A cure for fruit and vegetable underconsumption?

Originally printed in the January 2024 issue of Produce Business.

Food as medicine is far from a new concept. Hippocrates, the ancient Greek who lived in the fourth century B.C., made the connection by saying, “Let food be thy medicine and medicine be thy food.”

Today, this concept should be front-row center on our plates. There are three reasons why.

First, poor diet contributes to approximately 678,000 deaths annually in the U.S., according to a 2019-published report by the Center for Science in the Public Interest.

Second, only 10% of Americans eat enough vegetables and only 12% enough fruit, according to a 2022-published report by the Centers for Disease Control (CDC) and Prevention’s Behavioral Risk Factor Surveillance System. These deaths were due to nutrition- and obesity-related diseases, such as heart disease, cancer and diabetes.

Third, cost was the No. 1 barrier to buying fresh fruits and vegetables, according to a decade-old study cited by the CDC, and likely remains today due to rampant food inflation.

Enter a cure: produce prescriptions.

“I think produce prescriptions are the most significant opportunity we’ve seen in decades to increase consumption,” says Mollie Van Lieu, vice president, nutrition and health policy, for the International Fresh Produce Association (IFPA). “It addresses affordability, and data shows there’s a higher adoption rate when a healthcare provider recommends eating fresh produce.”

Benefits have the potent potential to ripple throughout the entire fresh produce industry.

“Produce prescription programs offer a chance to connect with new customers and educate them about the benefits of fresh, healthy produce,” says Melanie Marcus, MA, RD, nutrition and health communications manager for the Dole Food Company, in Charlotte, NC. “With more people recognizing the importance of a nutritious diet, there’s never been a better time for growers to showcase the amazing variety and quality of their products.”

Retailers can play a critical role in promoting health initiatives by partnering with health systems or incentive programs, adds Elisa Sloss, senior vice president, HealthMarkets, at Hy-Vee, a 285-plus store chain based in West Des Moines, IA.

“They can also utilize signage and promotion in stores, social media and newsletters to spread the word about these programs. In addition, retail dietitians can develop materials and provide nutrition education to support these efforts,” Sloss says.

“By working together, retailers and health organizations can help improve the health of their communities and provide valuable resources for customers.”

BUILDING ON SOLID FOUNDATION

Pilot programs linking low-income shoppers with local farmers and farmers markets started in several states in the 1980s. Outgrowths included the WIC Farmers Market Nutrition program a decade later and the Senior Farmers Market Nutrition Program in 2002.

The 2014 Farm Bill established the Food Insecurity Nutrition Incentive (FINI) grant program by earmarking $100 million to support produce incentive programs. Then, the 2018 Farm Bill renamed FINI as the Gus Schumacher Nutrition Incentive Program (GusNIP), increased funding to $250 million, and set a 10% maximum of program funding to support Produce Prescription Programs over the next five years, from 2019 to 2023.

Most importantly, research shows that produce prescription programs work. Research published in the August issue of the medical journal, Circulation, evaluated nine produce prescription programs at different sites in the U.S. In total, nearly 4,000 participants received an average of $63 per month over four to 10 months to purchase fruits and vegetables at grocery stores or farmers markets. Diabetes, hypertension, and obesity measures significantly improved, and produce consumption increased to nearly one cup daily.

“We don’t know what specific fruits and vegetables people were buying, but we do know that 77% of the dollars they were given were spent on produce. That’s a good redemption rate, and fairly good if we think of that as added purchasing power,” says Kurt Hager, Ph.D., MS, instructor in Population and Quantitative Health Sciences, at the University of Massachusetts Medical School, and lead author of the research.

Economic benefits within the food system have not been a primary focus of evaluation of produce prescription projects, says Christopher Long, Ph.D., principal research scientist at the Gretchen Swanson Center for Nutrition, in Omaha, NE.

To help address that knowledge gap, the GusNIP Nutrition Incentive Program Training, Technical Assistance, Evaluation, and Information Center (NTAE) is launching two efforts to address these questions, Long says.

“We are building a multi-state database of produce prescription transaction records to understand what produce prescription participants are buying at grocery retailers and other places where prescriptions are redeemed,” explains Long. “We are hoping to understand more about how produce prescriptions affect shoppers’ purchasing — to what extent are they buying more produce, different produce, and otherwise shifting their shopping habits to make the most of the produce prescriptions.”

The center is also in the initial stages of studies to learn more about producers’ experiences with produce prescription projects, he adds. Some of these questions include: What economic benefits are producers realizing? How can produce prescription initiatives be improved to ensure economic benefits for local and regional producers who may not have benefited from these types of initiatives in the past?

THE WHERE & HOW OF PRODUCE SUPPLY

There needs to be four people at the table to make produce prescriptions work in the U.S., says Melissa Melshenker Ackerman, former president of Produce Alliance, LLC, a major foodservice distributor in Buffalo Grove, IL, and now chief executive of Planet Harvest, which Ackerman calls a driving force in transforming healthcare through prescription produce.

“The first is a medical system that’s able to identify the patients who require the prescription. Second, a payer. For example, some pilots are funded by insurance companies, and others through philanthropic efforts. Third, is the research to show and validate that this type of program works. Fourth, is a produce supplier,” she says.

Retail supermarkets and pre-packed food boxes are the two main ways beneficiaries receive their prescribed produce. The fresh produce supply chain is already in place and well established, making this easy, although there are many industry opportunities for box format programs, too.

GusNIP core metrics collect the type of location where prescriptions are redeemed. “We include farmers markets, community-supported agriculture (CSA) shares, and farm stands in the farm direct category, and we include corner stores and grocery stores in the brick-and-mortar category,” says Mallory Koenings, Ph.D., RDN, national program leader, Division of Nutrition, for the USDA National Institute of Food and Agriculture, in Washington, D.C.

“During the third year of the program, we know that $750,969 were redeemed at farm direct locations and $1,031,010 at brick-and-mortar locations. We will be exploring what strategies work best in the future as the dataset grows.”

RETAIL SHOPPING EXAMPLES

Paper prescriptions that work like coupons have been employed at retail, with a switch more recently to pre-paid electronic debit cards. Stop & Shop, a 400-plus-store chain headquartered in Quincy, MA, and an Ahold subsidiary, was the first major retailer to partner with About Fresh, a Boston-based nonprofit focused on supplying healthy foods to needy households, and to use the nonprofit’s Fresh Connect card technology in-store.

About Fresh works directly with healthcare providers to enroll eligible patients in the Fresh Connect program.

“Enrolled patients receive funds on their Fresh Connect card to purchase fresh fruits and vegetables. Healthcare providers determine the amount of money allocated to participants, but it averages $100 per month,” explains Adam Shyevitch, chief program officer. “We average 4,000 cardholder participants who receive benefits for six to nine months at a time.”

All Fresh Connect customers have access to complimentary nutrition education through Stop & Shop Nutrition Partners’ registered dietitians, according to Caroline Medeiros, the retailer’s public relations manager. “This includes educational webinars, personalized nutrition consultations, grocery shopping tours, and more.”

Nutrition education plays a key role in the success of produce prescription programs, emphasizes Leslie Jefferson, MS, CNS, LDN, community health program manager and nutritionist for Giant Food, a 165-store chain headquartered in Landover, MD, and an Ahold subsidiary. It embarked on its first produce prescription program with nonprofit DC Greens a few years ago and now partners with About Fresh’s Fresh Connect.

“One program shared some of their survey evaluation data with us,” says Jefferson. “It showed the purchase rate of yellow and orange fruits and vegetables increased from 7% to 26% and green vegetables from 10% to 26%.”

Last March, the Boise, ID-based Albertsons Companies partnered with FIS, a global financial services company that represents platforms such as Fresh Connect. The retailer, and its banners, such as Safeway, Jewel-Osco, Vons, Shaw’s, Tom Thumb and ACME, also entered into a partnership to accept benefit cards from Bentonville, AR-headquartered Soda Health, to purchase eligible food items such as fresh fruits and vegetables.

There are also opportunities to fulfill produce prescriptions online. One is via Instacart Health, launched in 2022 by the San Francisco, CA-based grocery delivery and pick-up service, Instacart.

“Our platform has particularly resonated with produce prescription programs,” says Sarah Mastrorocco, vice president and general manager. “A good example of this is how our platform has supported Partnership for a Healthier America and their Good Food at Home program. Through the program, more than 1,100 families in Indianapolis, IN; Milwaukee, WI; Englewood, NJ; Denver, CO; and Washington D.C. have received produce stipends that they can redeem online at any of Instacart’s 1,400-plus retail partner banners nationwide.”

Program results found that 79% of those who received produce credits planned to continue to eat more fruits and vegetables, and 78% said produce credits allowed them to purchase more fruits and vegetables than they could usually afford to buy, according to Mastrorocco.

Earlier this year, Instacart announced an industry-first online advertising capability, enabling produce brands to advertise fresh, weighted items — such as grapes, onions, carrots, oranges, sweet potatoes and watermelons — across grocery partners on the Instacart Marketplace, says Mastrorocco.

“This means produce brands, agriculture boards and farms can now amplify their weighted produce to the top of the digital shelf, leveraging our advertising solutions. On average, packaged produce advertisers on Instacart see a 30% increase in sales, so with this new ad capability, we’re leveling the playing field for traditional produce brands to take advantage of retail media and, at the same time, helping consumers discover even more nutritious options on our platform,” says Mastrorocco.

DELIVERED FOOD BOX EXAMPLES

Hy-Vee has embarked on a hybrid voucher and box program in six of its Sioux Falls, SD, stores in partnership with a research study by Avera Health Institute’s Food as Medicine Program.

In the first, participants receive four $25 vouchers a month to shop anytime during the month and select their produce. In the second, Avera sends the store an email with the customer’s name and address, and the retailer selects the produce and delivers it to the patient at a specific time. Each order is $25 per week and the customer receives four deliveries each month.

“We work with South Dakota State University Extension to help guide the selections by season. Plus, we work with the produce managers at Hy-Vee to find out what is available and what makes the most sense to put in the boxes. It’s usually a mix of common items like carrots, apples, grapes and celery, more costly items like berries, and items they might not have tried, like rutabaga,” says Christine Hockett, Ph.D., director of community research at the Avera Research Institute, in Sioux Falls, SD.

The idea of the hybrid voucher-box study is to compare the two groups and measure outcomes, says Tina Potthoff, Hy-Vee’s senior vice president of communications. “Does one group benefit significantly more if the produce is delivered versus going to the store to select the product themselves?”

Initial research findings suggest produce boxes offer unique benefits. Together, Brighter Bites, a national nonprofit, and UT (University of Texas) physicians have partnered to deliver a produce prescription program and pilot study of 150 families with Medicaid-eligible children ages 5-12 in the Houston, TX, area for eight months. Part of this program includes families receiving deliveries of produce boxes full of about 20 pounds of fresh fruits and veggies, or 8 to 10 types of fruits and vegetables, delivered every two weeks for 32 weeks directly to their home via DoorDash.

“Early indications are that families who received Produce Rx were able to significantly increase their fruit and vegetable consumption. Families have seen a wide array of produce items, such as kohlrabi, eggplant, and dragon fruit, in addition to many items they were already familiar with,” says Mike Pomeroy, MPH, vice president of operations, Brighter Bites.

“One parent commented, ‘My son and I are always excited to see what will come in the bag next week. We work together in the kitchen to find ways to use all the unique produce items.’ These families have learned to love new produce varietals that they will purchase with their own dollars in the years to come, increasing produce sales for everyone,” says Pomeroy.

Produce boxes also offer more direct ways for growers/shippers, wholesalers, and distributors to be actively involved with produce prescriptions. For example, Ackerman’s Planet Harvest packs the produce boxes for another pilot with high-risk prenatal women at the Harris Health System, in Houston.

Harris Health produces the list of fruits and vegetables, she explains. They consider cultural relevance in doing so, and makes sure there is a choice. And since mental health is important, and the boxes include flowers.

Planet Harvest works with a network of 150 to 160 distributors and staff who can create these boxes since they are used to breaking pallets down and putting them together again for foodservice customers. “Having the existing infrastructure to pack these boxes is important to grow programs like this without as much financial burden from an asset-heavy type of investment,” says Ackerman.

While many produce prescription programs focus on increasing total produce consumption of all fruits and vegetables, both whole and fresh-cut, others customize offerings to meet health goals.

An example of one box contents from the Harris Health prenatal pilot was cabbage, apples, citrus, carrots, leafy greens, sweet potatoes, bell peppers and summer and winter squash to help meet prenatal needs for vitamins A, B6, and C; folic acid; iron; calcium; potassium; magnesium; and dietary fiber.

Another way produce prescription boxes are curated is around meal-based recipe kits. This is the case in the Healthy Food RX project, part of the Abbott Fund’s Future Well Communities initiative, whose clinical and community partnerships include the Public Health Institute in Oakland, CA, and Stockton Food Bank, in Stockton, CA.

The boxes are produce-rich and contain additional items like berries and tangerines that aren’t part of the recipe. The boxes also included pantry staples, such as eggs, beans, rice and nuts, along with a recipe card and link to an online cooking class with food bank personnel.

“Results after receiving two boxes a month for six months showed the diabetic participants significantly improved their blood sugar control. Seventy-five percent followed the recipes exactly, compared to only 58% before enrolling in the project, and in general, were overwhelmingly satisfied, which was a pleasant surprise to us,” says Maggie Wilkin, director of research and evaluation at the Public Health Institute’s Center for Wellness and Nutrition, in Oakland, CA.

She adds the institute will be increasing participation from 200 to 1,000 people this year.

The meal-based recipe kits are purchased through the Stockton Food Bank, in Stockton, CA, adds Alexandra Marapao, nutrition education program manager. “We give a spreadsheet list of produce and other recipe items to Ratto Brothers, which, in turn, sources and packs the boxes. We either pick the boxes up from their Modesto facility or they deliver them to us. The boxes are then delivered to participants by DoorDash. We work three months in advance to take advantage of fresh seasonal availability.”

This partnership is a perfect fit for Ratto Brothers, a fourth-generation grower, shipper and wholesaler that offers more than 70 varieties of herbs, leafy greens, other vegetables, and fruits throughout the year from operations in California and Arizona.

“We’ve worked with a garden program at Valley Children’s Hospital in Modesto, and when the chance to work with the Healthy Food RX program presented itself, we jumped at the opportunity,” says Frank Ratto, president.

“They buy the produce at cost, and we just bill the labor to pack the boxes. The boxes are all packed in our facility, which is food safety certified to the highest level. Our workers wear hairnets and gloves, and we maintain the integrity of the cold chain. We don’t treat this any differently than the other products and services we provide to our customers.”

In the end, a combination of supermarket shopping and delivered produce boxes likely yield the best results to improve health, offer the greatest opportunities to engage the produce industry, and ultimately boost fruit and vegetable consumption.

“If you have 200 patients, for example, there’s probably some 30% of them for whom there’s a barrier to going to the grocery to shop,” says Brent Ling, director of external affairs for Wholesome Wave, a Washington, D.C.-headquartered nonprofit that creates partnership-based programs connecting underserved consumers with healthy food.

“So, if those 30% can get something like a produce box, it is immensely important to their utilization and the overall success of the program.”

LOOKING AHEAD

There is a lot of momentum for integrating Food is Medicine initiatives into national, state and healthcare industry policy and practice, says the Gretchen Swanson Center for Nutrition’s Long. “Produce prescriptions, and medically tailored prepared meals are two of the most common versions of Food is Medicine projects. Both are likely to become increasingly common as reimbursable services in health care.”

“At this time, 90% of the monies under insurance plans go to cover medication and surgeries after we are sick and diagnosed with an illness. If we can get health insurance companies to pay for healthy food such as fresh produce, we may prevent people from getting sick in the first place,” says Shreela V. Sharma, Ph.D., RD, LD, Brighter Bites co-founder.

Research published in 2019 in the scientific journal, PLOS Medicine, showed providing Medicaid and Medicare enrollees with a 30% subsidy for the purchase of fruits and vegetables would save $39.7 billion in formal healthcare costs if enacted on a national level over a lifetime.

Add those who receive Veterans Administration and Indian Health Service benefits, and the number of potential Americans with more produce money in their pocket soars to 150 million, or nearly half the U.S. population.

“The research is convincing that produce prescriptions work just like any other clinical medication in terms of improving health,” says Ling. “In terms of coverage determination, that’s where fruits and vegetables could become a billion-dollar drug.”

• • •

WHAT IS A PRODUCE PRESCRIPTION?

A widely accepted definition of a produce prescription program, according to the March 2021-published report, Mainstreaming Produce Prescriptions, a Policy Strategy Report, by the Center for Health Law and Policy Innovation of the Harvard Law School, is:

“a medical treatment or preventative service for patients who are eligible due to a diet-related health risk or condition, food insecurity or other documented challenges in access to nutritious foods, and are referred by a healthcare provider or health insurance plan. These prescriptions are fulfilled through food retail and enable patients to access healthy produce with no added fats, sugars, or salt, at low or no cost to the patient. When appropriately dosed, produce prescription programs are designed to improve healthcare outcomes, optimize medical spend, and increase patient engagement and satisfaction.”