analyzed changes in food security status, all reported significant (P < 0.05) improvements after the PPR program. Approximately half of the included studies found significant (P < 0.05) increases in fruit, vegetable, and/or FV intake. Only studies in adult populations included cardiovascular risk factor outcomes. In these studies, mixed findings were reported; however, there were significant (P < 0.05) improvements in HbA1c when PPR programs enrolled individuals with type 2 diabetes.

CONCLUSIONS AND IMPLICATIONS

PPR programs provide an opportunity to improve food security in child/family, and adult populations. Evidence to support whether PPR programs increase FV intake and improve cardiovascular disease risk factors outside of HbA1c in adult populations with high HbA1c upon enrollment is less known.

Addressing diabetes by elevating access to nutrition (ADELANTE) - A multi-level approach for improving household food insecurity and glycemic control among Latinos with diabetes: A randomized controlled trial

BACKGROUND

Latinx adults are disproportionately impacted by the interrelated challenges of food insecurity and nutrition sensitive chronic diseases. Food and nutrition insecurity can exacerbate the development and progression of chronic diseases, such as diabetes. Sustainable, effective interventions aimed at improving food insecurity and diabetes management for Latinx populations are needed.

METHODS

This hybrid type 1 trial evaluates the effectiveness of a multi-level intervention that includes a medically supportive food and behavioral lifestyle program on the primary outcome of Hemoglobin A1c (HbA1c) at 6 months. Latinx adults (n = 355) with type 2 diabetes (HbA1c of 6.0-12.0 %), overweight/obesity (BMI > 25 kg/m2), and self-reported risk of food insecurity will be randomized 1:1 to intervention (12 weekly deliveries of vegetables, fruits, and whole-grain foods + culturally-modified behavioral lifestyle program) versus control (food deliveries after a 6-month delay). Outcome asessments will occur at 0, 6 and 12 months, and include HbA1c, dietary intake, psychosocial health outcomes, and diabetes-related stressors. In addition, food insecurity and the impact of the intervention on up to two household members will be measured. Qualitative interviews with patients, healthcare providers, and community partners will be conducted in accordance with Reach, Effectivenes, Adoption, Implementation, and Maintenence (RE-AIM) framework to identify barriers and best practices for future dissemination.

CONCLUSIONS

The ADELANTE trial will provide novel insight to the effectiveness of a multi-level intervention on diabetes-related outcomes in Latinx adults. The mixed-method approach will also identity the reach of this 'Food is Medicine' intervention on additional household members to inform diabetes prevention efforts.

CLINICAL TRIAL REGISTRATION

NCT05228860.

Stakeholder Perspectives on the Acceptability, Design, and Integration of Produce Prescriptions for People with Type 2 Diabetes in Australia: A Formative Study

Produce prescription programs can benefit both individuals and health systems; however, best practices for integrating such programs into the Australian health system are yet unknown. This study explored stakeholders' perspectives on the acceptability, potential design and integration of produce prescription programs for adults with type 2 diabetes in Australia. Purposive sampling was used to recruit 22 participants for an online workshop, representing six stakeholder groups (government, healthcare service, clinician, food retailer, consumer, non-government organisation). Participant responses were gathered through workshop discussions and a virtual collaboration tool (Mural). The workshop was video-recorded and transcribed verbatim, and thematic analysis was conducted using a deductive-inductive approach. Stakeholders recognised produce prescription as an acceptable intervention; however, they identified challenges to implementation related to contextuality, accessibility, and sustainability. Stakeholders were vocal about the approach (e.g., community-led) and infrastructure (e.g., screening tools) needed to support program design and implementation but expressed diverse views about potential funding models, indicating a need for further investigation. Aligning evaluation outcomes with existing measures in local, State and Federal initiatives was recommended, and entry points for integration were identified within and outside of the Australian health sector. Our findings provide clear considerations for future produce prescription interventions for people with type 2 diabetes.

Addressing cost barriers to healthy eating with Eat Well, a prescription produce subsidy, for patients with diabetes and at risk for food insecurity: Study protocol for a type 1 hybrid effectiveness-implementation pragmatic randomized controlled trial

BACKGROUND

Patients with diabetes at risk of food insecurity face cost barriers to healthy eating and, as a result, poor health outcomes. Population health management strategies are needed to improve food security in real-world health system settings. We seek to test the effect of a prescription produce program, 'Eat Well' on cardiometabolic health and healthcare utilization. We will also assess the implementation of an automated, affirmative outreach strategy.

METHODS

We will recruit approximately 2400 patients from an integrated academic health system in the southeastern United States as part of a two-arm parallel hybrid type 1 pragmatic randomized controlled trial. Patients with diabetes, at risk for food insecurity, and a recent hemoglobin A1c reading will be eligible to participate. The intervention arm receives, 'Eat Well', which provides a debit card with $80 (added monthly) for 12 months valid for fresh, frozen, or canned fruits and vegetables across grocery retailers. The control arm does not. Both arms receive educational resources with diabetes nutrition and self-management materials, and information on existing care management resources. Using an intent-to-treat analysis, primary outcomes include hemoglobin A1C levels and emergency department visits in the 12 months following enrollment. Reach and fidelity data will be collected to assess implementation.

DISCUSSION

Addressing food insecurity, particularly among those at heightened cardiometabolic risk, is critical to equitable and effective population health management. Pragmatic trials provide important insights into the effectiveness and implementation of 'Eat Well' and approaches like it in real-world settings.

REGISTRATION

ClinicalTrials.gov Identifier: NCT05896644; Clinical Trial Registration Date: 2023-06-09.

Factors Associated With Uptake of an Open Access Health Center-Based Mobile Produce Market: A Case for Expanded Eligibility

BACKGROUND

Health care-based food assistance programs show promise but are underutilized. Strict eligibility requirements and program scheduling may dampen reach and outcomes.

OBJECTIVE

To explore factors associated with uptake of a health center-based mobile produce market with no eligibility requirements and few barriers to entry.

DESIGN

A cross-sectional analysis of medical record, sociodemographic, environmental, and market attendance data was used.

PARTICIPANTS/SETTING

The study sample consisted of 3071 adults (18+ years) who were patients of an urban health center in eastern Massachusetts and registered for the mobile market during the study period of August 2016 to February 2020.

MAIN OUTCOME MEASURES

The main outcome measure was monthly market attendance over the study period.

STATISTICAL ANALYSES

T-tests and χ2 tests were used to compare market users and never-users. Multiple logistic regression was used to analyze variables associated with market attendance each month.

RESULTS

In multiple variable analyses, Supplemental Nutrition Assistance Program enrollment was associated with slightly less frequent monthly market use (odds ratio [OR], 0.989; 95% CI, 0.984-0.994). Day-of, on-site market registration was associated with more frequent monthly use than self-registration on nonmarket days (OR, 1.08; 95% CI, 1.07-1.08). Having a psychiatric or substance use disorder diagnosis was associated with slightly less frequent market attendance (OR, 0.99; 95% CI, 0.98-0.99; and OR, 0.96; 95% CI, 0.95-0.97, respectively) compared with registrants without these diagnoses.

CONCLUSIONS

Individual, community-level, and organizational factors are associated with uptake of a free mobile produce market and should be considered when designing programs.

Food inequity and insecurity and MASLD: burden, challenges, and interventions

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an 'upstream' risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Pilot study of a heart-healthy food box intervention for Native Americans with uncontrolled hypertension: methods and results from the Chickasaw Healthy Eating Environments Research Study

We sought to evaluate the acceptability and feasibility of a culturally tailored food box intervention for improving blood pressure (BP), food security and Body Mass Index (BMI) among Chickasaw Nation adults with uncontrolled hypertension. As part of the Chickasaw Healthy Eating Environments Research Study (CHEERS), we administered a group randomized pilot study in four tribal communities (two intervention, two control). Participants in the intervention communities received six heart-healthy food boxes, culturally tailored to traditional Chickasaw diet and current food context. Outcomes were measured over 6 months. We enrolled 262 participants, and 204 with complete data on key variables were included in the analysis. The food boxes were very popular, and we achieved high retention for follow-up data collection. Intervention community participants had 2.6 mmHg lower mean systolic BP and improved diet quality and BMI compared with control participants, although, as expected for a pilot study, the differences were not statistically significant. The culturally tailored diet intervention and randomized trial study design were acceptable and feasible for Chickasaw Nation adults with uncontrolled hypertension. Our findings support the value of tribal-food bank partnerships as a potential approach for reducing food insecurity and hypertension-related disparities in Native American communities.

Dietary Modulations in Preventing Cardiometabolic Risk in Individuals with Type 2 Diabetes

PURPOSE OF REVIEW

Type 2 diabetes mellitus (T2DM) is a complex health issue include obesity, high cholesterol, high blood pressure, and chronic inflammation that increase the risk of cardiovascular diseases (CVDs). CVDs are of great concern in the disease progression and prognosis of T2DM. This review is a comprehensive examination of the literature on the relationship between T2DM and cardiovascular risk, nutrition-related cardiometabolic risk (CMR) factors, and impact of dietary modulations on CMR.

RECENT FINDINGS

In recent years the researches has been focus on the importance of a comprehensive treatment approach like dietary modulations to address multiple cardiovascular risk reductions, including hypertension and dyslipidemia. Modulation of dietary patterns are the most promising interventions to prevent CMR factors and T2DM via affecting the body weight, glucose control, and microbial diversity of individuals. Current evidence suggests that high-quality dietary patterns such as the Dietary Approaches to Stop Hypertension (DASH) eating plan and the Mediterranean diet is important in the metabolic control processes of T2DM with anti-inflammatory and antioxidant compounds, glucagon-like peptide agonist compounds, and intestinal microbiota changes. Nutrition plays a critical role in preventing and improving CVD outcomes in patients with T2DM. Dietary modulations should be planned considering individual differences in responses to dietary composition and nutritional changes, personal preferences, eating behaviors and gut microbiota differences.

A virtual culinary medicine intervention for ethnically diverse individuals with type 2 diabetes: development of the Nourishing the Community through Culinary Medicine

Virtual culinary medicine education interventions have the potential to improve dietary behaviors, nutrition knowledge, cooking skills, and health outcomes for ethnically diverse individuals with type 2 diabetes. The purpose of this study is to describe the adaptation of the Nourishing the Community through Culinary Medicine (NCCM) program for virtual delivery, and the protocol for pilot testing this intervention. The intervention includes five 90-min virtual NCCM sessions streamed live from a Teaching Kitchen. Feasibility outcomes are recruitment, retention, acceptability, and satisfaction. Short-term effectiveness outcomes are measured through self-administered questionnaires, including perceived health, average daily servings of fruits and vegetables, frequency of healthy food consumption, shopping, cooking, and eating behaviors, cooking self-efficacy, diabetes self-management, perceived barriers to healthy eating, and nutrition knowledge. Demographics and biometric outcomes are sourced from the patient's electronic medical records including glycosylated hemoglobin (HbA1c), Body Mass Index, and blood pressure. We will conduct a single-arm pilot study to test the feasibility and short-term effectiveness of NCCM program with individuals with type 2 diabetes.

The integration of complementary and integrative health and whole person health in gastrointestinal disorders: a narrative review

Background and Objective

Complementary and integrative health (CIH) approaches are increasingly popular among patients with gastrointestinal (GI) disorders. Whole person health has been identified as an important perspective in integrative health. While complementary approaches have been discussed in the GI literature, the whole person health framework has not yet been incorporated. Whole person health is particularly relevant as we shift to patient-centered care to facilitate holistic healing for this population. The aim of this paper is to apply a conceptualization of whole person health and its relevance in understanding how CIH approaches can be utilized for patients with stress-sensitive GI disorders, such as disorders of gut-brain interaction (DGBI) and inflammatory bowel disease (IBD).

Methods

Between July 2023 and December 2023 numerous major databases were reviewed to identify relevant articles for this narrative review. Keywords searched included (but not limited to) complementary alternative medicine, integrative medicine, DGBI, IBD, whole person health, and CIH categories (nutritional, mind-body, psychological). We limited our search to peer-reviewed English language articles. Studies were also cross-referenced to incorporate additional relevant studies.

Key Content and Findings

This narrative review describes how to integrate CIH approaches with whole person health for patients with some of the most common stress-sensitive GI disorders, including DGBIs and IBD. In each section, we highlight how each domain of the whole person health framework (biological, behavioral, social, environmental) can be addressed through CIH approaches: psychological, mind-body practices, and nutritional.

Conclusions

The integration of CIH approaches into the treatment of GI disorders is a growing area of interest that holds promise for enhancing patient outcomes. The two concepts of CIH and whole person health are harmonizing, and their integration serves to support patients who are already using CIH approaches, and providers who can facilitate shared-decision-making and patient-centered care. While not exhaustive, this review demonstrates positive associations between the use of CIH and beneficial outcomes across all whole person health domains for patients with GI disorders.

Engagement in a pilot produce prescription program in rural and urban counties in the Southeast United States

Introduction

In the United States, over one in every ten households experiences food insecurity. Food insecurity is associated with often co-occurring adverse health consequences, including risk for obesity, type 2 diabetes, and hypertension. Within the "Food is Medicine" intervention space, Produce Prescription Programs (PRx) seek to alleviate food insecurity and improve diet and health outcomes by leveraging access to produce through healthcare organizations. Though these programs are burgeoning across the United States, research surrounding their implementation and outreach is limited.

Methods

This study evaluates the implementation, reach, engagement, and retention of a PRx program piloted in two regions of Georgia (US) from 2020 to 2022. The study included 170 people living with one or more cardiometabolic conditions recruited from clinical sites in metropolitan and rural areas. The program provided pre-packaged produce boxes and nutrition education over six months. We examine participants' baseline demographics, food security status, dietary patterns, and loss to follow-up across contexts (metropolitan and rural). We employ regression analyses and model comparison approaches to identify the strongest predictors of loss to follow-up during the pilot period.

Results

In the pilot period of this program, 170 participants enrolled across rural and metropolitan sites. Of these, 100 individuals (59%) remained engaged for the six-month program. While many individuals met the target criteria of living with or at-risk of food insecurity, not all lived with low or very low food security. Metropolitan participants, males, and those with children in the household had significantly higher odds of loss to follow-up compared to rural participants, females, and those without children in the household. No other significant demographic or household differences were observed.

Discussion

This study demonstrates the potential of PRx programs to enhance food and nutrition security and cardiometabolic health in metropolitan and rural clinical settings. Future research should focus on addressing barriers to engagement and expanding the reach, impact, and sustainability of PRx programs across diverse contexts.

From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service

Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.

How does fresh food prescribing fit into the social service landscape? A qualitative study in Ontario, Canada

INTRODUCTION

Food prescription programs are part of the broader social prescribing movement as an approach to address food insecurity and suboptimal diet in health care settings. These programs exist amid other social services, including income-based supports and food assistance programs; however, evaluations of the interactions between these programs and pre-existing services and supports are limited. This study was embedded within a larger evaluation of the 52-week Fresh Food Prescription (FFRx) program (April 2021-October 2022); the objective of this study was to examine how program participation influenced individuals' interactions with existing income-based supports and food assistance programs.

METHODS

This study was conducted in Guelph, Ontario, Canada. One-to-one (n = 23) and follow-up (n = 10) interviews were conducted to explore participants' experiences with the program. Qualitative data were analyzed thematically using a constant comparative analysis.

RESULTS

Participants described their experience with FFRx in relation to existing income-based supports and food assistance programs. FFRx reportedly extended income support further to cover living expenses, allowed participants to divert income to other necessities, and reduced the sacrifices required to meet basic needs. FFRx lessened the frequency of accessing other food assistance programs. Aspects of FFRx's design (e.g. food delivery) shaped participant preferences in favour of FFRx over other food supports.

CONCLUSION

As food prescribing and other social prescribing programs continue to expand, there is a need to evaluate how these initiatives interact with pre-existing services and supports and shape the broader social service landscape.

Food prescribing in Canada: evidence, critiques and opportunities

INTRODUCTION

There is growing interest in food prescriptions, which leverage health care settings to provide patients access to healthy foods through vouchers or food boxes. In this commentary, we draw on our experiences and interest in food prescribing to provide a summary of the current evidence on this intervention model and critically assess its limitations and opportunities.

RATIONALE

Food insecurity is an important determinant of health and is associated with compromised dietary adequacy, higher rates of chronic diseases, and higher health service utilization and costs. Aligning with recent discourse on social prescribing and "food is medicine" approaches, food prescribing can empower health care providers to link patients with supports to improve food access and limit barriers to healthy diets. Food prescribing has been shown to improve fruit and vegetable intake and household food insecurity, although impacts on health outcomes are inconclusive. Research on food prescribing in the Canadian context is limited and there is a need to establish evidence of effectiveness and best practices.

CONCLUSION

As food prescribing continues to gain traction in Canada, there is a need to assess the effectiveness, cost-efficiency, limitations and potential paternalism of this intervention model. Further, it is necessary to assess how food prescribing fits into broader social welfare systems that aim to address the underlying determinants of food insecurity.

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.

The Potential of Bioactive Fish Collagen Oligopeptides against Hydrogen Peroxide-Induced NIH/3T3 and HUVEC Damage: The Involvement of the Mitochondria

Extensive in vivo investigations have demonstrated the antioxidant properties of fish collagen oligopeptides (FCOPs). One of the main causes of aging and chronic non-communicable diseases is oxidative stress. Therefore, FCOPs have a broad range of applications in illness prevention and delaying aging from the standpoint of the "food is medicine" theory. However, the mechanisms that underpin the antioxidant activity of FCOPs are not completely understood. The specific objective of this essay was to investigate the antioxidant effect of FCOPs and its possible mechanism at the cellular level. Mouse embryonic fibroblasts NIH/3T3 and human vein endothelial cells (HUVECs) were exposed to 200 µM hydrogen peroxide containing different concentrations of FCOPs for 4 h and were supplemented with different concentrations of FCOPs for 24 h. Normal growth medium without FCOPs was applied for control cells. An array of assays was used to evaluate the implications of FCOPs on cellular oxidative stress status, cellular homeostasis, inflammatory levels, and mitochondrial function. We found that FCOPs exerted a protective effect by inhibiting reactive oxygen species (ROS) production, enhancing superoxide dismutase (SOD) and endothelial nitric oxide synthase (eNOS) activities and cell viability, inhibiting cell cycle arrest in the G1 phase, suppressing interleukin-1β (IL-1β), IL-6, matrix metalloproteinase-3 (MMP-3) and intercellular adhesion molecule-1(ICAM-1) secretion, downregulating nuclear factor-kappa B (NF-κB) activity, protecting mitochondrial membrane potential, and increasing ATP synthesis and NAD+ activities in both cells. FCOPs had a stronger antioxidant impact on NIH/3T3 than on HUVECs, simultaneously increasing glutathione peroxidase (GSH-Px) activity and decreasing malondialdehyde (MDA) content in NIH/3T3. These findings indicate that FCOPs have antioxidant effects on different tissue cells damaged by oxidative stress. FCOPs were therefore found to promote cellular homeostasis, inhibit inflammation, and protect mitochondria. Meanwhile, better health outcomes will be achieved by thoroughly investigating the effective dose and intervention time of FCOPs, as the absorption efficiency of FCOPs varies in different tissue cells.

Developing and testing a produce prescription implementation blueprint to improve food security in a clinical setting: a pilot study protocol

BACKGROUND

Food insecurity is common in the United States, especially in Rhode Island, where it affects up to 33% of residents. Food insecurity is associated with adverse health outcomes and disproportionally affects people from minoritized backgrounds. Produce prescription programs, in which healthcare providers write "prescriptions" for free or reduced cost vegetables, have been used to address food insecurity and diet-related chronic disease. Although there is growing evidence for the effectiveness of produce prescription programs in improving food security and diet quality, there have been few efforts to use implementation science methods to improve the adoption of these programs.

METHODS

This two-phase pilot study will examine determinants and preliminary implementation and effectiveness outcomes for an existing produce prescription program. The existing program is funded by an Accountable Care Organization in Rhode Island and delivered in primary care practices. For the first phase, we conducted a formative evaluation, guided by the Consolidated Framework for Implementation Research 2.0, to assess barriers, facilitators, and existing implementation strategies for the produce prescription program. Responses from the formative evaluation were analyzed using a rapid qualitative analytic approach to yield a summary of existing barriers and facilitators. In the second phase, we presented our formative evaluation findings to a community advisory board consisting of primary care staff, Accountable Care Organization staff, and staff who source and deliver the vegetables. The community advisory board used this information to identify and refine a set of implementation strategies to support the adoption of the program via an implementation blueprint. Guided by the implementation blueprint, we will conduct a single-arm pilot study to assess implementation antecedents (i.e., feasibility, acceptability, appropriateness, implementation climate, implementation readiness), implementation outcomes (i.e., adoption), and preliminary program effectiveness (i.e., food and nutrition security). The first phase is complete, and the second phase is ongoing.

DISCUSSION

This study will advance the existing literature on produce prescription programs by formally assessing implementation determinants and developing a tailored set of implementation strategies to address identified barriers. Results from this study will inform a future fully powered hybrid type 3 study that will use the tailored implementation strategies and assess implementation and effectiveness outcomes for a produce prescription program.

TRIAL REGISTRATION

Clinical trials: NCT05941403 , Registered June 9, 2023.

Clients' experiences and satisfaction with produce prescription programs in California: a qualitative evaluation to inform person-centered and respectful program models

Background

Produce prescription programs have strong potential to improve food security, fruit and vegetable consumption, and health across the life course. Understanding clients' experiences and satisfaction with produce prescription programs is critical for evaluating the person-centeredness and quality of these programs. The objectives of this study were to (1) describe client experiences and satisfaction with produce prescription programs, with an emphasis on the extent to which they felt they were treated with respect and dignity, and (2) identify recommendations for improving client experiences.

Methods

We conducted four focus group discussions with clients of produce prescription programs in two Federally Qualified Health Centers in California. We used a modified framework analysis approach and organized participants' experiences with programs into themes.

Results

Three themes captured participants' program experiences. First, respectful produce prescription programming encompassed interactions with individuals delivering the programs that felt respectful (e.g., program staff showing they cared about participants' health and offering timely assistance with financial incentives) and disrespectful (e.g., not receiving prompt responses to questions about incentives), as well as aspects of program design perceived to be respectful (e.g., provision of gift cards as financial incentives, which offered privacy when purchasing produce). Second, having autonomy to use gift cards to choose their preferred fresh fruits and vegetables was viewed as a positive experience, though participants desired greater autonomy to shop at stores other than the program designated stores. Third, participants frequently discussed program usability, with some reporting that joining the programs and using the cards was easy, and others describing difficulties activating cards and using them at stores due to cashiers' lack of awareness of the programs. Overall, participants were highly satisfied with the programs. To improve client experiences, they recommended increasing privacy (e.g., by educating cashiers on the programs so that clients do not need to explain in public what the card is for) and autonomy (e.g., allowing cards to be used at other chain or local stores).

Discussion

Our findings inform efforts to make produce prescription programs more person-centered and respectful, which in turn may increase program demand, engagement, and impact.

Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities

Food insecurity and the lack of access to affordable, nutritious food are associated with poor dietary quality and an increased risk of diet-related diseases, including cardiovascular disease, diabetes, and certain types of cancer. Those of lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, are more likely to live in under-resourced food environments, and continue to bear the greatest burden of diet-related chronic diseases in the United States. Despite the growing body of literature in this area, there are still significant gaps in our understanding of the various pathways that link food insecurity and neighborhood food environments to racial/ethnic and socioeconomic disparities in health and the most effective intervention strategies to address these disparities. To better understand the science in this area, the National Institutes of Health, in collaboration with the Centers for Disease Control (CDC) and Prevention and the United States Department of Agriculture (USDA), convened a virtual 3-d workshop 21-23 September 2021: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop brought together a diverse group of researchers, practitioners, policymakers, and federal partners with expertise in nutrition, the food environment, health and social policy, and behavioral and social sciences. The workshop had the following 3 research objectives: 1) summarize the state of the science and knowledge gaps related to food insecurity, neighborhood food environments, and nutrition health disparities, 2) identify research opportunities and strategies to address research gaps, and 3) examine evidence-based interventions and implementation approaches to address food insecurity and neighborhood food environments to promote health equity. This article summarizes workshop proceedings and describes research gaps and future opportunities that emerged from discussions.

Food is Medicine Initiative for Mitigating Food Insecurity in the United States

OBJECTIVES

While several food assistance programs in the United States tackle food insecurity, a relatively new program, "Food is Medicine," (FIM) initiated in some cities not only addresses food insecurity but also targets chronic diseases by customizing the food delivered to its recipients. This review describes federal programs providing food assistance and evaluates the various sub-programs categorized under the FIM initiative.

METHODS

A literature search was conducted from July 7, 2023 to November 9, 2023 using the search term, "Food is Medicine", to identify articles indexed within three major electronic databases, PubMed, Medline, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Eligibility criteria for inclusion were: focus on any aspect of the FIM initiative within the United States, and publication as a peer-reviewed journal article in the English language. A total of 180 articles were retrieved; publications outside the eligibility criteria and duplicates were excluded for a final list of 72 publications. Supporting publications related to food insecurity, governmental and organizational websites related to FIM and other programs discussed in this review were also included.

RESULTS

The FIM program includes medically tailored meals, medically tailored groceries, and produce prescriptions. Data suggest that it has lowered food insecurity, promoted better management of health, improved health outcomes, and has, therefore, lowered healthcare costs.

CONCLUSIONS

Overall, this umbrella program is having a positive impact on communities that have been offered and participate in this program. Limitations and challenges that need to be overcome to ensure its success are discussed.

"Food Is Medicine" Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review

"Food Is Medicine" (FIM) represents a spectrum of food-based interventions integrated into health care for patients with specific health conditions and often social needs. Programs include medically tailored meals, groceries, and produce prescriptions, with varying levels of nutrition and culinary education. Supportive advances include expanded care pathways and payment models, e-screening for food and nutrition security, and curricular and accreditation requirements for medical nutrition education. Evidence supports positive effects of FIM on food insecurity, diet quality, glucose control, hypertension, body weight, disease self-management, self-perceived physical and mental health, and cost-effectiveness or cost savings. However, most studies to date are quasiexperimental or pre/post interventions; larger randomized trials are ongoing. New national and local programs and policies are rapidly accelerating FIM within health care. Remaining research gaps require rigorous, iterative evaluation. Successful incorporation of FIM into health care will require multiparty partnerships to assess, optimize, and scale these promising treatments to advance health and health equity.

Exploring the prospective acceptability of a healthy food incentive program from the perspective of people with type 2 diabetes and experiences of household food insecurity in Alberta, Canada

OBJECTIVE

FoodRx is a 12-month healthy food prescription incentive program for people with type 2 diabetes (T2DM) and experiences of household food insecurity. In this study, we aimed to explore potential users' prospective acceptability (acceptability prior to program use) of the design and delivery of the FoodRx incentive and identify factors influencing prospective acceptability.

DESIGN

We used a qualitative descriptive approach and purposive sampling to recruit individuals who were interested or uninterested in using the FoodRx incentive. Semi-structured interviews were guided by the theoretical framework of acceptability, and corresponding interview transcripts were analysed using differential qualitative analysis guided by the socioecological model.

SETTING

Individuals living in Alberta, Canada.

PARTICIPANTS

In total, fifteen adults with T2DM and experiences of household food insecurity.

RESULTS

People who were interested in using the FoodRx incentive (n 10) perceived it to be more acceptable than those who were uninterested (n 5). We identified four themes that captured factors that influenced users' prospective acceptability: (i) participants' confidence, views and beliefs of FoodRx design and delivery and its future use (intrapersonal), (ii) the shopping routines and roles of individuals in participants' social networks (interpersonal), (iii) access to and experience with food retail outlets (community), and (iv) income and food access support to cope with the cost of living (policy).

CONCLUSION

Future healthy food prescription programs should consider how factors at all levels of the socioecological model influence program acceptability and use these data to inform program design and delivery.

Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use: A Randomized Clinical Trial

Importance

Food-as-medicine programs are becoming increasingly common, and rigorous evidence is needed regarding their effects on health.

Objective

To test whether an intensive food-as-medicine program for patients with diabetes and food insecurity improves glycemic control and affects health care use.

Design, Setting, and Participants

This stratified randomized clinical trial using a wait list design was conducted from April 19, 2019, to September 16, 2022, with patients followed up for 1 year. Patients were randomly assigned to either participate in the program immediately (treatment group) or 6 months later (control group). The trial took place at 2 sites, 1 rural and 1 urban, of a large, integrated health system in the mid-Atlantic region of the US. Eligibility required a diagnosis of type 2 diabetes, a hemoglobin A1c (HbA1c) level of 8% or higher, food insecurity, and residence within the service area of the participating clinics.

Intervention

The comprehensive program provided healthy groceries for 10 meals per week for an entire household, plus dietitian consultations, nurse evaluations, health coaching, and diabetes education. The program duration was typically 1 year.

Main Outcomes and Measures

The primary outcome was HbA1c level at 6 months. Secondary outcomes included other biometric measures, health care use, and self-reported diet and healthy behaviors, at both 6 months and 12 months.

Results

Of 3712 patients assessed for eligibility, 3168 were contacted, 1064 were deemed eligible, 500 consented to participate and were randomized, and 465 (mean [SD] age, 54.6 [11.8] years; 255 [54.8%] female) completed the study. Of those patients, 349 (mean [SD] age, 55.4 [11.2] years; 187 [53.6%] female) had laboratory test results at 6 months after enrollment. Both the treatment (n = 170) and control (n = 179) groups experienced a substantial decline in HbA1c levels at 6 months, resulting in a nonsignificant, between-group adjusted mean difference in HbA1c levels of -0.10 (95% CI, -0.46 to 0.25; P = .57). Access to the program increased preventive health care, including more mean (SD) dietitian visits (2.7 [1.8] vs 0.6 [1.3] visits in the treatment and control groups, respectively), patients with active prescription drug orders for metformin (134 [58.26] vs 119 [50.64]) and glucagon-like peptide 1 medications (114 [49.56] vs 83 [35.32]), and participants reporting an improved diet from 1 year earlier (153 of 164 [93.3%] vs 132 of 171 [77.2%]).

Conclusions and Relevance

In this randomized clinical trial, an intensive food-as-medicine program increased engagement with preventive health care but did not improve glycemic control compared with usual care among adult participants. Programs targeted to individuals with elevated biomarkers require a control group to demonstrate effectiveness to account for improvements that occur without the intervention. Additional research is needed to design food-as-medicine programs that improve health.

Trial Registration

ClinicalTrials.gov Identifier: NCT03718832.

Current State of Food Prescriptions Used to Treat Cardiometabolic Risk Factors in the US Adult Population

Cardiometabolic syndrome is unfortunately widely prevalent in medically underserved areas with one possible non-pharmacological solution being food prescriptions from food pharmacies. Food prescriptions are defined as when a physician prescribes certain foods as a treatment for health conditions. There seems to be a promising future for food prescriptions; however, there is a huge literature gap. Given this lack of knowledge regarding this burgeoning practice, we decided to review the current state of food prescriptions used to treat cardiometabolic conditions in the US adult clinical setting. A thorough search of PubMed and Google Scholar databases for articles written about food prescriptions' impact on cardiometabolic risk factors was done. The keywords used included "food prescriptions, vegetables prescription, produce prescription, fruit prescriptions, food pharmacy, food as medicine, cardiometabolic, blood pressure, glucose, insulin, cholesterol, obesity, BMI, body mass index, triglycerides, and microalbuminuria." Of the 637 articles found with the associated keywords, 115 were kept after being screened by title and abstract. Finally, after a full-text record screening, 30 articles were deemed eligible based on our inclusion criteria. We analyzed the health markers, patient populations, methods of food procurement, and financial incentives in food prescription programs. On average, the implementation of food prescription programs decreased participants' BMI, waist circumference, blood pressure, and HbA1c. Participants in the programs were primarily comprised of African American, Hispanic, underinsured, low-income, older, and women groups. Programs with subsidies and vouchers had a higher compliance rate, and food sourced from farmers' markets, grocers, and mobile vendors had the best program compliance rates. According to the literature, adherence to food prescription programs on average decreases the BMI, blood pressure, waist circumference, and Hb1Ac of participants. However, those are the only biomarkers being studied currently, and future studies should incorporate other markers of chronic conditions. For example, a reliable indicator of cardiometabolic health is total cholesterol/HDL cholesterol, which should be measured in future experiments. Additionally, insulin, glucose, triglycerides, and LDL cholesterol are all great markers of cardiometabolic health that can be measured in the future. The current implementation of many food prescription programs is in medically underserved areas. The patient populations are typically low-income, under- or uninsured, food insecure, and originating from diverse ethnic backgrounds. In the future, food prescription studies should be done on other ethnic populations including but not limited to Native Americans who also carry a large burden of preventable and chronic illnesses.

The evolution and scope of Medicaid Section 1115 demonstrations to address nutrition: a US survey

Poor nutrition and food insecurity are drivers of poor health, diet-related diseases, and health disparities in the U.S. State Medicaid Section 1115 demonstration waivers offer opportunities to pilot food-based initiatives to address health outcomes and disparities. Several states are now leveraging 1115 demonstrations, but the scope and types of utilization remain undefined. To fill this gap, we conducted a systematic analysis of state Medicaid Section 1115 applications and approvals available on Medicaid.gov through July 1, 2023. We found that 19 approved and pending 1115 waivers address nutrition, with 11 submitted or approved since 2021. Fifteen states provide or propose to provide screening for food insecurity, referral to food security programs, and/or reporting on food security as an evaluation metric. Thirteen provide or propose to provide coverage of nutrition education services. Ten provide or propose to provide direct intervention with healthy food. The primary target populations of these demonstrations are individuals with chronic diet-sensitive conditions, mental health or substance use disorders, and/or who are pregnant or post-partum. Since 2021, state utilization of Medicaid 1115 demonstrations to address nutrition has accelerated in pace, scope, and population coverage. These findings and trends have major implications for addressing diet-related health and healthy equity in the United States.

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.

Evaluation of a Distribution Model to Increase Access to Affordable Fruits and Vegetables

Introduction

Identifying effective, sustainable strategies to increase fruit and vegetable consumption is critical to addressing chronic disease risk. Models that provide incentives for produce purchases through reduced-cost or no-cost produce shares are promising. The purpose of our study was to examine the impact on fruit and vegetable intake of Good Food for All, a community-based program to distribute no-cost produce boxes to participants with low incomes. We also assessed program satisfaction and future interest in purchasing an affordable produce box.

Methods

The Good Food for All program was implemented in 22 US cities. Surveys were administered at baseline and postintervention. An online research panel was used as a comparison group and weighted to be demographically comparable to the intervention group. Descriptive statistics and adjusted difference-in-difference (ADID) models were used to examine differences in outcomes between groups.

Results

Respondents (intervention n = 632; comparison n = 1,153) were primarily White, non-Hispanic, and female. Intervention participants had a greater increase in total fruit consumption frequency (ADID: 0.43 times/d; 95% CI, 0.21-0.64; P < .001), total vegetable consumption frequency (ADID: 0.52 times/d; 95% CI, 0.12-0.91; P = .01), and total fruit and vegetable consumption frequency (ADID: 1.03 times/d; 95% CI, 0.49-1.56; P < .001) than comparison respondents. Most intervention participants reported boxes contained the right amount of food (71.9%) and high-quality produce (68.4%) and were willing to purchase a future produce box (85.0%).

Conclusion

Findings indicate that a produce box distribution model increased fruit and vegetable consumption, had high satisfaction among participants, and generated interest in purchasing affordable produce boxes. Future studies should explore feasibility of offering low-cost produce boxes at grocery stores and determine appropriate pricing models to enhance access and sustainability.

Optimizing clinical nutrition research: the role of adaptive and pragmatic trials

Evidence-based nutritional recommendations address the health impact of suboptimal nutritional status. Efficacy randomized controlled trials (RCTs) have traditionally been the preferred method for determining the effects of nutritional interventions on health outcomes. Nevertheless, obtaining a holistic understanding of intervention efficacy and effectiveness in real-world settings is stymied by inherent constraints of efficacy RCTs. These limitations are further compounded by the complexity of nutritional interventions and the intricacies of the clinical context. Herein, we explore the advantages and limitations of alternative study designs (e.g., adaptive and pragmatic trials), which can be incorporated into RCTs to optimize the efficacy or effectiveness of interventions in clinical nutrition research. Efficacy RCTs often lack external validity due to their fixed design and restrictive eligibility criteria, leading to efficacy-effectiveness and evidence-practice gaps. Adaptive trials improve the evaluation of nutritional intervention efficacy through planned study modifications, such as recalculating sample sizes or discontinuing a study arm. Pragmatic trials are embedded within clinical practice or conducted in settings that resemble standard of care, enabling a more comprehensive assessment of intervention effectiveness. Pragmatic trials often rely on patient-oriented primary outcomes, acquire outcome data from electronic health records, and employ broader eligibility criteria. Consequently, adaptive and pragmatic trials facilitate the prompt implementation of evidence-based nutritional recommendations into clinical practice. Recognizing the limitations of efficacy RCTs and the potential advantages of alternative trial designs is essential for bridging efficacy-effectiveness and evidence-practice gaps. Ultimately, this awareness will lead to a greater number of patients benefiting from evidence-based nutritional recommendations.

Design and protocol of a clinic-based comparative effectiveness randomized controlled trial to determine the feasibility and effectiveness of food prescription program strategies in at-risk pediatric populations

BACKGROUND

Produce prescription programs are gaining traction in the U.S.; however, data on the impact of such approaches in pediatric populations are limited. The purpose of our clinic-based comparative effectiveness randomized controlled trial (CE RCT) is to evaluate the preliminary effectiveness of two produce prescription strategies (at-home delivery and grocery store vouchers) implemented by the Brighter Bites non-profit organization in improving obesity-related health outcomes and dietary behaviors among low-income 5-12-year-olds in Houston, Texas. This paper presents the study design, intervention components, and the study measures.

METHODS

Participants (n = 150) are being recruited from two pediatric clinics in Houston, Texas. Child eligibility criteria are aged 5-12 years, Medicaid recipients, body-mass index (BMI) percentile ≥85 and living within 10 miles of a Brighter Bites distribution site. Following consent and baseline measures, children are randomized into one of three arms: (1) Bi-weekly $25 vouchers redeemable for produce at stores (n = 50), (2) Bi-weekly produce delivery to participants' homes through DoorDash (n = 50), and (3) wait-list usual care controls (n = 50). Intervention participants also receive Brighter Bites nutrition education materials. Main child outcome measures are BMI z-scores, blood pressure, hemoglobin A1c, liver panels, and lipid panels. Other outcomes including household food insecurity, child diet quality, and home nutrition environment will be collected through parent surveys. Outcome measures are collected at baseline and post-intervention. Process evaluation will measure program dosage, reach, acceptability, and feasibility.

CONCLUSIONS

Our paper presents the design and next steps to ensure the successful implementation of a produce prescription program in a pediatric clinic setting.

A Rural Delivery-Based Produce Prescription Intervention Improves Glycemic Control and Stress

OBJECTIVE

We examined the impact of a pilot 24-week delivery-based produce prescription (PRx) intervention with tailored education and culinary resources for rural patients (n = 40) with type-2 diabetes in underresourced communities on behavioral and clinical outcomes.

METHODS

We used a single group pretest-posttest design that included a home-delivered PRx, culturally tailored recipes, and health/nutrition education handouts. Measures included hemoglobin A1c (HbA1c), self-reported fruit/vegetable consumption, and stress. Descriptive statistics, t-tests, and Wilcoxon signed rank tests were conducted.

RESULTS

Mean HbA1c decreased from 7.6 ± 1.6% to 7.1% ± 1.4% (P = 0.001). Self-reported consumption of fruit/vegetables improved, including frequency and serving size of beans (P = 0.01 and P = 0.01), serving size of lettuce salad (P = 0.02), and serving size of vegetable soup (P = 0.001). Perceived stress decreased (P = 0.01).

CONCLUSION AND IMPLICATIONS

Findings from this pilot PRx intervention suggest a delivery-based PRx with tailored educational resources has the potential to reduce HbA1c and stress while improving fruit/vegetable consumption within rural patients with type-2 diabetes in underresourced communities.

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 Is Medicine: A Presidential Advisory From the American Heart Association

Unhealthy diets are a major impediment to achieving a healthier population in the United States. Although there is a relatively clear sense of what constitutes a healthy diet, most of the US population does not eat healthy food at rates consistent with the recommended clinical guidelines. An abundance of barriers, including food and nutrition insecurity, how food is marketed and advertised, access to and affordability of healthy foods, and behavioral challenges such as a focus on immediate versus delayed gratification, stand in the way of healthier dietary patterns for many Americans. Food Is Medicine may be defined as the provision of healthy food resources to prevent, manage, or treat specific clinical conditions in coordination with the health care sector. Although the field has promise, relatively few studies have been conducted with designs that provide strong evidence of associations between Food Is Medicine interventions and health outcomes or health costs. Much work needs to be done to create a stronger body of evidence that convincingly demonstrates the effectiveness and cost-effectiveness of different types of Food Is Medicine interventions. An estimated 90% of the $4.3 trillion annual cost of health care in the United States is spent on medical care for chronic disease. For many of these diseases, diet is a major risk factor, so even modest improvements in diet could have a significant impact. This presidential advisory offers an overview of the state of the field of Food Is Medicine and a road map for a new research initiative that strategically approaches the outstanding questions in the field while prioritizing a human-centered design approach to achieve high rates of patient engagement and sustained behavior change. This will ideally happen in the context of broader efforts to use a health equity-centered approach to enhance the ways in which our food system and related policies support improvements in health.

Adoption and implementation of produce prescription programs for under-resourced populations: clinic staff perspectives

Background

Produce prescription programs represent a promising intervention strategy in the healthcare setting to address disparities in diet quality and diet-related chronic disease. The objective of this study was to understand adoption and implementation factors related to these programs that are common across contexts and those that are context-specific.

Methods

In this qualitative case comparison study, we conducted qualitative interviews with eight clinic staff from five primary care "safety net" clinics, identified by a partnering non-profit organization that operated the programs, in April-July 2021.

Results

Across clinics, the ability to provide a tangible benefit to patients was a key factor in adoption. Flexibility in integrating into clinic workflows was a facilitator of implementation. Fit with usual operations varied across clinics. Common challenges were the need for changes to the workflow and extra staff time. Clinic staff were skeptical about the sustainability of both the benefits to patients and the ability to continue the program at their clinics.

Discussion

This study adds to a growing body of knowledge on the adoption and implementation of produce prescription programs. Future research will further this understanding, providing the evidence necessary to guide adopting clinics and to make informed policy decisions to best promote the growth and financial sustainability of these programs.

Food is medicine intervention shows promise for engaging patients attending a safety-net hospital in the Southeast United States

Public health organizations, including the Academy of Nutrition and Dietetics and the American Hospital Association, recognize the importance of achieving food and nutrition security to improve health outcomes, reduce healthcare costs, and advance health equity. In response, federal, state, and private agencies are increasingly seeking to fund healthcare-based interventions to address food insecurity among patients. Simultaneously, nutrition-based interventions targeting chronic diseases have grown across the United States as part of the broader "Food is Medicine" movement. Few studies have examined the successes, challenges, and limitations of such efforts. As Food is Medicine programs continue to expand, identifying common approaches, metrics, and outcomes will be imperative for ensuring program success, replicability, and sustainability. Beginning in 2020, the Food as Medicine (FAM) program, a multipronged, collaborative intervention at Grady Health System has sought to combat food insecurity and improve patient health by leveraging community resources, expertise, and existing partnerships. Using this program as a case study, we (1) outline the collaborative development of the FAM program; (2) describe and characterize patient engagement in the initial 2 years; and (3) summarize strengths and lessons learned for future hospital-based food and nutrition programming. As this case study illustrates, the Food as Medicine program provides a novel model for building health equity through food within healthcare organizations.

Development and Validation of the US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) Model: Health Disparity and Economic Impact Model

BACKGROUND

Few simulation models have incorporated the interplay of diabetes, obesity, and cardiovascular disease (CVD); their upstream lifestyle and biological risk factors; and their downstream effects on health disparities and economic consequences.

METHODS

We developed and validated a US Diabetes, Obesity, Cardiovascular Disease Microsimulation (DOC-M) model that incorporates demographic, clinical, and lifestyle risk factors to jointly predict overall and racial-ethnic groups-specific obesity, diabetes, CVD, and cause-specific mortality for the US adult population aged 40 to 79 y at baseline. An individualized health care cost prediction model was further developed and integrated. This model incorporates nationally representative data on baseline demographics, lifestyle, health, and cause-specific mortality; dynamic changes in modifiable risk factors over time; and parameter uncertainty using probabilistic distributions. Validation analyses included assessment of 1) population-level risk calibration and 2) individual-level risk discrimination. To illustrate the application of the DOC-M model, we evaluated the long-term cost-effectiveness of a national produce prescription program.

RESULTS

Comparing the 15-y model-predicted population risk of primary outcomes among the 2001-2002 National Health and Nutrition Examination Survey (NHANES) cohort with the observed prevalence from age-matched cross-sectional 2003-2016 NHANES cohorts, calibration performance was strong based on observed-to-expected ratio and calibration plot analysis. In most cases, Brier scores fell below 0.0004, indicating a low overall prediction error. Using the Multi-Ethnic Study of Atherosclerosis cohorts, the c-statistics for assessing individual-level risk discrimination were 0.85 to 0.88 for diabetes, 0.93 to 0.95 for obesity, 0.74 to 0.76 for CVD history, and 0.78 to 0.81 for all-cause mortality, both overall and in three racial-ethnic groups. Open-source code for the model was posted at https://github.com/food-price/DOC-M-Model-Development-and-Validation.

CONCLUSIONS

The validated DOC-M model can be used to examine health, equity, and the economic impact of health policies and interventions on behavioral and clinical risk factors for obesity, diabetes, and CVD.

HIGHLIGHTS

We developed a novel microsimula'tion model for obesity, diabetes, and CVD, which intersect together and - critically for prevention and treatment interventions - share common lifestyle, biologic, and demographic risk factors.Validation analyses, including assessment of (1) population-level risk calibration and (2) individual-level risk discrimination, showed strong performance across the overall population and three major racial-ethnic groups for 6 outcomes (obesity, diabetes, CVD, and all-cause mortality, CVD- and DM-cause mortality)This paper provides a thorough explanation and documentation of the development and validation process of a novel microsimulation model, along with the open-source code (https://github.com/food-price/ DOCM_validation) for public use, to serve as a guide for future simulation model assessments, validation, and implementation.