Implementation of Food is Medicine Programs in Healthcare Settings: A Narrative Review.

Food is Medicine (FIM) programs to improve the accessibility of fruits and vegetables (FVs) or other healthy foods among patients with low income and diet-related chronic diseases are promising to improve food and nutrition security in the United States (US). However, FIM programs are relatively new and implementation guidance for healthcare settings using an implementation science lens is lacking. We used a narrative review to describe the evidence base on barriers and facilitators to FIM program integration in US healthcare settings following the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework. Evidence surrounding the EPIS Inner Context was a focus, including constructs Leadership, Organizational Characteristics, Quality and Fidelity Monitoring and Support, Organizational Staffing Processes, and Individual Characteristics. Peer-reviewed and grey literature about barriers and facilitators to FIM programs were of interest, defined as programs that screen and refer eligible patients with diet-related chronic disease experiencing food insecurity to healthy, unprepared foods. Thirty-one sources were included in the narrative review, including 22 peer-reviewed articles, four reports, four toolkits, and one thesis. Twenty-eight sources (90%) described EPIS Inner Context facilitators and 26 sources (84%) described FIM program barriers. The most common barriers and facilitators to FIM programs were regarding Quality and Fidelity Monitoring and Support (e.g., use of electronic medical records for tracking and evaluation, strategies to support implementation) and Organizational Staffing Processes (e.g., clear delineation of staff roles and capacity); although, barriers and facilitators to FIM programs were identified among all EPIS Inner Context constructs. We synthesized barriers and facilitators to create an EPIS-informed implementation checklist for healthcare settings for use among healthcare organizations/providers, partner organizations, and technical assistance personnel. We discuss future directions to align FIM efforts with implementation science terminology and theories, models, and frameworks to improve the implementation evidence base and support FIM researchers and practitioners.

Perspective: Leveraging Electronic Health Record Data Within Food Is Medicine Program Evaluation: Considerations and Potential Paths Forward.

Government, health care systems and payers, philanthropic entities, advocacy groups, nonprofit organizations, community groups, and for-profit companies are presently making the case for Food is Medicine (FIM) nutrition programs to become reimbursable within health care services. FIM researchers are working urgently to build evidence for FIM programs' cost-effectiveness by showing improvements in health outcomes and health care utilization. However, primary collection of this data is costly, difficult to implement, and burdensome to participants. Electronic health records (EHRs) offer a promising alternative to primary data collection because they provide already-collected information from existing clinical care. A few FIM studies have leveraged EHRs to demonstrate positive impacts on biomarkers or health care utilization, but many FIM studies run into insurmountable difficulties in their attempts to use EHRs. The authors of this commentary serve as evaluators and/or technical assistance providers with the United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program National Training, Technical Assistance, Evaluation, and Information Center. They work closely with over 100 Gus Schumacher Nutrition Incentive Program Produce Prescription FIM projects, which, as of 2023, span 34 US states and territories. In this commentary, we describe recurring challenges related to using EHRs in FIM evaluation, particularly in relation to biomarkers and health care utilization. We also outline potential opportunities and reasonable expectations for what can be learned from EHR data and describe other (non-EHR) data sources to consider for evaluation of long-term health outcomes and health care utilization. Large integrated health systems may be best positioned to use their own data to examine outcomes of interest to the broader field.

Social Risks, Social Needs, and Attitudes Toward Social Health Screening 1 Year Into the COVID-19 Pandemic: Survey of Adults in an Integrated Health Care Delivery System.

Introduction Information about demographic differences in social risks, needs, and attitudes toward social health screening in non-highly vulnerable adult populations is lacking. Methods The authors analyzed data for 2869 Kaiser Permanente Northern California non-Medicaid-covered members aged 35 to 85 who responded to a 2021 English-only mailed/online survey. The survey covered 7 social risk and 11 social needs domains and attitudes toward social health screening. The authors used data weighted to the Kaiser Permanente Northern California membership to estimate prevalence of risks, needs, and screening receptivity in the overall population, by race/ethnicity (White, Black, Latinx, Asian American/Pacific Islander) and age (35-65 years old, 66-85 years old). Multivariable regression was used to evaluate differences between groups. Results Overall, 26% of adults were financially strained, 12% food insecure, 12% housing insecure, and 5% transportation insecure. Additionally, 7%, 8%, and 17% had difficulty paying for utilities, medical expenses, and dental care, respectively. Over 40% of adults wanted help with ≥ 1 social need. Dental care, vision/hearing care, paying for medical expenses and utilities, and managing debt/credit card repayment surpassed food, housing, and transportation needs. Prevalence of social risks and needs was generally higher among middle-aged versus older and Black and Latinx versus White adults. Among the 70% of adults receptive to screening, 85% were willing to complete a questionnaire and 40% were willing to have staff ask questions; 18% did not want to be screened. Conclusion When implementing social health screening in diverse patient populations, the prevalence of social risks and needs, as well as the acceptability of social health screening and screening modalities, will vary among demographic subgroups.

A Qualitative Exploration of Approaches Applied by Nutrition Educators Within Nutrition Incentive Programs.

OBJECTIVE: To explore the approaches applied by nutrition educators who work with the US Department of Agriculture Gus Schumacher Nutrition Incentive Program (GusNIP), Nutrition Incentive (NI), and Produce Prescription (PPR) programs. METHODS: Multiple data collection methods, including descriptive survey (n = 41), individual interviews (n = 25), and 1 focus group (n = 5). Interviewees were educators who deliver nutrition education as a component of GusNIP NI/PPR programs. Descriptive statistics were calculated from survey responses. Transcripts were coded using thematic qualitative analysis methods. RESULTS: Four overarching themes emerged. First, educators have many roles and responsibilities beyond providing curriculum-based nutrition education. Second, interviewees emphasized participant-centered nutrition education and support. Third, partnerships with collaborating cross-sector organizations are essential. Fourth, there are common challenges to providing nutrition education within GusNIP NI/PPR programs, and educators proposed solutions to mitigate these challenges. CONCLUSIONS: Nutrition educators promote multilevel solutions to improve dietary intake, and it is recommended they be included in conversations to improve GusNIP NI/PPR programs.

Preference for fruits and vegetables is linked to plate waste among preschool children.

BACKGROUND: A large portion of preschool-aged children in the United States (US) do not consume enough fruits and vegetables (FV). It is important for childcare providers to know what food choices children in their care are making at mealtime and how to encourage them to eat more FV. The objective of this pilot study was to examine the relationship between FV preference and plate waste among pre-school aged children in a childcare setting using a rapid assessment tool. METHODS: The rapid assessment tool was first pilot tested with 23 children and revised. A repeated cross-sectional design was carried out for three days during fall 2016 in one childcare center. Over three days, the research team collected 100 FV plate waste observations from 30 children who were surveyed simultaneously about their preference (did not try, tried, liked, loved) towards FV. RESULTS: Food preference for FV by preschool children is significantly (p < 0.05) related to plate waste and age. Children that indicated they loved a fruit or vegetable generated the least plate waste. Children that indicated that they did not try a fruit or vegetable generated the most plate waste. CONCLUSIONS: FV preference and plate waste are significantly and inversely correlated. The rapid assessment tool developed should be validated to be used in implementing strategies that increase child preferences and consumption of FV that support lifelong healthy eating behaviors.

Examining Equitable Online Federal Food Assistance during the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): A Case Study in 2 Regions.

The USDA Supplemental Nutrition Assistance Program (SNAP) provides food and financial assistance to food-insecure individuals and families. In the midst of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, SNAP benefits evolved. Policy changes and federal legislation expanded SNAP eligibility, raised benefit levels, and introduced program waivers that enabled online ordering to reduce participants' exposure to community-acquired SARS-CoV-2. Although rapid expansion of SNAP benefits in the online space represents significant progress for federal food assistance, changes also introduced unforeseen partiality in how benefits and services were accessed and utilized, as illustrated by 2 populations and regions in the early months of the SARS-CoV-2 pandemic: low-income older adults in rural Alabama and low-income Hispanic adults in urban California. Opportunities exist to build on the recent progress in SNAP, while also ensuring continued inclusiveness of eligible persons. Efforts should be informed by evidence that supports equitable access to federal food assistance.

Milk Consumption and Waste Across 5 Montana High School Lunch Programs.

BACKGROUND: Few studies document milk selection and waste among high school lunch programs. METHODS: This observational research assesses the types of milk selected and wasted among 5 Montana high school lunch programs. Over 6 days across the 2014-2015 school year, 3842 milk cartons were collected. Direct weighing was used to assess the ounces of milk wasted and consumed by milk type. Outcomes included the number of milks selected by type at each school, ounces of milk consumed and wasted on average per student. Descriptive and inferential statistics were used to assess demographics of school lunch participation, milk consumption and waste, and the amount of waste per type of milk. RESULTS: Students were most likely (p < .05) to select fat-free flavored milk, followed by 1% plain milk, and fat-free plain milk. Fat-free flavored (mean = 0.86, SD = 0.55) was the least wasted, followed by fat-free plain (mean = 1.08 oz, SD = 1.55), and 1% plain (mean = 1.26 oz, SD = 1.02). CONCLUSIONS: Across all milk options, milk waste was low. The findings indicate that high school students are more likely to select and consume greater amounts of, and waste less, fat-free flavored milk.

Resources Lack as Food Environments Become More Rural: Development and Implementation of an Infant Feeding Resource Tool (InFeed).

Evaluating the availability and affordability of breastfeeding and formula-feeding supplies are critical for building food environments that support healthy infant development. This study details the development and implementation of the Infant Feeding Resource Tool (InFeed) in retail settings across Montana (n = 21). Interrater reliability was tested (n = 9), kappa 0.620. Analysis of variance found significant differences by rurality for InFeed scores, with infant feeding resources lacking in more rural Montana retail settings: Formula, p = .05 (rounded value); Equipment, p = .02; and Total, p = .03. Prices of infant feeding resources did not differ by rurality and InFeed scores did not differ by store type.

Sleep, physical activity, waist circumference and diet as factors that influence health for reproductive age women in northern Greenland.

BACKGROUND: This study explored community and individual factors that influence the health of reproductive age women in a settlement in northern Greenland. This is important because Greenland has a declining population, a high abortion rate and because of projected environmental shifts due to climate change. METHODS: This study collected mixed methods data to explore diet, physical activity, sleep and waist circumference for reproductive age women in Kullorsuaq, Greenland. The daily steps and sleeping hours of 13 reproductive age women were measured using activity monitoring bracelets. Waist circumference measurements and in-depth interviews about daily eating and physical activity were conducted with 15 participants and ethnographic participant observations were recorded using field notes. RESULTS: Waist circumference measurements were above recommended cutoffs established by the World Health Organization. Physical activity measured by daily steps was within the 'active' range using the cutoff points established by Tudor and Locke. Physical activity is social and is important for communal relationships. Sleeping hours were within normal ranges based on US guidelines; however, the quality of this sleep, its variability across seasons and cultural expectations of what healthy sleep means must be further explored. Diets of women included a mixture of locally harvested meats and imported packaged foods. Study participants experienced less satiety and reported getting hungrier faster when eating packaged foods. This research took place in Spring 2016 and women reported that their sleep, physical activity and diet fluctuate seasonally. CONCLUSION: The reported findings suggest further investigation of sleep, diet and physical activity combined with the measurement of reproductive hormones to determine linkages between lifestyle factors and reproductive health outcomes is needed.

Advancing healthy and sustainable food environments: The Flathead Reservation case study.

This case study describes a methodological approach to evaluating and improving food environments in an indigenous community in the United States of America. A community-research partnership was developed to support healthy diets from sustainable food systems. Our team implemented complementary methodologies to evaluate multiple dimensions of the food environment, including food availability, convenience, affordability and desirability. Our findings were used to design and implement multiphase food-environment interventions that elucidated the following: (1) food-environment measurements should be multifaceted and context-specific; (2) food desirability, including sensory attributes, diversity and phytonutrient quality, are important but overlooked aspects of the food environment; (3) successful food-environment interventions are community-based and incremental; (4) food-environment interventions should seek to forge links with existing institutional structures to influence policy; and (5) findings from food-environment interventions should be disseminated in various ways to diverse stakeholders.

Factors affecting farmers' willingness and ability to adopt and retain vitamin A-rich varieties of orange-fleshed sweet potato in Mozambique.

The addition of orange-fleshed sweet potato (OFSP) to the food environment is an effective nutrition-sensitive agricultural approach to improve vitamin A intakes. However, the adoption of this biofortified crop merits further study. The objective of our research was to understand factors that affect Mozambican farmers' adoption and retention of OFSP varieties, with a specific interest in the retention of planting material. Field research was conducted in three provinces of Mozambique during 2015. Provinces with different OFSP intervention histories were selected to allow for the identification of site-specific factors and the impact of variable approaches over time. Qualitative inquiry was used to assess participants' progress through the five stages of the Innovation-Decision process in the Diffusion of Innovations Theory. Ninety-five producers, consumers, and market stakeholders of OFSP participated in semi-structured in-depth interviews and focus groups. Results indicate that diverse factors influenced the adoption and retention of OFSP, including organoleptic qualities, taste preferences, access to planting material, agronomic traits, environmental conditions, lack of capital for inputs and labor, unstable markets, and limited sharing of information and planting material across farmer networks. Current OFSP varieties were acceptable to Mozambican farmers and consumers, but there are several remaining challenges to reaching a critical mass such as lack of access to planting material, perceptions of superior drought tolerance of white-fleshed sweet potato (WFSP), and the belief that OFSP requires additional effort to cultivate (e.g. weed removal, measuring space between plants). Key recommendations which may be considered in future planning for OFSP interventions in Mozambique and other countries include enabling decentralized vine multipliers to provide vines to community members at no cost, continued focus on breeding and distribution of more drought tolerant varieties of OFSP, and training on the similarities in agronomic practices required for producing and preserving OFSP and WFSP.

The Grocery Store Food Environment in Northern Greenland and Its Implications for the Health of Reproductive Age Women.

The population of Greenland is diminishing and environmental and social shifts implicate food availability and the health of reproductive age women. There is little knowledge of the grocery store food environment in Greenland. To address this gap and provide baseline information the present study measured food availability in five grocery stores in northern Greenland. As well, 15 interviews were conducted with reproductive age women, three grocery store managers were interviewed and one interview was conducted with a food distribution manager. Results show few fresh fruits and vegetables are available in grocery stores and in some stores no fresh foods are available. In Kullorsuaq, the primary location for this study, the Nutrition Environment Measures Survey in Stores score in spring 2016 was (3/30) and the Freedman Grocery Store Survey Score was (11/49). Interview results highlight a need to increase communication within the food system and to tailor food distribution policies to the Arctic context with longer term planning protocols for food distribution. These findings can be used to inform future food store environment research in Greenland and for informing policies that improve healthful food availability in grocery stores in northern Greenland.

Food Insecurity Experience: Building Empathy in Future Food and Nutrition Professionals.

OBJECTIVE: To assess changes in empathy in students completing a food insecurity experience. DESIGN: Mixed methods; quantitative data from survey in years 1 and 2; qualitative data extracted from students' workbooks in years 2-5. This study was conducted over 10 weeks annually for 5 years. SETTING: Northwest US land-grant university. PARTICIPANTS: Students enrolled in a community nutrition course who chose to complete the food insecurity exercise. Total included 58 students in quantitative analysis in years 1 and 2 and 119 in qualitative analysis, years 2-5. INTERVENTION(S): The intervention was a food insecurity experience in which participants spent no more than $3/d on food for 5 days ($15 total) while striving for a nutritious diet and reflecting on their experience. MAIN OUTCOME MEASURES: Empathy scores measured by Likert scales; participant responses and reflections recorded in workbook journals. ANALYSIS: Comparison of means across time using paired t tests (P < .05); coding and sorting themes from workbook journals. RESULTS: Quantitative findings indicated that both classroom content and experiential exercises were important for enhancing empathy about food insecurity. Empathy scores increased from time I to time II and from time I to time III. Qualitative reflections among participants included terms such as guilt, empathy, compassion, and raised consciousness about food insecurity. CONCLUSIONS AND IMPLICATIONS: Experiential and transformational learning to develop empathy can take place in a 5-day food insecurity experience during a typical university-level community nutrition course. This intervention can be tested for applications in other contexts.

A Reach, Effectiveness, Adoption, Implementation, Maintenance Evaluation of Weekend Backpack Food Assistance Programs.

PURPOSE: The purpose of this study was to evaluate an ongoing statewide weekend backpack program through the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. DESIGN: Mixed-methods inquiry was used to explore the reach, effectiveness, adoption, implementation, and maintenance of backpack programs within Montana. SETTING: Study participants completed audio-recorded one-on-one phone interviews. PARTICIPANTS: Key informants (e.g., managers at food banks, staff at participating schools, policy makers) were purposively sampled (N = 20). METHOD: Semistructured interviews were conducted to gather data to describe each RE-AIM dimension. Interviews were transcribed verbatim and deductively (i.e., using RE-AIM as themes) coded for meaning units, placed into higher-order categories, and summarized in narrative. Supporting quantitative data (e.g., the proportion of eligible students that joined the program, rate of school-level adoption) were calculated using descriptive statistics. RESULTS: Backpack programs with a broad reach and evidenced effect may be appealing to adopt. Weekend food bags cost an average $3.87 (SD ± .94) and there were some positive (i.e., ease, protecting participants' privacy) and very few negative (logistical) components of implementation. Collaborators and community partners are necessary for long-term sustainability. CONCLUSION: Backpack programs are widespread and have potential to relieve weekend hunger; however, more efforts need to be made to end childhood hunger.