Ronit Adina Ridberg
Published: 2018
Total Pages:
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Background: The intersection of health care, food insecurity and diet is increasingly a focus of policies and programs targeting the related crises of high rates of obesity and other forms of malnutrition, associated chronic disease risks, impaired performance at work and school, and soaring health care and other economic costs, specifically in low-income families. Nutrition incentive programs may mitigate the severity of food insecurity and low fruit and vegetable (FV) consumption by augmenting federal nutrition benefits and improving access to and affordability of FV with financial incentives at their point of purchase. Fruit and vegetable prescription programs, an innovative nutrition incentive model, aim to increase access to health-supporting foods for patients at risk of chronic disease. Only a few prescription program studies have been published in the peer-reviewed literature, demonstrating decreased hemoglobin A1c levels and BMI, and increased FV consumption, and important gaps remain. No prescription study analyzes pediatric prescription programs; most incentive studies focus on changes in FV purchasing or sales rather than consumption or food security; and incentive studies rarely account for measured and unmeasured confounders in the largely self-selected, convenience samples of participants. The two papers that comprise this dissertation assess changes in household food security and children’s fruit and vegetable consumption for low-income families participating in a pediatric fruit and vegetable prescription program. Methods: The Wholesome Wave FVRx program is a 4-6 month intervention offered since 2011 in select cities and states across the country. In pediatric programs during 2012-15, health care providers enrolled children and youth aged 2-18 years (one per household) who were clinically obese or overweight. Participants received nutrition education by a clinician, nutritionist, or trained health educator at each clinical visit or in a class setting (approximately monthly), including guidance on FV consumption and replacement of unhealthy foods with fresh FV. Providers distributed prescriptions allocated by household size ($0.50-$1.00/per person per day) and shared details of partnering farmers markets, where prescriptions were redeemed for produce. Change in food security was assessed among 578 households from 2013-15, using five measures from the USDA Household Food Security Supplement. Change in fruit and vegetable consumption was calculated for 1024 children between their first and last visits in the years 2012-2015 using an adapted National Cancer Institute screener. Paired t-tests and McNemars paired tests were used to compare study variables between first and last visits, and multiple linear regression analyses, including propensity dose-adjusted models, were used to model the change scores of each as a function of important socio-demographic and program-specific covariates. Results: The percentage of households experiencing very low FS was greatly reduced and those with high/marginal FS increased more than 30%, demonstrating the desired program impact, consistent with SNAP-based incentive programs. Moreover, highest program exposure (specifically, 5 or 6 clinical visits) was associated with a higher food security change score, suggesting that increased levels of participation could indicate a larger degree of change in household food security from the beginning to end of program participation. Households whose primary caretaker had attained higher than high school education also had a greater mean change score. We found both an unadjusted mean increase in children’s FV consumption of 0.33 cups between first and last visit, as well as a dose propensity-adjusted increase in the mean change score of more than a quarter-cup for each 1-unit change in total visits while holding predicted number of visits and site constant. Contrary to common findings in children’s nutrition interventions, a greater portion of the change score increase was attributed to vegetable consumption as compared to fruit consumption. In all outcomes, select clinical sites had higher change scores than those in the reference site, suggesting implications for program design and implementation. Conclusion: Fruit and vegetable prescription programs in clinical settings have the potential to increase food security and children’s fruit and vegetable consumption in low-income households. Future research should utilize a comparison group, complete validated measures, and include qualitative analysis of site-specific barriers and facilitators to success. Comparative effectiveness research could help build the business case for weaving food-based programming into usual care. Integrating food security screenings and referral to local food resources are important steps in improving food access for all and should be adopted by health care providers regardless of an accompanying fruit and vegetable prescription program.