Cardiovascular Disease: Produce Prescriptions May Help Reduce Risks

How the study suggests a link between produce prescriptions and better health

Hager and his team set out to assess whether or not produce prescriptions could affect clinical health outcomes and partnered with the national nonprofit Wholesome Wave.

The new study included 3,881 participants considered at higher risk for heart disease from 12 states. Of them, 2,064 were adults ages 18 and older, and the remaining 1,817 were children ages 2-17. Participants received a median monthly financial incentive of $63 to buy produce at local stores and farmers’ markets, plus education via nutrition classes.

The program duration ranged from 4 to 10 months, with an average of six months. After the program, individuals completed questionnaires about their produce consumption, food security, and health status.

They also underwent routine testing for blood pressure, weight and height, and hemoglobin A1c (HbA1c), which measures a person’s average blood glucose over 3 to 4 months.

There wasn’t a control group, but researchers compared participants’ outcomes prior to and following the completion of the produce prescription program.

According to the data:

• Adults’ produce intake went up by nearly one cup daily (0.85 cups), and children’s intake increased by more than a quarter of a cup daily (0.26 cups daily).
• The chances of being food insecure declined by one-third in adult and pediatric participants.
• Self-reported health status improved by about two-thirds in adults and saw more than a two-fold improvement in children.
• Blood sugar levels declined in adult participants who entered the program with HbA1c of 6.5% or greater.
• Adults who enrolled in the study with high blood pressure saw decreased systolic and diastolic blood pressure.
• BMI decreased slightly in adults but not in children.

“This modeling study provides evidence that produce prescription programs may increase consumption of nutritious fruits and vegetables and reduce food insecurity,” Elkind says. “These prescriptions also seem to improve subjective and objective health measures, such as blood pressure.”

Why produce prescription may decrease heart disease risk and food insecurity 

The study’s suggestion that blood pressure and glucose levels and BMI might improve in people receiving food prescriptions caught one board-certified cardiothoracic surgeon’s eye.

“This is important because high blood pressure, diabetes, and obesity are significant risk factors for cardiovascular disease,” says Dr. Alexandra Kharazi, FACS, the founder of The Heart Motivation Consulting.

Access to nutrient-dense foods can play a pivotal role in decreasing these risk factors. Though the 2020–2025 Dietary Guidelines for Americans state adults should eat 1.5-2 cups of fruits and 2-3 cups of vegetables daily, CDC data reports that 1 in 10 adults don’t eat enough fruits and vegetables daily.

“Food prescriptions can help with heart health by encouraging the consumption of fruits and vegetables rich in fiber, antioxidants, and potassium,” says Kelsey Costa, MS, RDN, a registered dietitian and nutrition consultant for Consumer Health Digest. “These nutrients are known to reduce LDL cholesterol levels, lower blood pressure, and mitigate inflammation, all of which are crucial in preventing heart disease.”

Moreover, what’s not in the foods is also helpful.

”Hypertension and heart failure are driven in part by increased sodium consumption, which is common in prepared foods,” Elkind says. “Cardiometabolic disorders such as diabetes and obesity are due in part to eating calorie-dense carbohydrates, including sugar-sweetened beverages.”

Elkind says there are many barriers to food, including:

• Food and nutrition insecurity
• Food marketing
• Access and affordability of healthy foods
• Behavioral tendencies, such as a focus on immediate versus delayed gratification

Food prescriptions might help fill these gaps, thereby improving heart health outcomes.

Limitations of the study

While the study makes a case for food prescriptions, experts share it has flaws. Notably, there isn’t a control group, and it is not a randomized control trial (RCT). Had there been, researchers could have compared people who received produce prescriptions to those who did not.

“It did not involve randomizing patients to one intervention versus another, Elkind says. “Randomization is important because it eliminates many of the differences among those who seek out healthy foods and those who don’t. Without it, we don’t know whether the patients are eating healthier food because of the prescription or because of some other underlying characteristic.”

Hager agrees the design is a limitation but hopes it prompts further research.

“Overall, our new findings support the need for large, randomized controlled trials of produce prescriptions to confirm our findings,” he says. “Scientists generally agree that these studies, in which participants would be randomized to receive or not receive produce prescriptions, provide the best evidence, and they may be required for programs to expand significantly throughout U.S. health insurance.”

Additionally, the study also relied heavily on self-reported data.

“The surveys are subjective; the only objective measures are those which were measures in the clinic — HbA1C, blood pressure, and BMI,” says Kharazi.

Costa also cautions that the study doesn’t dig into the practicality and feasibility of long-term application of produce prescriptions.

“The study…doesn’t provide information regarding the long-term sustainability and cost-effectiveness of these produce prescription programs,” Costa says. “It also does not explore the potential challenges in scaling up these programs to a national level or their applicability in different cultural contexts.”

What are food prescriptions?

The idea of produce prescriptions or medically tailored meals may be new to some. However, this study is not the first to discuss them.

In October 2022, another Hager-led study was published, indicating that medically tailored meals could decrease hospitalizations by 1.6 million, resulting in a net cost savings of $13.6 billion annually.

Unlike money-for-produce prescriptions assessed in the newest study, medically-tailored meals are usually fully prepared, home-delivered to individuals, and tailored to meet their health needs.

For example, there would be a maximum amount of carbohydrate for someone with diabetes or sodium for a person with blood pressure, explains Dr. Daphne Miller, a practicing family physician, science writer, and clinical professor at the University of California San Francisco, and research scientist at the University of California Berkeley School of Public Health.

Though there are distinctions, the concept fits under the same umbrella.

“All together, they are described as medically sourced food,” says Miller, who is a professor in family and community medicine at the University of California San Francisco. “The idea behind all of them is that they are paid for, in some form or another, and are prescribed by their health care provider.”

Challenges and potential risks of food prescriptions

Miller says the idea of medically-tailored meals and food prescriptions is reasonable. However, she raises concerns.

Miller understands that food access can be a challenge and says that the decrease in food insecurity in the new study is impressive. However, other scaled federal initiatives also exist to address this issue.

“We have SNAP, WIC, Meals on Wheels, and food banks,” Miller says. “We have lots of other safety-net programs for food. SNAP, in particular, which is the modern rendition of food stamps, has been shown to achieve the same health outcomes the study has shown.”

Indeed, research from 2018 indicated that higher SNAP benefits might be linked to a lower likelihood of hypertension-related emergency room claims. An older study published in 2015 suggested that SNAP could:

• Increase self-reports of “excellent” or “very good” health
• Decrease time spent in bed sick by about 3 days annually
• Lower reported office-based doctor visits by between 1 to 2 per year

For policymakers, Miller says the question is not “Are food prescriptions a good idea?”

Instead, the question is: “Are they the best way to offer these food benefits, or should we invest deeper in current programs?

Moreover, Miller fears that as the drumbeat around food prescriptions grows louder, the small community non-profits, like Community Kitchen in Boston, will get pushed aside.

She says these organizations are often sourced from local farmers and make essentially homemade meals. Now, big box chains can swoop in, and she fears the quality will decrease with mass production.

“As dollars come in, big companies are getting involved in produce prescriptions and medically-tailored meals,” Miller says. “It looks like something you’d find at Taco Bell or McDonalds. It’s highly processed…the loophole is that they are meeting the nutrient profiles and calorie requirements of medically tailored meals, so they are able to slip it in as something legitimate. But it is a highly processed food product…and less palatable and delicious.”

How to access food prescriptions

Currently, Miller says food prescriptions are not widely available. However, there are ways individuals can gain access to them.

“Medicare Advantage is covering some fresh foods and medically-tailored meals,” Miller says.

States, including California, have waivers that allow individuals with specific conditions like type 2 diabetes to use dollars from Medicaid to purchase food for a specific amount of time.

Right now, an individual’s best bet is similar to most other, more common prescriptions.

“Key to Food Is Medicine programs is a physician’s prescription,” Elkind says. “People should discuss these programs with their physician to see whether they might be eligible. They may also want to check with their health insurance program to see whether food resources are available under their plan.”

Takeaway

A new study indicates that produce prescriptions could lead to higher intake of fruits and vegetables and lower risk factors linked with an increased chance of developing heart disease, including improvements in BMI and blood pressure in adults.

Researchers also indicated that adults and children who participated in produce prescriptions were less likely to report being food insecure.

Experts say that food prescriptions may help people get the nutrients they need, thereby leading to improved cardiovascular health outcomes. Moreover, the access to food for people struggling to make ends meet was also promising.

However, the study did not have a control group, and some experts caution that implementation and practicality of produce prescriptions pose a challenge.

Still, diet is a crucial part of overall health. People interested in food prescriptions should speak to a doctor and check with their insurance provider for availability.