Miranda Cook, MPH, Laney Graduate School, Emory University Food as medicine? How $1 per day can increase food security and improve health Miranda Cook, MPH, Laney Graduate School, Emory University

introduction Diet behavior change is made more challenging by economic barriers for individuals in low-income food insecure communities Especially true for those who experience diet-related chronic disease Food insecurity is associated with chronic disease, especially among women Food security associated w/ disease based on NHANES data: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806885/

Food Insecurity in Georgia 1.7 million Georgian’s received SNAP benefits every month 1 in 7 Georgians are food insecure Stats from 2016 1 in 5 Georgian children are food insecure

FVRx Program Overview Participants receive FVRx prescriptions* 2. Participants receive FVRx prescriptions* 3. Participants redeem prescriptions for fresh fruits and vegetables at local farmers markets 1. Participants attend FVRx clinic visits, cooking and nutrition education classes 4. Participants prepare and eat healthy meals with family and schedule their next FVRx visit Description of WW National model and how it has evolved FVRx program objectives: Decrease food insecurity Improve clinical and behavioral health outcomes Increase exposure to and demand for healthy, Georgia-grown food Eligibility criteria: Food insecurity At least 1 chronic disease risk factor Photo & visual courtesy of: Wholesome Wave Georgia *FVRx prescription is equal to $1/day for each participant and household member; e.g., a family of 4 would receive $28 per week

Sites of intervention Morehouse Healthcare (East Point, Georgia) N = 14 Good Samaritan Health Center (Atlanta, Georgia) N = 50 Athens Nurses Clinic in Athens, Georgia N = 23 6 primary care clinics serving low-income communities in Atlanta, Athens, & Augusta, Georgia Partnership development: Partnerships with healthcare sites were developed through local connections- usually a farmers market tied to another WWG program (GF4L) which then connected to their local clinic. From there a leadership committee was formed with community members and representatives from the market, health care site, nutrition education provider, etc to develop the program. The main exception to this was Grady where WWG connected to staff through a board member (Jada Bussey Jones) and took a more active role in developing the program. The FVRx coordinator for Grady was housed under WWG (Sajani) but the Grady sites have since taken more ownership of their individual program. Grady Ponce De Leon Center (Atlanta, Georgia) N = 29 Grady Primary Care Clinic (Atlanta, Georgia) N = 25 Harrisburg Family Health Care Clinic in Augusta, Georgia N = 43 Photos: Google Maps Street View images

Evaluation - Survey tools Pre- & Post-surveys Participants completed surveys at baseline and at the end of the 6-month program Monthly-collected measures Clinical measurements & monthly surveys collected at monthly program visits Surveys were completed in paper format Data from surveys and monthly clinic visits double-entered into Qualtrics by staff at each site

Evaluation – Data collected Information Collected in Pre-/Post-Surveys: Demographic characteristics Food security Nutrition and cooking knowledge and confidence Difficulties involved in purchasing & consuming produce Frequency of fruit & vegetable consumption Information Collected Monthly at all sites: Fruit & vegetable consumption Weight Blood pressure Waist circumference (all except Augusta) Some sites collected additional monthly measures: Grady IDP site: A1c Triglycerides HDL LDL Total cholesterol Augusta: Heart rate Blood glucose Information collected over the course of the 6-month program

Results 219 households enrolled in the program 76% reported household income <$25,000 54% reported receiving public assistance 78% were of non-Hispanic black race 118 participants successfully graduated the program (~54% retention rate) $47,376 food subsidies redeemed *Graduation involved completing at least 50% of the visits (3 out of 6 total monthly visits)

Results - Food security OVERALL At baseline: Post-intervention: 21% often couldn’t afford a balance meal 8% often couldn’t afford a balance meal 37% often cut the size of meals or skipped meals due to financial constraints 20% often cut the size of meals or skipped meals due to financial constraints 32% were often hungry because there wasn’t enough food 5% were often hungry because there wasn’t enough food * Only includes individuals with data available at both time points

Results: Difficulties Decreased and & Knowledge improved Categories of knowledge BL mean score (N) Post-Intervention Mean Score (N) % Difference Mean Change (95% CI) T-test P-Value Types of fruits and vegetables grown locally 1.3 (76) 2.0 (75) 53.8 0.8 (0.5, 1.0) <.0001 How to prepare fresh fruits & vegetables 2.1 (76) 2.6 (76) 23.8 0.6 (0.4, 0.8) Where to buy produce 1.8 (60) 2.4 (75) 33.3 0.6 (0.3, 0.9) Importance of fruits & vegetables in family’s diet 2.2 (76) 2.8 (75) 27.3 0.5 (0.3, 0.7)

Results – Diet and Clinical Outcomes Number of daily fruit servings increased by 0.77-0.82 servings per visit Number of daily vegetable servings increased significantly by 0.85-0.88 servings per visit Diastolic blood pressure reduced significantly by 0.76-0.75 mmHg per visit *There were no significant findings for BMI, cholesterol, waist circumference, or hemoglobin A1c outcomes

Questions & Contact Information Miranda Cook, MPH PhD student, Nutrition & Health Sciences, Laney Graduate School, Emory University macook2@emory.edu Amy Webb-Girard, PhD Assistant Professor, Rollins School of Public Health, Emory University awebb3@emory.edu Denise Blake Executive Director, Wholesome Wave Georgia denise@wholesomewavegeorgia.org