Wholesome Wave:

Generating essential new evidence on produce prescriptions

Poor diet is among the top risk factors for both overall disease burden and health disparities in the United States (U.S.) and around the world, leading to substantial preventable chronic diseases, years of life lost, and health care spending. In our prior work, we have estimated that more than 300,000 deaths per year from cardiovascular diseases (CVD) and diabetes and 80,000 new cancer cases per year in the U.S. are directly attributable to suboptimal diet.  The direct U.S. medical costs of CVD, diabetes, and cancer alone exceed $740 billion in 2015.  And these burdens disproportionately affect the most vulnerable in our society, including low-income Americans, minorities, and the elderly.

Growing evidence indicates that health care systems can provide a key role in addressing determinants of health including food insecurity and poor nutrition. Produce prescription programs are among the most promising interventions, wherein health care providers providing guidance on and economic incentives for access to healthy foods for patient populations with food insecurity and diet-related chronic health conditions. A systematic review and meta-analysis conducted by Bhat et al reported an increase in fruits and vegetable consumption by 0.79 servings/day and reduction in glycated hemoglobin A1c (HbA1c) by 0.81%, pooling results from five studies published prior to 2020. More recently, two studies (Veldheer et al 2021; Bryce et al 2021) using pre and post intervention comparisons showed 1.3% and 0.5% reduction in post-program Hba1c measurement. Participation in a program that provided $40/month vouchers to pregnant women was associated with decreased food insecurity score and increased fruits and vegetable intake (Ridberg et al 2021). 

In a national simulation study, we have estimated that the provision of a 30% subsidy for fruit and vegetable purchases in Medicare and Medicaid would prevent 1.93 million CVD and diabetes and save nearly $40 billion in health care costs on a national level over a lifetime of the current enrollees. However, rigorous empirical assessments of the efficacy of produce prescription programs on clinical outcomes, health care utilization, and cost savings are lacking. Several key knowledge gaps exist. First, as noted above, the few prior reports on produce prescription programs have generally been performed by the program implementers themselves, with no independent evaluation. Second, many programs are on a small scale, and meaningful results may only be generated when data from multiple programs are pooled. Third, effects on health outcomes and health care utilization have not often been reported. Fourth, program operational costs have generally not been reported, which is a key element for evaluating cost-effectiveness.

In partnerships with a leading national produce prescription program, Wholesome Wave, we will address these key gaps to evaluate program impacts on food insecurity, health outcomes, and health care utilization. Wholesome Wave is a frontline community-based organization and a leading national organization working to increase affordable access to fruits and vegetables for Americans struggling with hunger. Since launching the country’s first Fruit & Vegetable Prescription (FVRx) program in 2010, Wholesome Wave has supported and developed over 60 nutrition incentive programs at markets throughout the country, reaching one million underserved population nationwide. With 10 years of investments, Wholesome Wave has established a robust program data archive which is ripe to be leveraged for this project. The Rockefeller Foundation’s Request for Proposal for Advancing the Research on Produce Prescription provides a unique opportunity for a timely, rigorous, and objective evaluation of these programs. In addition, Wholesome Wave will facilitate full engagement with Hartford HealthCare, a comprehensive health care network in CT, for selecting matched controls to be analyzed along with program participants enrolled in the Hartford Produce Prescription Program for health and health care utilization.

We will have complete access to collected data across 9 distinct produce prescription programs, together representing over 5,000 participants. We will conduct both individual and pooled analyses of 9 produce prescription programs across the nation, providing the largest assessment to date on the efficacy of such programs. A range of programmatic and participant characteristics across these 9 programs will also allow us to explore whether impacts vary by prescription dose and duration, program utilization, implementation model, or by participants’ sociodemographic and disease status. In addition, we will perform pioneering analyses of program costs to address critical gaps in knowledge of potential cost savings of produce prescription programs, and conduct qualitative research to understand how Produce Rx programs could be improved to best meet the needs of the communities they serve. This proposed work will generate essential new evidence on produce prescriptions, informing policy, practice, and further needed research for integrating produce prescriptions into health care.

Aim One

To evaluate the impact of Produce Prescription (Produce Rx) programs on health outcomes (HbA1c, blood pressure, and weight/BMI), fruit and vegetable intake, food security, and health status among participants in the pooled analysis of nine Wholesome Wave produce prescription programs.

Aim Two

To evaluate the impact of the Hartford HealthCare Produce Rx program on health outcomes (HbA1c levels, blood pressure, and weight/BMI) and healthcare utilization (inpatient admissions and emergency department.

Aim Three

To evaluate and analyze program costs of eight Wholesome Wave produce prescription programs

Aim Four

To further explore whether the program impact varies by participant characteristics (age, gender, and race/ethnicity) and Rx characteristics (dose, duration, and implementation method).

Aim Five

To obtain inputs from participants and health care clinics on the successes and challenges of Produce Rx programs in meeting the needs of the communities they serve, and to explore how produce prescription programs could be improved to best support the communities.