Shenica Graham was at risk of needing insulin to manage her diabetes until her doctor at Broadlawns Medical Center wrote her a prescription for fresh fruits and vegetables. Within six months of participating in the Produce Prescription Program, her glucose levels lowered to the point of no longer needing medication.
A mental health advocate and nonprofit leader, Graham especially appreciates how the program helped in several ways: She could purchase foods with less salt, carbohydrates, and sugar; learn about healthy food options and recipes; and above all, cook fresh meals with her son.
“Instead of me grabbing something that’s just convenient,” said Graham during a national presentation, “we’re taking time to spend together, which helps us in more than just food; it’s our relationship.”
Graham’s story demonstrates the muti-faceted impact the Produce Prescription Program has had by approaching food as medicine that can be prescribed to address patients’ chronic health issues. Iowa Healthiest State Initiative partnered with Broadlawns Medical Center to launch the pilot incentive program in June 2021, and, based on impressive results, has leveraged new funding to expand the program into pediatrics and other clinics across the state.
“Patient outcomes were a huge success,” said Aryn McLaren, Director of Healthy Incentives at the Healthiest State, “to show that patients are indicating they really haven’t changed other medical interventions but have added on the ability to access and eat healthier foods and are seeing decreases in biometrics.”
Mid-Iowa Health Foundation joined the Community Foundation of Greater Des Moines in supporting the launch of the pilot, with a focus on spurring innovative solutions that move upstream to improve health outcomes.
“Produce prescription programs are a recognized strategy to increase access to healthy food consumption and, as a result, positively impact patients’ overall health outcomes,” said Dr. Nalo Johnson, President & CEO of Mid-Iowa Health Foundation. “Supporting a data-informed strategy like this was an easy decision for our organization.”
More than half of Dr. Dana Danley’s patients at the Broadlawns Family Health Center are diabetic and many have other chronic health issues that could partially be addressed with diet changes. But when talking with patients about eating less carbs and more produce, Danley said, “their responses are that: ‘I can only get corn, or potatoes, or pasta. That’s all I can afford.’”
Knowing that social and economic factors greatly influence health outcomes, Broadlawns prioritizes efforts that promote well-being, such as offering job training for nearby residents and books to children. Food insecurity has been an area of particular concern even prior to the pandemic, said Broadlawns Foundation Director Jenna Knox, “because it’s such a chronic issue that then leads to the continuation of health needs that we see at the medical center."
"As a community hospital positioned in 50314, which is one of the poorest areas in the state, we have an obligation to make sure that people have access to healthy, nutritious food," said Knox
To begin to address the issue, the hospital set up produce stands on campus and provided flyers with information about nearby food pantries and other resources. But these efforts were not enough to ensure that patients could consistently access nutritious foods.
Knox connected with McLaren at the Healthiest State to explore how an incentive program, like Double Up Food Bucks, could support Broadlawns’ patients. In existence since 2016, the program offers Iowans who receive SNAP benefits extra dollars when they purchase fruits and vegetables at specific locations.
Conversations evolved into how a produce prescription program might work to make incentives available to more patients. “It’s about having that ability to address social determinants of health within a medical organization and not have to refer outside and hope patients can connect the dots and figure it out on their own,” said McLaren.
Because of the model’s success in other parts of the country, the federal government was offering grants to support expansion and sustainability, but first, the Healthiest State needed to show that it could successfully implement the program in Iowa. Thus, the pilot project was developed and funded.
“Why not prescribe to keep us from getting sick in the first place?”
This was a question Dr. Lyndi Buckingham-Schutt first considered as an undergraduate student. While her nutrition education program primarily focused on clinical-setting treatment and management of chronic diseases related to diet, she was captivated by a lesson on the 2008 Farm Bill that provided funding to test healthy eating incentive programs. The success of a pilot in Massachusetts made her rethink her focus.
“Why are we so focused on treating chronic disease when we know diet has such a huge impact,” she said. “The majority of chronic diseases that cause death are related to diet.”
Buckingham-Schutt was brought into the Produce Prescription pilot while the Director of Wellness and Nutrition Policy at The Harkin Institute at Drake University because of her background in studying these types of programs. In addition to helping inform the structure of the model, she set up the external evaluation of the project to review the impact the intervention had on patients’ health and well-being.
“I feel I won the lottery to be able to partner on this,” she said. She especially appreciated the opportunity to study how the model could work with a larger group of immigrant and refugee patients that Broadlawns serves and to consider how components of the model in an urban setting could be adapted to other regions of the state.
Based on other successful models, the Broadlawns pilot had these components:
Providers identified patients who had a diet-related disease, such as diabetes, obesity, or high blood pressure, and invited them to join the program. Once enrolled, patients completed a survey about their habits, access to foods, and other related information, while the clinic also captured their biometric measures, including cholesterol, blood pressure, and weight. Then each patient set a specific and attainable goal to focus on for the month.
Each month, participants returned to the clinic to either meet with a health coach or their medical provider. They would discuss a new goal and receive vouchers to purchase fresh produce. The patient received $30 for themselves, as well as an additional $30 for each member of their household at each check in.
Providing vouchers for the entire family was especially important based of other models that showed if a family is struggling to purchase enough food, caregivers will prioritize feeding children first. Changing eating habits also becomes easier if everyone participates. The vouchers were time-limited, encouraging families to use them within a couple of months rather than saving them for a larger event, while still giving flexibility to get to the store.
Also important was ensuring that patients could access produce not just from farmers’ markets, like some models, but also grocery stores close to where they lived. The Healthiest State already had existing relationships with Hy-Vee and Fareway, but also worked with Broadlawns to establish a partnership with C Fresh Market in the 50314 neighborhood, which offers diverse produce options.
“We were trying to meet people where they were geographically, but also within their cultural preferences,” said Knox, who noted that retailers had to be willing to accept paper vouchers and have the Healthiest State reimburse. “They could have very easily said no. It’s not like we changed and improved their bottom line. It’s such a great example of the power of bringing together a private sector, nonprofit, and public health to make an impact.”
The program also had an educational component. In addition to talking with a health coach or provider each month, participants received materials from the Healthiest State that offered ideas for integrating healthy foods into meals and shared additional resources they could access, such as Double Up Food Bucks.
At the end of six months, patients completed another survey and had their biometric data gathered to determine any changes in lifestyle, health, and access to foods.
Anthony Fields went from rarely eating produce to sometimes going entire days only eating fruits and vegetables. He liked cooking spinach, kale, collard greens, and other leafy foods, ate a lot of bananas to increase his iron and potassium intake, and purchased whole watermelons in the summer. The health information he received encouraged him to try edamame and parsnip, and he met his goal of going 30 days without eating junk food.
“I think it was an awesome program,” he said. “I was feeling better. Every time I got my blood pressure taken, it seemed better.”
While he was able to fit monthly appointments around his schedule as a medical support assistant at an eye clinic near Broadlawns, he sometimes struggled taking the bus to a grocery store that accepted the vouchers until the program expanded locations. The extra steps were worth it, though. Not only did his blood pressure become manageable with some medication, but his wife and grandson, age 3, also experienced improved health.
This was just one of many stories Danley heard of how the program allowed patients to make different choices and improve their daily habits.
In total, 82 patients enrolled in the Produce Prescription pilot, and 179 people benefited as entire households received the vouchers.
The results were impressive: Among the full group, A1C (the long-term metric for blood glucose control) decreased significantly, along with cholesterol, and non-HDL cholesterol. In addition, patients reported eating more fruits and green leafy vegetables. Ninety percent reported having a positive or very positive experience. They were less likely to skip a meal or cut the size of a meal because they didn’t have enough money for food. The redemption rate of vouchers was also high compared with other programs—93 percent.
“I think people saw the benefit of changing little things and trying different foods,” said Danley, “A lot of people don’t want to have another medicine and another medicine. The biggest thing is that people did well with their health, and they saw that this made a big difference for their household.”
Children were also impacted by the program, said Danley. “We’ll see patients with children who have childhood obesity, and it’s because they’re not eating the healthiest foods, but if we can get their parents to buy-in, then a lot of times it spreads. I’m impacting not only the parents’ diabetes, but I’m hopefully impacting the child who is exposed to different foods and healthier foods and will make those choices on their own later.”
Buckingham-Schutt said the results are “consistent with what we found across the board when you look at other evidence on produce prescription programs, so it’s reassuring.” The effects on the A1C marker for people with diabetes were especially “astounding,” she said.
The Healthiest State Initiative’s goal “is to create programs that are scalable, sustainable, and recognizable in the state,” said McLaren, who has worked on program development for nine years, “so they become trusted programs that people are aware of and willing to access.”
The results of the Produce Prescription pilot allowed the Healthiest State to leverage funding to expand. The Healthiest State won the US Mayors 2022 Childhood Obesity Prevention and Environmental Health and Sustainability Award, with a grant to test the model in pediatric clinics in Des Moines. Healthiest State also received the federal USDA Gus Schumacher Nutrition Incentive grant to scale the program to five new locations in Iowa, serving individuals on Medicaid or receiving government food assistance.
The USDA grant especially gives planners time to develop an effective model for different settings and populations. Based on learning from the initial pilot, the Healthiest State is working on the following changes with stakeholders, including Buckingham-Schutt who is now at Iowa State University:
One area of focus is reducing the amount of work on health care providers and making it easier for patients to participate by managing the program through the Iowa Community Hub. When a patient is referred to the Produce Prescription Program, they will create an account on the Hub and complete an initial survey. The Hub will also gather their medical records from their clinic. This set up allows health data for participants across a variety of health centers to be collected in one place to track and analyze more easily.
Instead of having to visit the health care clinic each month, patients will download an app to receive their monthly vouchers while also completing monthly goal setting and self-guided education. ISU Extension and Outreach is developing the curriculum and materials by pulling from evidence-based content. After a six-month period, participants will be prompted to complete another survey and to visit the doctor again for a checkup and to collect biometric measures.
The technology company also is working on a system to interact with grocers, so vouchers can be accepted electronically instead of paper and redeemed more easily as more locations participate. A partnership with Capital City Fruit is testing the option of allowing people to order produce online and having it delivered to their home the next day.
These adjustments are especially meant to serve populations in rural areas without easy access to public transportation, health care clinics, and grocery stores. Meeting different cultural needs is an important consideration as well when stakeholders look at retailers to partner with and how to share information.
Broadlawns and Primary Health Care are wrapping up the pediatric pilot to better understand the effectiveness of the model in that setting. In addition to providing vouchers for produce, the program has focused on sharing 5-2-1-0 Healthy Choices Count information that encourages daily habits of five fruits and vegetables, two hours or less of screen time, one hour of exercise, and zero sugary drinks. Buckingham-Schutt’s team will soon begin evaluating the data, along with examining how an extension of the Broadlawns adult pilot with a limited group of participants has gone.
This initiative “is really rethinking the health care system to go upstream,” Danley said. “It’s about trying to meet patients where they are, instead of trying to fit them into a box of a program.”
As Broadlawns wraps up its pilot phase, it’s considering if and how the program can be sustained, and what other solutions are needed. One hope is that those who participated will continue to practice healthy eating habits, leveraging community resources to support. Providers also continue to share the educational materials with patients and encourage them to access Double Up Food Bucks and nearby pantries.
“You put yourself in the shoes of people who are breaking generational obesity and eating habits and we’re trying to make it risk-free to try something new,” said Knox. “I went into this with the notion of not understanding how complex the problem is of hunger and nutrition insecurity. It’s a very complex problem.”
Stakeholders hope to make the case that the outcomes demonstrate that incentive programs are a cost-effective strategy for Medicaid Managed Care Organizations and other insurance companies to consider covering, allowing for long-term sustainability.
Buckingham-Schutt appreciates how the project goes beyond just health care to focus on a community’s overall food system. For example, participants are better connected to farmers markets and food hubs that support local farmers and retailers.
“Nationally, there’s a shift in focus to programs like this that really do try to prevent disease and, at the same time, affect the food system,” she said. “The fact that the USDA is investing in these types of programs speaks to how big of an impact they can have on Iowa businesses and farmers.”
“It’s amazing that organizations, foundations, and people in Iowa have found the value in the Produce Prescription program,” she added, “and have really pushed it forward.”
Fields hopes programs like these continue to exist. Without the monthly vouchers and with the increase in food prices, he’s been unable to regularly purchase produce and fruit—and he’s seen the impact on his health.
“I just hope in the near future,” he said, “someone will be able to make this type of program a staple in somebody’s life.”
An incentive program has provided a model for increasing access to nutritious foods and improving health outcomes.
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