Prescribing prevention

Necessity is the mother of invention. The Fruit and Vegetable Prescription (FVRx) Program began with the testimonials of the families enrolled in the childhood weight management clinic I had started in my community health center in 2006. Through my efforts to engage families in health behavior change, I found that while exercise increased and juice and soda decreased for many families, fruit and vegetable consumption almost never changed.

Shikha Anand, MD, MPHOne family in particular drove my passion, a Latina mother and daughter who were really committed to changing their behaviors. When I saw them in the first 2 weeks of the month, they would report a healthy diet. In the last 2 weeks of the month, they would report eating only rice and beans. When I inquired about the pattern, they told me, with tears in their eyes, that their Supplemental Nutrition Assistance Program benefits were distributed at the beginning of the month. They ate fresh fruits and vegetables for as long as they could on their benefits. The rest of the month they could only afford to eat rice and beans.

When I asked other families about barriers to fruit and vegetable consumption, it became clear that fresh produce was often not available in the neighborhoods I served. Moreover, where it was available, it was not affordable. Discouraged by the idea that I had been recommending the unattainable to my patients, I made it my mission to improve healthy food access in the community I serve.

The 'food desert' challenge

More than 13 million low-income Americans live in food deserts-urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food. Instead of supermarkets and grocery stores, these communities may have no food access or are served only by fast-food restaurants and convenience stores that offer few healthy, affordable food options.¹ In addition, energy-dense “junk” foods cost on average $1.76 per 1000 calories, compared with $18.16 per 1000 calories for low-energy but nutritious foods, contributing to the well-established disparities in childhood obesity rates across the country.²

Aware that the path to solving the food desert challenge would be a long one, I began to consider programs that would provide healthy food access to the families I served, focusing on farmers’ markets because they could expand access more quickly than a grocery store or other large retailer. In March 2010, I met the team from Wholesome Wave, Bridgeport, Connecticut. They were as passionate as I was about fresh food access for underserved families and brought expertise in food systems and farmers. Together we developed the concept for the FVRx program, which rolled out 4 months after we met.

Rx for healthy foods

The concept is simple. Primary care teams serving low-income communities identify obese children in their practices who are unable to afford fresh fruits and vegetables. A team consisting of a nutritionist, a primary care provider, and often a community health worker act together to help families understand the health benefits of replacing calorically dense foods with fresh fruits and vegetables and how to access them within their communities. The provider administers the prescription, which is then brought to a local farmers’ market and redeemed for fresh, unprocessed fruits and vegetables. Each family receives enough voucher dollars for 1 serving of fresh fruits and vegetables for every member of their household per day. The family returns to the farmers’ market every 1 to 2 weeks and to the primary care practice every month.

The feasibility test went well. The clinics and farmers’ markets believed in our vision and were able to overcome the significant differences in their operating and data systems to create a program that was truly integrated across sectors. Over 4 seasons, the FVRx program has spread across 8 states-California, Connecticut, Maine, Massachusetts, New Mexico, New York, Rhode Island, Texas-and the District of Columbia, and it continues to grow. This year we are adapting the program to serve adults with diabetes and partner with local grocers in addition to farmers’ markets.

The FVRx program has been incredibly well received by families, primary care teams, and market teams alike. Families continue to tell us how much the program means both to their ability to eat healthfully and their relationship with their primary care team. Providers like me relish the ability to replace a recommendation for unattainable foods with an opportunity to prescribe prevention. Farmers and market managers who have always believed in the health benefits of fresh foods really appreciate the opportunity to formally participate in health promotion.

Serving the underserved

The most valuable lesson our team has learned is that a health initiative that bridges sectors is a powerful presence in an underserved community. Working together, clinical and farmers’ market teams have creatively carried health messaging across each community. This has helped to revitalize a culture of healthy that has extended from each clinic to farmers’ market, and often beyond. In addition, this program has driven expansion of, and in some cases prevented closure of, farmers’ markets located in underserved neighborhoods, increasing fresh produce access for all community residents.

Personally, I have learned that a successful community program begins with the self-expressed needs of community residents. By listening to my patients, I was able to advocate for them and help develop a program that helped them overcome some of their barriers to healthy food access.

If all pediatricians can use what we hear from families to advocate for changes in the system, through both programs and policies, we will be able to meet the needs of our families like never before.

REFERENCES

1. US Department of Agriculture Marketing Service. Food deserts. Available at: http://apps.ams.usda.gov/fooddeserts/foodDeserts.aspx. Accessed May 23, 2014.

2. Story M, Kaphingst KM, Robinson-O'Brien R, Glanz, Glanz K. Creating healthy food and eating environments: policy and environmental approaches. Annu Rev Public Health. 2008;29:253-272.

Dr Anand is medical director and interim advisory board chair, Fruit and Vegetable Prescription Program, Wholesome Wave, Bridgeport, Connecticut. She serves as director, Strategic Alliances and Initiatives, and director, Obesity Program, National Institute for Children’s Health Quality. She also is assistant professor, Boston University School of Medicine, and pediatrician, Codman Square Health Center, Boston, Massachusetts.