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FRONTIERS The Quarterly Newsletter of the American Academy of Home Care Medicine  |  Winter 2022

Groceries

COMMUNITY HEALTH 

Taking FoodRX Programs From Start-up to Sustainability

RACHEL ZIMMER, DNP, AGPCNP-C
INTERNAL MEDICINE, GERONTOLOGY, WAKE FOREST BAPTIST HEALTH 

Background

Food insecurity (FI), defined as the limited or uncertain availability of nutritionally balanced foods to maintain an active and healthy lifestyle, is closely linked with social and economic disadvantage and is a major public health problem.1-4 In 2020 nearly 13.5 million households (representing about 38.3 million people) in the United States reported FI, including 5.2 million older adults.5-7 The number of people who report having FI is rising due to the coronavirus disease 2019 (COVID-19), and disproportionately affects households with children and communities of color.8 In addition, the number of older adults aged 65 or older are expected to increase to over 73 million by 2030, with projected rates of FI rising in this population.9 Older adults who live alone, individuals of color or who live in poverty, and those who have limited transportation are at a higher risk for FI than other community-dwelling older adults.10

Health care organizations are increasingly addressing social drivers of health (SDOH), such as FI, in partnership with community-based organizations (CBOs) to improve the overall health of communities, and there is a growing interest in collaborating around food prescription programs.11-13 Even though community nutritional programs, such as food pantries and meal delivery services, fill a critical need as an emergency food source for people, many individuals do not utilize these due to stigma and/or lack of customization to individual needs or desires.14-16 An additional nutritional resource is the Supplemental Nutrition Assistance Program (SNAP), the largest federal safety net for older adults. However, only 48% of older adults take advantage of SNAP, meaning that most are missing out on this benefit.17

Impacts of Food Prescription Programs

As the pandemic continues, cumulative effects of FI and isolation are taking a toll on the older adults who are homebound. A qualitative study found that Meals on Wheels (MOW) drivers who were interacting with participants in England noted a significant increase in reported loneliness by the participants during the COVID-19 pandemic.18 A systematic review by DeMarchis, et al. and another study evaluating MOW found that home delivery food prescription programs have the potential to positively impact health and well-being in older adults, including those with diabetes. This is an attractive option to support the nutritional needs of older adults, and can reduce FI by up to 94%.14-16,19 Food prescription programs also seem to have more impact on FI and FV intake than providing food resource information, referrals, or voucher programs.14,20 

However, despite the growth in programs addressing FI, there is an overall lack of theoretical grounding and community input in the development of programs, negatively affecting their impact. Theoretical grounding helps make sense out of complex problems, assists in identifying modifiable variables that can be targeted for intervention, contributes to development of achievable outcomes, and provides structure for the evaluation of programs.21-23 In addition, gaining community input with the engagement of stakeholders and potential participants allows for the co-creation of health programs with communities, offering space for all parties to contribute to the implementation and evaluation.24  Theory-informed approaches and active partnerships with communities are essential elements of program development, as addressing SDOH is complex and require multilevel interventions within diverse settings.11,13  The unprecedented impact of COVID-19 on the food supply chain and the increasing prevalence of FI has emphasized the need for the development and evaluation of community and theoretically-informed food prescription delivery programs for older adults.8,25

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One important aspect of addressing FI for older adults is feeling comfortable with having open dialogue about their food assistance options. Creating a space in which a patient is comfortable having a conversation about food is important, and house call providers are well positioned to have these conversations, with such unique access to the homes of our patients. A lot of older adults are lonely, with over 83% of older adults reportedly living alone, and this by itself causes health hazards. They are unable to leave their home and navigate ways to gain access to food themselves in many cases. Consider opening conversations by asking “What did you have for dinner last night?” or “What are you planning to eat tonight?” This simple gesture can provide space for your patient to discuss a sensitive topic such as hunger.

Evolving Utilization of Food Prescriptions

Addressing FI is a community effort, requiring a community solution. Historically, food prescription programs have varied widely and depended heavily on grants to cover the cost of food, which has been a primary policy barrier to scaling up such programs. These funding challenges result in stakeholders, such as farmers and other CBOs, bearing the burden of costs, affecting sustainability. In addition, when compared to other prevention-related interventions, produce and food prescription programs are relatively young in their science. There are varying types of implementation strategies used to address FI, and funding varies from state to state, preventing adequate comparison of food prescription program health-related outcomes or implementation strategies.15,26

In response to the growing prevalence of FI during the pandemic, The American Rescue Plan Act (ARPA) has provided funding to allow for the provision of meals via home delivery and within congregate settings, as well as the delivery of produce bags for participants over the age of 60.27  With renewed federal funding efforts and a healthcare focus on addressing FI, there has been the emergence of some promising food prescription programs. SuperSNAP™, a produce prescription program in North Carolina, is one example of how health professionals are partnering with SNAP to provide participants with access to healthy foods. SuperSNAP™ participants receive an electronic benefit transfer card, which allows for $40 per month of produce at Food Lion grocery stores across the state.28

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As future produce prescription programs take shape, it is essential that healthcare professionals, community-based organizations, farmers, and participants partner to develop the infrastructure of such programs, while also accounting for partner needs, costs, as well as the role that government assistance programs and insurance companies could play in program sustainability. A recent review of literature noted that as health professionals develop food prescription programs, they should focus on testing a variety of program models to explore the outcomes on participant health as well as the trade-offs between participant wellbeing, fairness, and autonomy.

In the end, older adults want to live with dignity, live in their own homes, and live in a community that cares for them. Finding ways to effectively address food insecurity for this population is a necessary part of caring for their overall health and well-being.

References

  1. Core indicators of nutritional state for difficult-to-sample populations. J Nutr 1990;120 Suppl 11:1559-600.
  2. Christian A. Gregory AC-J. Food Insecurity, Chronic Disease, and Health Among Working-Age Adults, ERR-235: U.S. Department of Agriculture, Economic Research Service; 2017.
  3. Coleman-Jensen A, Gregory, C. & Singh, A. Household Food Security in the United States in 2013. U.S. Department of Agriculture; 2014.
  4. Pickett KE, Wilkinson RG. Income inequality and health: a causal review. Soc Sci Med 2015;128:316-26.
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  8. Hunger in America. 2020. (Accessed October 30, 2020, at https://www.feedingamerica.org/hunger-in-america?s_src=WXXX1MTMG&_ga=2.13719 )
  9. US Census Bureau. U.S. Census Bureau Population Division. Projected 5-Year age groups and sex composition: Main projections series for the United States, 2017-2060: National Population Projections Tables. Washington: DC2017.
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  11. DeWit EL, Meissen-Sebelius EM, Shook RP, et al. Beyond clinical food prescriptions and mobile markets: parent views on the role of a healthcare institution in increasing healthy eating in food insecure families. Nutrition Journal 2020;19:94.
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  14. De Marchis E FC, Gottlieb LM. . Food insecurity interventions in health care settings: A review of the evidence. . San Francisco, CA2020.
  15. De Marchis EH, Torres JM, Benesch T, et al. Interventions addressing food insecurity in health care settings: A systematic review. The Annals of Family Medicine 2019;17:436-47.
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  17. NCOA. 7 facts about older adults and SNAP. 2021. (Accessed January 14, 2022, at https://www.ncoa.org/article/7-facts-about-older-adults-and-snap.)
  18. Papadaki A, Ali B, Cameron A, et al. ‘It’s not just about the dinner; it’s about everything else that we do’: A qualitative study exploring how Meals on Wheels meet the needs of self-isolating adults during COVID-19. Health & Social Care in the Community;n/a.
  19. Healthy incentives pilot final report. 2014. at https://fns-prod.azureedge.net/sites/default/files/ops/HIP-Final-Summary.pdf.)
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  21. Heath G, Cooke R, Cameron E. A theory-based approach for developing interventions to change patient behaviours: A medication adherence example from paediatric secondary care. Healthcare (Basel) 2015;3:1228-42.
  22. Michie S, van Stralen M, West R. The Behaviour Change Wheel: a new method for characterising and designing behaviour change interventions. Implementation science : IS 2011;6:42.
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  24. Jull J, Giles A, Graham ID. Community-based participatory research and integrated knowledge translation: advancing the co-creation of knowledge. Implementation Science 2017;12:150.
  25. Wolfson JA, Leung CW, Kullgren JT. Food as a critical social determinant of health among older adults during the Coronavirus Disease 2019 (COVID-19) Pandemic. JAMA Health Forum 2020;1:e200925-e.
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  27. American Rescue Plan of 2021. 2022. (Accessed Jan 11, 2022, at https://www.fns.usda.gov/american-rescue-plan.)
  28. Reinvestment Partners. Produce prescriptions. 2021. (Accessed December 29, 2021, at https://reinvestmentpartners.org/what-we-do/produce-prescriptions/.)
  29. Swartz H. Produce rx programs for diet-based chronic disease prevention. JAMA Journal of Ethics 2018;20:E960-73.

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