Food Is Medicine, but Are Produce Prescriptions?

The 21st century in the U.S. has seen a groundswell of interest in so-called foodis-medicine interventions in health care practice and policy. Novel endeavors have formed across the country to narrow the chasm between health care and food systems. Bringing these unusual partners to the table, with food representing the largest sector of our economy (1) and health care spending accounting for nearly onefifth of the gross domestic product, offers the potential to radically advance population health objectives and strengthen the economy. From the food lens, local food systems and food equity are among the perspectives represented. From the health care lens, the intersection of food and health is well aligned with the triple aim of offering food rather than (or in addition to) medicine to improve individual experience with care, addressing nutrition insecurity as a root cause of chronic disease to improve the health of populations, and reducing per capita costs of care with averted hospitalizations and health care expenditures. The most evidence exists for medically tailored meals, which are fully prepared and tailored to specific needs for individuals with serious health conditions, such as diabetes (2–7). Simulations modeling national implementation of medical tailored meals indicate that implementing food is medicine for Americans with diabetes could be associated with $19.3 billion in averted health care expenditures in 1 year, with a net policy cost savings of almost $11 billion (4). Additional food-is-medicine models include medically tailored groceries, which are selected by a nutrition professional, and produce prescriptions (Fig. 1) (2). Great heterogeneity exists particularly for produce prescription. Newman et al. (8) surveyed the landscape of U.S. produce prescription programs prior to the coronavirus disease 2019 (COVID-19) pandemic and confirmed that diabetes is the most common eligibility criterion, followed by economic risk or food insecurity. Most programs included a health care visit (87%) and delivered nutrition education (83%) that covered chronic disease management, increasing/limiting nutrients, and food resource management, delivered by a registered dietitian via counseling or classes. Generally, the intervention design findings are consistent with a scoping review of prescription programs (9). Most produce prescription programsmeasure food and vegetable intake, food insecurity, HbA1c, and participant feedback. However, evidence for produce prescriptions and medically tailored groceries remains limited. In this issue of Diabetes Care, Hager et al. (10) retrospectively evaluated changes in HbA1c and other health outcomes in a 6-month produce prescription program for patients from two clinics in Hartford, CT. Eligible patients were identified and referred by clinicians based on uncontrolled diabetes (HbA1c >6.5%) and residence in lowerincome zip codes. Notably, enrollment into the produce prescription program began in November 2019 to March 2020, at which point all in-person nutrition education was cancelled due to the COVID-19 pandemic and no adaptations were described. Program implementation continued through October 2020. Wholesome Wave, a large, nonprofit organization operating across many U.S. states (wholesomewave.org), administered the program. Participants received $60 permonth (regardless of family size) for 6 months in paper vouchers, in clinic or by mail (exclusively by mail after March 2020), to purchase fruits and vegetables at a local grocery retail chain. Nutritional education offered included registered dietitian-led grocery store tours focused on label reading and using the vouchers at checkoutanda launcheventon2November 2019. For evaluation of the program, patients had at least one HbA1c measurement during the program period using electronic health record data. A control group of nonparticipants with baseline and follow-up HbA1c measures was created using overlap weight propensity scores to estimate the probability of being enrolled in the program based on sociodemographics, comorbidities, health care utilization parameters, HbA1c, systolic blood pressure, diastolic blood pressure, and BMI. The authors examined change in HbA1c from baseline to 6 months after enrollment, using generalized estimating equations with overlap weights from propensity scores. All HbA1c measurements taken within the 6-month windowwere used for the primary analysis.