FVRx: Focus On What Matters Most

What follows is a response from Jim Prevor pertaining to this month’s research perspective. That article can be found here.

The theory behind a Fruit & Vegetable Prescription Program (FVRx) is simple. If a patient presents himself to a doctor with an ailment, say diabetes or a pre-diabetic condition, the doctor will likely prescribe a medication whose purpose is to ameliorate the symptoms or to avoid further harm. So, for Type 2 diabetes, perhaps even prediabetes, the doctor will probably prescribe metformin.

Yet we know that changes in diet and exercise can be effective ways of preventing or reversing these types of conditions. So why not have doctors give “prescriptions” out for healthy fruits and vegetables? Surely this type of program will be both cheaper and better than high-tech interventional medicine. Weren’t we all taught that an ounce of prevention is worth a pound of cure?

It is an appealing idea, but the problems these programs have encountered in the past have been manifold:

First, the original programs were imbued with a desire to address many problems at once and in a way that hurt the achievement of the primary goal – better health. For example, notice that the “prescription” here is good only at farmers markets – but why would this be? There is no evidence that produce acquired at a Farmers Market is healthier than produce acquired at a supermarket. In fact, it is a major inconvenience for many to be forced to go to a special place to use these prescriptions and so probably reduces utilization.

Second, the program conflates two variables, thus making it difficult to determine the cause of any dietary change. Generally, the patients must meet with their primary care provider, who introduces them to a nutritionist. The nutritionist meets with the family each month and adjusts a dietary program. As part of this, the patient is given a coupon good for produce. But this makes it very difficult to tell if the key variable is the counseling or the coupon.

Do the children in the program have better health than comparably situated children not enrolled in FVRx?

Third, it turns out there are many non-financial barriers to increasing produce consumption. For example, often children simply do not like produce, especially not the often-bitter greens that offer many of the nutritional advantages of produce. So even free distribution of the products may not move the needle on consumption very much.

Fourth, there is not really a great deal of evidence that this kind of small change in the diet has much impact on health even if it happens. There is no question, for example, that many people with Type-2 diabetes could reverse their condition with diet and exercise. But this generally involves a lot more than eating an extra plum every day. You often are talking about gastric bypass surgery or extreme calorie reduction diets – say 600 calories a day – that get blood glucose levels back to normal.

Many of the problems are of the chicken-and-the-egg variety. So, when you read about food deserts, for example, keep in mind that we have some pretty spirited capitalists in this country. If there is real demand for fresh food, it is hard to imagine someone wouldn’t like to profit by meeting that demand. So, it may be that the demand for fruits and vegetables is mostly theoretical… that, regardless of what people say in surveys, they prefer to buy KFC, not arugula.

One background problem is that many of the families that have qualified for FVRx programs in the past are so dysfunctional that it is hard to imagine increasing produce consumption as being a priority. Broken homes, drug addiction, dropping out of school, alcoholism, on and on. Although there is always a diamond in the rough among any group, in general, many of these families have serious problems with making good decisions, and it is hard to imagine they will make horrid decisions on everything else but good decisions on produce consumption.

So, expanding beyond those in socioeconomic distress, Ms. Chrisinger’s program has a better chance of succeeding. Yet even here –about 2/3rds of those families that received vouchers never turned them in. Some of the data seems contradictory. If parents didn’t change their fruit and vegetable purchasing behavior well, how, then, could the children eat more produce?

There is no indication that the evaluation of consumption went beyond self-reporting, nor indication of a control group that received the counseling but not the coupon. Finally, there seems to be no attempt to measure actual health outcomes, which is what matters. Do the children in the program have better health than comparably situated children not enrolled in FVRx?

One can only admire the efforts being made to find ways to encourage children to consume healthy diets. But much more work needs to be done before we can say we have a clear path to achieving this laudable goal.

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