Prescribing tomatoes and carrots could help some Americans eat better

CHARLOTTESVILLE, Va. — Audrey Oliver knows the difference between a store-bought tomato and one fresh from the farm. Nowadays, the fresh ones show up on her doorstep every other week.

That’s because for Oliver, 66, food literally is medicine. She receives her box of fruits and vegetables as part of a “farmacy” movement that treats fresh produce as a way to promote health just like a pill or other prescription. She says she eats the fresh ones right away; the flat-tasting tomatoes from the store sometimes just sat and spoiled.

“When we were kids, the farmers in the country brought crops to town and sold it. I had access to fresh farm food. I know the freshness, I know the taste,” she said during a conversation this summer at a social services clinic in a low-income housing project in Charlottesville called Westhaven. The food deliveries, provided by a group called Local Food Hub in partnership with several area health clinics, helped her change her diet, to eat more healthfully. During the pandemic, the program was broadened to help address emergency food needs, but even people who aren’t getting an actual food prescription get the health benefits.

“I’m very conscious of it,” Oliver said. These days, she added, if she feels a bit off, she’s more likely to reach for a healthy bite in the fridge than a bottle in the medicine cabinet.

The idea of “produce prescribing” has been around for several years but it’s been stuck in a niche. Health systems face legal limits and financial disincentives to spend money on carrots and tomatoes; the food system is largely siloed off from the health system. The food-health ventures that have survived often depend on philanthropy and grants.

“These programs haven’t had their moment,” said Michel Nischan, a chef and food advocate who started Wholesome Wave, which promotes and assists produce prescribing, in tandem with local community groups. “They are very difficult to fund.”

One of the upsides of the Covid-19 pandemic, which disrupted the nation’s food supply and at its peak put tens of millions of people out of work, is that lots of organizations intensified their work on hunger, nutrition and food security. And that has driven new interest in increasing access to healthy food, the kind of food that doesn’t just ease hunger but actively promotes health. The kind of food that people need during Covid — and will keep needing after Covid.

An overwhelming share of the people in the U.S who became seriously ill or died from the coronavirus were at heightened risk because they had other health problems related to their diet or food insecurity, including diabetes, obesity, hypertension and heart failure, according to research from the Friedman School of Nutrition Science and Policy at Tufts and data from the Centers for Disease Control and Prevention.

“The pandemic was an accelerant on this conversation,” said Devon Klatell, managing director for food at the Rockefeller Foundation, which is working with some prescribing projects and related researchers. “For health care payers, providers, policymakers — it’s a wake-up call.”

The pandemic made hunger visible — both emergency needs arising from the economic fallout and the unmet structural food insecurity that had been there all along, said Rebecca Onie, a co-founder of The Health Initiative and a pioneer in the movement to weave together health and social needs.

For several years before Covid hit, health care practitioners and policymakers in liberal and conservative states alike had begun looking at so-called social determinants of health, how conditions like homelessness, food insecurity, lack of transportation or domestic violence shaped health status, risk and outcomes. Given that the pandemic also highlighted racial disparities and inequity, those conversations have become more urgent.

Both advocates and researchers are looking at how addressing social drivers could not only improve health outcomes for patients but could also create potential savings to the health care system. A recent Rockefeller Foundation report, for instance, found that poor nutrition and diet alone added nearly $1 billion a year in health costs — $359 million from obesity and overweight and $604 million from food-related noncommunicable diseases such as cardiovascular disease, hypertension, cancer and diabetes.

But while those drivers of health, including hunger and nutrition, became part of the conversation, they haven’t really become part of the medical system, apart from scattered pilot programs and state experiments.

That’s what some health groups, advocates and researchers are trying to change now. They want to make food insecurity part of the actual metrics used to evaluate and pay hospitals and physicians in Medicare. Health systems or providers would be held accountable for screening patients for food and nutritional needs – and then addressing them.

Gary Price, a Connecticut surgeon who is president of The Physicians Foundation, which formally submitted the proposed metric, noted that existing quality programs can penalize doctors financially if their patients do poorly under some rubrics. But doctors don’t have a lot of control, for instance, when patients with diabetes can’t afford fruits and vegetables, filling up instead on processed food that may be cheap but isn’t good for them.

“There are problems a prescription for medication simply won’t solve,” Price said. Giving doctors tools to address social factors — and holding them accountable for doing so — is overdue.

It’s a long, multi-step regulatory road — and there’s a parallel process with Medicaid. There’s no guarantee that it will turn out the way the advocates want; many other metrics are already in use, or under consideration, and they haven’t centered on poverty and health.

But it’s begun, with conversations about what the post-Covid health care system should look like occurring with officials from the federal down to the county level. There’s even data to support this new approach to integrating healthy food into medical care from Accountable Health Communities, the only federal health experiment that has incorporated such metrics.

Existing prescribing programs are a mélange of pilots, state waiver experiments and philanthropic ventures, and it’s been hard to cull and standardize data. Yet some things have been established, said Rocco Perla, who joined Onie in creating The Health Initiative, and is a veteran of the federal Center for Medicare and Medicaid Innovation.

For instance, a diabetic person who is food insecure — meaning they do not have reliable access to healthy affordable food — adds $4,500 in costs a year to a health plan.

That can buy an awful lot of tomatoes.

Handing someone a prescription for free fruits and vegetables isn’t the same thing as just pointing someone to a food pantry or using food stamps to buy subsidized healthy food at a farmer’s market. Making it a prescription — written by a trusted health care provider — directly connects food to health and can spur changes in consumption and behavior that promote health.

“When you look at being able to combine the power of a doctor’s advice, the intelligence and knowledge of a nutritionist, the engagement skills of community health workers to avoid Type 2 diabetes … that can bring results that can be measured,” said Nischan, the chef turned food activist.

Whether the goal is to prevent someone with prediabetes from developing full-blown diabetes, or to keep someone who already has a disease from getting worse, spending a few hundred dollars on fruits and vegetables is a lot cheaper than dialysis and amputation, he added.

And the healthful eating can have spillover benefits in the community. For instance, Oliver doesn’t eat all the eggs that show up in her delivery box, but a neighbor happily takes the extras. When some delicious Vermont farm cheese appears, she saves it for when her grandkids drop by.

Chinikqua Joseph, who also gets the food boxes and joined the conversation at the Westhaven center, tells a similar tale. She lost her home to a fire during the pandemic and had not been working steadily. But the food – from the Food Hub plus some additional vegetables she gets by working at a nearby community garden — means she’s got enough eggplant, radishes and zucchini to share with her mom and godmother. Sometimes she whips up veggie-rich smoothies for three.

“I can continue to make healthy choices,” she said. And it frees up some money she can spend on other needs, as she rebuilds her life after the fire.

But while Oliver and Joseph are getting healthy food, they aren’t getting “prescribed” food or any health coaching or monitoring that go with it. That part of the “farmacy” program got scaled back during the pandemic as the group scaled up overall emergency food distribution, said Laura Brown, Local Food Hub’s director of communication and policy. The Hub is feeding more people now than pre-pandemic, more than 500 households, but with less of an overt health tie-in. The organization doesn’t want to cut people off while Covid is still a problem, but in time it would like to restore a health and prescribing component, preferably with a reliable funding stream through Medicare, Medicaid or a health plan.

But until Medicare and Medicaid change policies to define food as medicine, funding from health plans is still a patchwork, a grant or donation there, a payment from an administrative fund there. It’s not paid out of health dollars — not yet.

Two hours south in Roanoke, Va., another produce prescribing plan run by the Local Environmental Agriculture Project, or LEAP, took a different path — but with similar goals. Driven by hunger, it too changed in unexpected ways during the pandemic.

LEAP brings a mobile farmers market — basically a food truck stocked with fruits and vegetables — and parks it by clinics, schools and other community focal points. Originally, the organization partnered with three local clinics and got some grants to subsidize the food, so eligible patients got a prescription and filled it at no cost from the truck, said executive director Maureen McNamara Best. They also got peer education, on how to cook and eat healthfully. The results were measurable — things like a drop in blood glucose readings in as little as 16 weeks.

During the pandemic, the emphasis changed from prescribing to simply getting good, fresh food to hungry people, just as it did in Charlottesville and other sites throughout the country. Emergency food relief isn’t normally LEAP’s focus, but it was an imperative this year, and by collaborating with food hubs a little further afield, it managed to stay open through the winter.

LEAP also has community gardens and a shared commercial kitchen to help local small food businesses get started — think bakers, jam makers and caterers — part of the group’s larger goal to change the food system. For health, McNamara Best thinks of produce prescribing as part of the “scaffolding” for addressing social determinants of health, and more sweeping challenges about health, poverty and equity.

By working with local farmers and paying them fairly, LEAP wants to make fresh, healthy, local food both affordable and accessible to everyone — not just to the relatively small number eligible on medical grounds for a few months of a prescription program, and not just to folks who can buy gourmet greens at a farmers market. There should be “a lot of different ways to have choice and dignity,” in the food that people select, she said. For everyone.

It’s a big goal. The prescribing programs do work, she said. “But it feels so hard sometimes … to figure out how to fund everything,” she said.

In the short term, with the country still reeling from the pandemic, getting healthy food to people is the obvious priority. But over the long run, integrating food, housing and other social needs into health care will get more attention — though not without pushback.

Matt Salo, the executive director of the National Association of State Medicaid Directors, notes states and their Medicaid programs have a whole lot to deal with, including child health, mental health, behavioral health and long-term care. Food isn’t necessarily the top of the list for the health sector, even its leaders can see the logic. And under current payment rules, it’s just not easy for Medicaid to jump in and cover it.

“There’s no line item for food or prescription produce. There’s no code for housing,” he said. In fact, rather than incentives to address social determinants, there are sometimes disincentives, tied to caps on how much a health plan can spend on patient supports other than medical services. And it’s not yet clear, he said, that health plans would really see a financial return from investing in food, rather than spending on one of the other myriad health and social needs that people with lower incomes have.

Advocates for such programs understand those obstacles. But they also understand the need.

As Nischan put it, a low-income household of four with $2 for dinner is going to rely on foods like white noodles and high-sodium canned soup. “Broccoli is not going to be on the table,” he said.

Unless someone with a prescription pad puts it there.