A six-month produce prescription program in Los Angeles clinics shows how food-as-medicine strategies can meaningfully improve access to healthy foods for patients with diabetes, but reveals why affordability remains a stubborn barrier.
Study: Nutrition Security Among Medicaid Patients With Diabetes or Prediabetes After Completing a Produce Prescription Program. Image credit: DC Studio/Shutterstock.com
A recent study in Annals of Family Medicine evaluated the effectiveness of a produce prescription program in improving short-term nutrition security among Medicaid patients with type 2 diabetes or prediabetes using a pre–post observational design and self-reported survey measures.
Dietary interventions to prevent chronic diseases
The food-as-medicine strategy involves using dietary interventions to prevent, treat, and manage diet-related diseases. The United States spends roughly $1.1 trillion annually on treating chronic conditions like hypertension and type 2 diabetes. Produce prescription programs (PPRs) provide patients experiencing food insecurity with vouchers to purchase fruits and vegetables. These programs focus on increasing produce consumption, supporting food security, and improving health outcomes, including glycemic control, with modeling studies suggesting the potential to prevent hundreds of thousands of cardiovascular events.
It is imperative for the US Department of Agriculture (USDA), as well as for other federal agencies, including the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), to understand how PPRs can shape a patient’s experience with access and availability to healthy foods. Existing research assessing the effectiveness of PPRs has focused on food security or food sufficiency. However, focusing solely on food sufficiency and dietary quality misses critical barriers to fruit and vegetable consumption, including affordability, grocery store access, transportation, cooking knowledge, and awareness of food assistance programs.
Nutrition security, distinct from food security, encompasses consistent access, availability, and affordability of healthy foods. Population studies show nutrition insecurity affects 18 % to 44 % of people and is linked to diabetes and poor mental health. While measurement methods are still evolving, researchers increasingly recognize nutrition security as essential for optimizing health outcomes and for capturing barriers not reflected in traditional food security metrics.
Evaluating nutrition security within a food-as-medicine intervention
The Los Angeles County Department of Public Health partnered with three Federally Qualified Health Centers (FQHCs) to implement a produce prescription program during 2020–2024. This before-and-after observational study assessed changes in nutrition and food security among participating Medicaid patients without a comparison group. The study also identified barriers to healthy eating, including participants’ perceptions of the price of healthy foods in their community and their ability to identify healthy foods.
Eligible participants were FQHC patients aged 18 or older, enrolled in Medicaid, diagnosed with type 2 diabetes or prediabetes, and screening positive for food insecurity. During 2021–2024, 2,374 patients enrolled across the three FQHCs. Selected participants received $40 per month for 6 months to purchase fresh produce with an electronic debit card.
All patients completed a 20-minute self-administered baseline questionnaire and received their activated debit card. They completed the same questionnaire at the six-month follow-up, either in person or by telephone.
The study assessed household nutrition security using a two-item screener developed by the Los Angeles County Department of Public Health, Kaiser Permanente, and Tufts University as the primary outcome. The authors note that this screener was still undergoing validation at the time of data collection, reflecting the evolving nature of nutrition security measurement. The screener assessed difficulty accessing healthy foods over 12 months, with responses categorized as secure or insecure, and 12 barriers to healthy eating rated as “never,” “sometimes,” or “often true.” Food security was measured using the six-item short form module, with scores of 0–1 considered secure and 2–6 considered insecure.
The study used McNemar tests to identify changes in nutrition and food security from baseline to follow-up. Binary multivariable logistic regression models tested these changes. Model 1 was unadjusted. Model 2 adjusted for baseline covariates and security status. Model 3 additionally adjusted for baseline fruit and vegetable consumption and change over time.
Significant improvements in nutrition and food security
A total of 1,309 participants completed both surveys, with 451 at FQHC 1, 524 at FQHC 2, and 334 at FQHC 3. The program distributed $575,820 in produce benefits, of which participants spent $404,025, or 70.2 %, on fresh fruits and vegetables at participating stores, although redemption data were not available at the individual participant level.
The majority of participants were female, at 71.1 %, with a mean age of 56.5 years. Nearly 80 % identified as Hispanic or Latino, and 12.9 % as Asian. Most participants, 80.4 %, had a high school education or less, and 25 % lived in households with five or more members.
Nutrition security increased significantly during the six-month program, rising from 23.2 % to 38.7 % of participants. Food security also improved substantially, increasing from 25.2 % to 42.9 %.
Beyond the overall increases in nutrition and food security, participants reported improvements across most specific barriers to healthy eating. While cost remained the primary barrier throughout the program, the proportion citing cost decreased significantly from 88.4 % to 85.6 %. The persistence of cost concerns occurred against a backdrop of rising food prices and inflation during the study period, which the authors note may have limited the program’s impact on affordability.
Participants also reported an enhanced ability to identify healthy foods and improved access to stores that offer healthy options. Additionally, the difficulty making culturally appropriate foods healthy declined from 62.0 % to 55.7 %, suggesting the program helped participants navigate cultural food preferences while improving nutrition.
Conclusions
The Los Angeles County produce prescription program was associated with significant improvements in both nutrition and food security among Medicaid patients with diabetes or prediabetes over six months. Nutrition security increased by 15.5 percentage points and food security by 17.7 percentage points, with participants also reporting reduced barriers to healthy eating. Because the study used a single-group, pre–post design, the findings cannot definitively attribute these changes solely to the intervention.
Overall, the results suggest that food-as-medicine interventions can be feasibly integrated into clinical settings to address fundamental social determinants of health, particularly access to affordable, nutritious foods, although longer-term and controlled studies are needed to assess sustained and causal effects.
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