"We don't separate out these things. Everything is related": Partnerships with Indigenous Communities to Design, Implement, and Evaluate Multilevel Interventions to Reduce Health Disparities.

Multilevel interventions (MLIs) are appropriate to reduce health disparities among Indigenous peoples because of their ability to address these communities' diverse histories, dynamics, cultures, politics, and environments. Intervention science has highlighted the importance of context-sensitive MLIs in Indigenous communities that can prioritize Indigenous and local knowledge systems and emphasize the collective versus the individual. This paradigm shift away from individual-level focus interventions to community-level focus interventions underscores the need for community engagement and diverse partnerships in MLI design, implementation, and evaluation. In this paper, we discuss three case studies addressing how Indigenous partners collaborated with researchers in each stage of the design, implementation, and evaluation of MLIs to reduce health disparities impacting their communities. We highlight the following: (1) collaborations with multiple, diverse tribal partners to carry out MLIs which require iterative, consistent conversations over time; (2) inclusion of qualitative and Indigenous research methods in MLIs as a way to honor Indigenous and local knowledge systems as well as a way to understand a health disparity phenomenon in a community; and (3) relationship building, maintenance, and mutual respect among MLI partners to reconcile past research abuses, prevent extractive research practices, decolonize research processes, and generate co-created knowledge between Indigenous and academic communities.

The UnProcessed Pantry Project (UP3): A Community-Based Intervention Aimed to Reduce Ultra-Processed Food Intake Among Food Pantry Clients.

Low-income populations are more likely to experience food and nutrition insecurity and suffer a greater burden of noncommunicable disease than the general population. The UnProcessed Pantry Project (UP3) is an intervention aimed to reduce ultra-processed food availability and consumption of food pantry clients accessing the emergency food system. The pilot study included nutrition education, food boxes, and social support for 16 weeks at 2 food pantries. Data collection included the ASA24 dietary recall to calculate Healthy Eating Index-2015 (HEI-2015) scores, biomarkers (hemoglobin A1c, total cholesterol, blood pressure, waist circumference, body mass index [BMI]), and a demographic and psychosocial survey. Dietary quality among 43 participants significantly (P < .05) improved as measured by the HEI-2015 for total HEI-2015, whole grains, total protein foods, and added sugars scores. BMI, total cholesterol, and waist circumference also significantly improved across study participants. Findings indicate that the emergency food system may be an effective access point to apply frameworks including UP3 to address ultra-processed food consumption, dietary quality, and noncommunicable chronic disease risk among food-insecure populations. Programs and policies that limit the amount of ultra-processed food in the emergency food system should be further tested and could be efficacious in addressing inequities among vulnerable populations.

The effects of foods available through the Food Distribution Program on Indian Reservations (FDPIR) on inflammation response, appetite and energy intake.

OBJECTIVE: To compare the effects of a typical Food Distribution Program on Indian Reservations (FDPIR) diet with an FDPIR diet that meets Dietary Guidelines for Americans (DGA) on inflammation response, appetite and energy intake on a combination of American Indian (AI) and non-AI individuals. DESIGN: A within-subjects, randomised, crossover design was used to compare two dietary conditions: (1) a FDPIR diet that met DGA and (2) a FDPIR diet that did not meet DGA. Each participant served as their own control and was exposed to both dietary conditions. Repeated-measures ANOVA and t tests assessed significance between the two dietary conditions. SETTING: This took place in the Montana State University Nutrition Research Laboratory in the USA. PARTICIPANTS: Female and male participants (n 13) aged 18-55 years from the university and local community. RESULTS: There were no significant differences in inflammatory response and appetite sensations between the two dietary conditions. Findings indicated that participants ate 14 % more (P < 0·01) kcal on a typical FDPIR diet compared with a FDPIR diet that met DGA. CONCLUSIONS: Higher energy intake during a typical FDPIR diet compared with a FDPIR diet that meets DGA may increase risk for obesity and nutrition-related diseases, including type 2 diabetes and other chronic inflammatory conditions.

An ethnographic study exploring factors that minimize lunch waste in Tokyo elementary schools.

OBJECTIVE: To explore factors that minimize lunch waste in Tokyo elementary schools and to consider how such factors can be modified and applied in US schools. DESIGN: Focused ethnographic study using interviews, observation, participant observation and document review. Data were analysed using thematic analysis. SETTING: Tokyo, Japan. PARTICIPANTS: Five school dietitians participated in the study. Data collection methods included in-depth interviews, observation of nutrition education lessons, participant observation of school lunchtime and review of relevant school documents (e.g. lunch menus, food waste records). RESULTS: Five themes emerged from the analysis: (i) reinforcement of social norms to eat without waste; (ii) menu planning to increase exposure to unfamiliar and/or disliked foods; (iii) integration of food and nutrition education into the school curriculum; (iv) teacher lunchtime practices related to portion sizes, distributing leftover food and time management; and (v) engagement of students in reducing school lunch waste. Practical and tangible applications to US schools include measuring and reporting lunch waste to influence social norms, teaching students about the importance of reducing food waste, offering flexible school lunch portion sizes and providing students with meaningful opportunities to contribute to solving the problem of school lunch waste. CONCLUSIONS: Japan offers a model for minimizing school lunch waste through a holistic approach that includes factors that operate at and interact across multiple levels of society. Modifying and applying such an approach in US schools is worth considering given the urgent need to address food waste in order to support healthy diets and sustainable food systems.

Perceptions of food environments and nutrition among residents of the Flathead Indian Reservation.

BACKGROUND: Indigenous food systems have been displaced with the emergence of colonization, industrialization, and cultural, economic, political, and environmental changes. This disruption can be seen in marked health and food environment disparities that contribute to high obesity and diabetes mellitus prevalence among Native American peoples. METHODS: A Community-Based Participatory Research (CBPR) approach was used to document food environment experiences among residents of the Flathead Reservation in rural Montana. Participants were identified using purposive sampling techniques to participate in a survey and a semi-structured interview. Descriptive statistics helped to describe participant demographics, food access variables, and household food security status. Food environment perceptions were analyzed using the constant comparison method among trained researchers. RESULTS: Participants completed surveys (n = 79) and interviews (n = 76). A large number participated in federal nutrition assistance programs. Many self-reported experiencing diet-related chronic diseases. Major themes included the community food environment, dietary norms, and food-health connections. Subthemes were represented by perceptions of food environment transitions and the important role of food in familial life. Further, opportunities and challenges were identified for improving community food environments. CONCLUSIONS: Perceptions of the food environment were linked to strategies that could be targeted to improve dietary quality along a social-ecological model continuum. There is need for skill-based education that directly addresses the time and monetary constraints that were commonly experienced by residents. Coinciding food environment interventions to promote dietary quality that engage community members, store management, and government policy stakeholders are also needed to reestablish healthy Native American food systems and environments within this community.

Dietary Quality Varies Among Adults on the Flathead Nation of the Confederated Salish and Kootenai Tribes in Montana.

Diet-related chronic disease is among the most pressing public health issues and represents a health disparity among Native American communities. A community-based participatory approach was taken to evaluate dietary quality of adult residents of the Flathead Reservation of the Confederated Salish & Kootenai Tribes in Montana (the Flathead Nation). A survey was administered to collect basic demographic information and food security status (N = 80). Dietary quality was assessed using the 24-h dietary recall method with subsequent calculation of Healthy Eating Index 2010 (HEI-2010) scores, modified HEI without a dairy category, and the Dietary Diversity Scores (DDS). Participants included 80 adults from different households across eight communities (n = 10 per community) at the Flathead Nation. Approximately 50% of participants reported low or very low food security status while the remainder scored high or marginal food security. The mean total HEI-2010 score of study participants was 45.5 out of 100 points with a range between 20.0 and 78.1. The mean DDS of study participants was 4.6 (± 1.365) out of a total of 9 points. Participants with higher DDS had significantly higher intake of dietary fiber (p < 0.0003), potassium (0.0024), and cholesterol (p < 0.0048) compared to the lower DDS group. No significant correlations were found between HEI-2010 scores with DDS, demographic information, or food security status while significant differences were found between food security status and income (p < 0.01) and enrollment in nutrition assistance programs (p < 0.03). This study highlights the need to evaluate multiple parameters of dietary quality coupled with a community-based participatory approach in order for findings to be culturally relevant and support food and nutrition interventions.

Factors Influencing Food Choices Among Older Adults in the Rural Western USA.

Nutrition is an essential component in promoting health and quality of life into the older adults years. The purpose of this qualitative research is to explore how the rural food environment influences food choices of older adults. Four focus groups were conducted with 33 older adults (50 years of age and older) residing in rural Montana communities. Four major themes related to factors influencing food choices among rural older adults emerged from this study: perception of the rural community environment, support as a means of increasing food access, personal access to food sources, and dietary factors. The findings from this current study warrant further research and promotion of specifically tailored approaches that influence the food choices of older adults in the rural western USA, including the developing and expanding public transportation systems, increasing availability of local grocers with quality and affordable food options, increasing awareness and decreasing stigma surrounding community food programs, and increasing nutrition education targeting senior health issues.

Assessing foods offered in the Food Distribution Program on Indian Reservations (FDPIR) using the Healthy Eating Index 2010.

OBJECTIVE: To assess the nutritional quality of food packages offered in the Food Distribution Program on Indian Reservations (FDPIR) using the Healthy Eating Index 2010 (HEI-2010). DESIGN: Data were collected from the list of the food products provided by the US Department of Agriculture's Food and Nutrition Handbook 501 for FDPIR. Nutritional quality was measured through a cross-sectional analysis of five randomly selected food packages offered through FDPIR. HEI-2010 component and total scores were calculated for each food package. ANOVA and t tests assessed significant differences between food packages and HEI-2010 maximum scores, respectively. SETTING: This study took place in the USA. SUBJECTS: Study units included food products offered through FDPIR. RESULTS: The mean total HEI-2010 score for the combined FDPIR food packages was significantly lower than the total HEI-2010 maximum score of 100 (66·38 (sd 11·60); P<0·01). Mean scores for total fruit (3·52 (sd 0·73); P<0·05), total vegetables (2·58 (sd 0·15); P<0·001), greens and beans (0·92 (sd 1·00); P<0·001), dairy (5·12 (sd 0·63); P<0·001), total protein foods (4·14 (sd 0·56); P<0·05) and refined grains (3·04 (sd 2·90); P<0·001) were all significantly lower than the maximum values. CONCLUSIONS: The FDPIR food package HEI-2010 score was notably higher than other federal food assistance and nutrition programmes. Study findings highlight opportunities for the FDPIR to modify its offerings to best support lifestyles towards prevention of diet-related chronic disease.

Availability, Price, and Quality of Fruits and Vegetables in 12 Rural Montana Counties, 2014.

We assessed the consumer food environment in rural areas by using the Nutrition Environment Measures Survey for Stores (NEMS-S) to measure the availability, price, and quality of fruits and vegetables. We randomly selected 20 grocery stores (17 rural, 3 urban) in 12 Montana counties using the 2013 US Department of Agriculture's rural-urban continuum codes. We found significant differences in NEMS-S scores for quality of fruits and vegetables; of 6 possible points, the mean quality score was 4.5; of rural stores, the least rural stores had the highest mean quality scores (6.0). Intervention strategies should aim to increase fruit and vegetable quality in rural areas.

Orange-Fleshed Sweet Potato: Successes and Remaining Challenges of the Introduction of a Nutritionally Superior Staple Crop in Mozambique.

BACKGROUND: Chronic vitamin A deficiency affects both women and children in Mozambique and populations worldwide and cannot be addressed through supplementation alone. Food-based approaches encouraging the consumption of vitamin A-rich foods, such as the orange-fleshed sweet potato (OFSP), have the potential to positively affect vitamin A status. A range of OFSP varieties have been introduced in sub-Saharan Africa in rural and urban environments and emergency and nonemergency contexts. OBJECTIVE: To highlight the successes to date and remaining challenges of the introduction of OFSP to increase vitamin A consumption in Mozambique, collating a time line of key events. METHODS: A systematic review of literature using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: The systematic search resulted in 20 studies that met inclusion criteria. Data extracted include author and year, study location and duration, project partners, project title, sample size and characteristics, objectives, methods and measures, and outcomes. CONCLUSIONS: Orange-fleshed sweet potatoes are widely accepted by Mozambican farmers and consumers, and various studies show a positive impact on vitamin A status due to the introduction of this nutritionally superior staple crop. Remaining challenges include vine preservation, pest and disease management, market development, and storage and processing.

Development and Validation of a Farmers' Market Audit Tool in Rural and Urban Communities.

The number of farmers' markets in the United States is growing. Although there are tools to analyze food availability at grocery stores, corner stores, and convenience stores, little research exists about the availability of food types at farmers' markets. This research developed an audit tool to measure the food environment at farmers' markets in rural and urban food environments and examined its psychometric properties, including face validity, interrater reliability, and discriminant validity. The Farmers' Market Audit Tool was reviewed by content experts, revised, and then tested in six farmers' markets by researchers across three states in 2013, including Kentucky, North Carolina, and Montana. Seven food categories were developed, including vegetables, fruits, meats, cheeses, eggs, grains, and samples. Interrater reliability was high within farmers' market across states. As expected, discriminant validity indicated a systematic disagreement within and between states due to seasonality and ability to grow different types of food across different farmers' markets. The total scores assessing the healthfulness of each farmers' market was 38 (range = 28-50). Using the Farmers' Market Audit Tool at farmers' markets is a reliable and valid method to capture the availability of food offerings.

Screening for Food and Nutrition Insecurity in the Healthcare Setting: A Cross-Sectional Survey of Non-Medicaid Insured Adults in an Integrated Healthcare Delivery System.

OBJECTIVES: Healthcare screening identifies factors that impact patient health and well-being. Hunger as a Vital Sign (HVS) is widely applied as a screening tool to assess food security. However, there are no common practice screening questions to identify patients who are nutrition insecure or acquire free food from community-based organizations. This study used self-reported survey data from a non-Medicaid insured adult population approximately one year after the start of the COVID-19 pandemic (2021). The survey examined the extent to which the HVS measure might have under-estimated population-level food insecurity and/or nutrition insecurity, as well as under-identified food and nutrition insecurity among patients being screened for social risks in the healthcare setting. METHODS: Data from a 2021 English-only mailed/online survey were analyzed for 2791 Kaiser Permanente Northern California (KPNC) non-Medicaid insured members ages 35-85 years. Sociodemographics, financial strain, food insecurity, acquiring free food from community-based organizations, and nutrition insecurity were assessed. Data from respondents' electronic health records were abstracted to identify adults with diet-related chronic health conditions. Data were weighted to the age × sex × racial/ethnic composition of the 2019 KPNC adult membership. Differences between groups were evaluated for statistical significance using adjusted prevalence ratios (aPRs) derived from modified log Poisson regression models. RESULTS: Overall, 8.5% of participants reported moderate or high food insecurity, 7.7% had acquired free food from community-based organizations, and 13% had nutrition insecurity. Black and Latino adults were significantly more likely than White adults to have food insecurity (17.4% and 13.1% vs 5.6%, aPRs = 2.97 and 2.19), acquired free food from community-based organizations (15.1% and 15.3% vs 4.1%, aPRs = 3.74 and 3.93), nutrition insecurity (22.1% and 23.9% vs 7.9%, aPRs = 2.65 and 2.64), and food and nutrition insecurity (32.4% and 32.5% vs 12.3%, aPRs = 2.54 and 2.44). Almost 20% of adults who had been diagnosed with diabetes, prediabetes, ischemic CAD, or heart failure were food insecure and 14% were nutrition insecure. CONCLUSIONS: Expanding food-related healthcare screening to identify and assess food insecurity, nutrition insecurity, and use of community-based emergency food resources together is essential for supporting referrals that will help patients achieve optimal health.

How does eligibility for GusNIP produce prescriptions relate to fruit and vegetable purchases and what factors shape the relationship? A protocol for a secondary analysis of nationally representative data in the USA.

INTRODUCTION: US Department of Agriculture (USDA) Gus Schumacher Nutrition Incentive Programme (GusNIP) produce prescription programme (PPR) 'prescriptions' provide eligible participants with low income, risk for diet-related chronic disease and food insecurity a healthcare issued incentive to purchase lower to no cost fruits and vegetables (FVs). However, GusNIP requirements specify that PPR prescriptions can only be redeemed for fresh (not frozen, canned or dried) FVs. This requirement may prevent participants from fully engaging in or benefiting from GusNIP PPR, given communities with lower healthy food access may have reduced fresh FV accessibility. METHODS AND ANALYSIS: We will use the nationally representative 2012-2013 National Household Food Acquisition and Purchase Survey (FoodAPS) and complementary FoodAPS Geography Component data in a secondary data analysis to examine how household GusNIP PPR eligibility relates to the quantity and variety of fresh, frozen, canned and dried FV purchases and to what extent individual, household and food environment factors shape the relationship. FoodAPS data include household food purchasing and acquisition information across a 7 day period from 14 317 individuals among 4826 households and was collected between April 2012 and January 2013. The FoodAPS Geography Component provides information about the local community/environment relative to FoodAPS households. This study will examine the correlation or association of selected variables between different quantities and varieties of fresh, frozen, canned and dried FVs, as well as correlations among multilevel predictors. ETHICS AND DISSEMINATION: We are following data integrity standards as outlined by agreements with the USDA Economic Research Service. All results of analyses will undergo a thorough disclosure review to ensure no identifiable data are shared. Results will be disseminated to research, practice and policy communities using an Open Access peer-reviewed manuscript(s), scientific and practice presentations, and a public facing report and infographic.

E-health Dietary Interventions for Participants of SNAP and WIC: A Systematic Review.

The migration of federal assistance services to online platforms during the COVID-19 pandemic sparked interest in digital nutrition education for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs. With federal government investing in the modernization of the nutrition education components of both programs, there is a need to identify science-backed electronic health (e-health) dietary interventions to improve health outcomes in this population. Therefore, the objective of this systematic literature review was to summarize the effectiveness, acceptability, and feasibility of e-health dietary interventions among individuals participating in WIC or SNAP. Keyword searches were performed in Google Scholar, PubMed, and Science Direct. The search included peer-reviewed literature from 2014 to 2023 and a few articles offering context about interventions used long-term by the nutrition assistance programs. PRISMA guidelines were followed to conduct this systematic literature review, which resulted in 36 articles eligible for extraction. The studies evaluated e-health (52.8%), short message service/text messaging (27.8%), and smartphone application interventions (19.4%) delivered to WIC or SNAP participants. The interventions identified aimed to modify food choice, eating behavior, and dietary intake among SNAP participants, SNAP-eligible adults, and WIC participants. Most interventions were developed using content delivery and health behavior theoretical frameworks (77.8%) and evidence-based nutritional recommendations (59.3%). Review findings show a high level of acceptability and feasibility for e-health and mobile health dietary interventions among WIC and SNAP participants but varying levels of effectiveness. Level of engagement, dosage, retention, and adherence were strong predictors of positive dietary behavior change regardless of the mode of intervention delivery. Future studies need to prioritize health equity by recruiting samples representative of food nutrition assistance participants and addressing digital health literacy as a potential barrier to intervention effectiveness, as none of the present studies measured literacy among participants.

Implementation and Impact of Perinatal Food Is Medicine Programs: A Qualitative Research Study.

BACKGROUND: Improving social determinants of health, such as access to nutritious food, is crucial for achieving health equity. Nutrition insecurity, especially during pregnancy and postpartum, can lead to poor maternal and birth outcomes. Food is Medicine (FIM) programs, which integrate food into the health care system to prevent or manage disease, have the potential to improve nutrition insecurity, but research about perinatal FIM programs is limited. OBJECTIVE: The purpose of this study was to explore perceptions of public health impacts of perinatal FIM programs from the perspectives of both program implementers and program supporters and implementation strategies used to enhance program adoption, implementation, and maintenance. DESIGN: Qualitative data were collected through semi-structured interviews. The interview guide was based on the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. PARTICIPANTS/SETTING: Program implementers (n = 16) and program supporters (n = 20) were recruited across the United States through purposive sampling in 2022 and 2023. ANALYSIS: Data were analyzed using deductive thematic analysis and an iterative feedback loop with the project partner. RESULTS: Interviews were completed with program implementers and program supporters and generated meaning units (n = 1,942), which were coded into themes aligned with each Reach, Effectiveness, Adoption, Implementation, Maintenance dimension. Perinatal FIM programs reached multiple priority populations who were mainly recruited through health care systems. Effectiveness measures typically included nutrition patterns and practices, as well as return on investment. Motivations for adopting programs primarily included partnerships and connections, financing, and policies and laws. Program components varied and were adapted to meet participants and setting needs. Policy, evidence, funding, and partnerships could lead to program maintenance. Implementation strategies applied by the program supporters included financial strategies and infrastructure changes. CONCLUSIONS: There is a need to identify the core functions and adaptable forms of perinatal FIM programs, which could lead to identification of standard evaluation metrics. This could result in greater uptake by potential delivery agents, increased funding and policy support, and enhanced benefits for perinatal population experiencing health disparities.

How the Gus Schumacher Produce Prescription Program Works: An Adaptation of a Nutrition Incentive Theory of Change.

The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports nutrition incentive (NI) and produce prescription programs (PPRs). PPRs allow healthcare providers to "prescribe" fruits and vegetables (FVs) to patients experiencing low income and/or chronic disease(s) and who screen positive for food insecurity. We developed a Theory of Change (TOC) that summarizes how and why PPRs work, identifies what the programs hope to achieve, and elucidates the causal pathways necessary to achieve their goals. We created the PPR TOC through an iterative, participatory process that adapted our previously developed GusNIP NI TOC. The participatory process involved food and nutrition security experts, healthcare providers, PPR implementors, and PPR evaluators reviewing the existing NI TOC and suggesting modifications to accurately reflect PPRs. The resulting TOC describes the mechanisms, assumptions, rationale, and underpinnings that lead to successful and equitable outcomes. Modifications of the NI TOC centered around equity and focused on inclusion of healthcare as an additional partner and the importance of health and healthcare utilization as outcomes. The TOC describes how the GusNIP PPR program reaches its goals. This understanding will be useful for PPR developers, implementers, funders, and evaluators for describing the pathways, assumptions, and foundations of successful PPRs.

Which Program Implementation Factors Lead to more Fruit and Vegetable Purchases? An Exploratory Analysis of Nutrition Incentive Programs across the United States.

Background: Nutrition incentive (NI) programs help low-income households better afford fruits and vegetables (FVs) by providing incentives to spend on FVs (e.g., spend $10 to receive an additional $10 for FVs). NI programs are heterogeneous in programmatic implementation and operate in food retail outlets, including brick-and-mortar and farm-direct sites. Objective: This study aimed to explore NI program implementation factors and the amount of incentives redeemed. Methods: A total of 28 NI projects across the United States including 487 brick-and-mortar and 1078 farm-direct sites reported data between 2020 and 2021. Descriptive statistics and linear regression analyses (outcome: incentives redeemed) were applied. Results: Traditional brick-and-mortar stores had 0.48 times the incentives redeemed compared with small brick-and-mortar stores. At brick-and-mortar sites, automatic discounts had 3.47 times the incentives redeemed compared with physical discounts; and auxiliary services and marketing led to greater redemption. Farm-direct sites using multilingual and direct promotional marketing had greater incentives redeemed. Conclusions: To our knowledge, this is the first national study to focus on NI program implementation across sites nationwide. Factors identified can help inform future programming and research.

Measurement of Fruit and Vegetable Intake Incorporating a Diversity, Equity, and Inclusion Lens. Comment on Di Noia, J.; Gellermann, W. Use of the Spectroscopy-Based Veggie Meter® to Objectively Assess Fruit and Vegetable Intake in Low-Income Adults. Nutrients 2021, 13, 2270.

Disparities in fruit and vegetable intake (FVI) and diet-related diseases exist among low-income and racial/ethnic minority populations [...].

A Case for Using Electronic Health Record Data in the Evaluation of Produce Prescription Programs.

Produce prescription programs within clinical care settings can address food insecurity by offering financial incentives through "prescriptions" for fruits and vegetables to eligible patients. The electronic health record (EHR) holds potential as a strategy to examine the relationship between these projects and participant outcomes, but no studies address EHR extraction for programmatic evaluations. We interviewed representatives of 9 grantees of the U.S. Department of Agriculture's Gus Schumacher Nutrition Incentive Grant Program's Produce Prescription Projects (GusNIP PPR) to understand their experiences with and capacity for utilizing EHR for evaluation. Five grantees planned to use EHR data, with 3 main strategies: reporting aggregate data from health clinics, contracting with external/third party evaluators, and accessing individual-level data. However, utilizing EHRs was prohibitive for others due to insufficient knowledge, training and/or staff capacity; lack of familiarity with the Institutional Review Board process; or was inappropriate for select target populations. Policy support for produce prescription programs requires a robust evidence base, deep knowledge of best practices, and an understanding of expected health outcomes. These insights can be most efficiently and meaningfully achieved with EHR data, which will require increased financial support and technical assistance for project operators.