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Our Community's Health: Prescribing Produce

L to R Susan Ringler Cerniglia and Allison Mankowski
L to R Susan Ringler Cerniglia and Allison Mankowski - Doug Coombe
Bad habits are hard to break; good habits harder to establish. For years, social marketers have attempted to overcome the "extraordinary science of junk food addiction," without "extraordinary" funds, as referenced in a recent New York Times article.
 
"Just say 'no'," doesn't cut it. But public health professionals in Washtenaw County have found a way to get people to say "yes" to fruits and vegetables when they otherwise might resort to something deep fried or otherwise full of empty calories. It takes a little incentive, sustained over time, but good habits can be learned.
 
This got the attention of the Public Health Foundation, which awarded its 2012 Future of Public Health Award last year to Washtenaw County Public Health Department' s "Prescription for Health" program. 
 
Surrounded by fatty, salty process foods, poor nutritional knowledge, and lack of energy or mobility to choose healthy options, low income people are mired in a culture of obesity and chronic disease. People are told that they're overweight, that they need to improve their diet, and then they leave the clinic and face an abundant source of junk food and little fresh food. 
 
"We have a health system that doesn't necessarily give advice based on the reality of everything that influences an individual's health and we have an environment that offers us a lot of cheap unhealthy choices," says Susan Ringler Cerniglia, lead evaluator of the Prescription for Health program. "Depending on our individual resources, we might not have the ability to make other choices." 
 
But when health providers at community health centers "prescribe" fresh fruits and vegetables, with a voucher redeemable in cash at a farm market, people choose the road to gastronomical health.
 
The farmers market in downtown Ypsilanti could be a world away from patients at the Hope Clinic, one of four clinics participating in the Food Prescription program. Health providers serving low income, chronically ill people, "prescribe" weekly shopping trips to three farmer's markets in the county, with a voucher redeemable in cash. At the market they receive healthy recipes and nutritional counseling. After awhile, produce consuming becomes natural. 870 patients participated in the two-year program, underwritten by the Kresge Foundation.
 
Clients need to express a commitment to change their diet, notes Allison Mankowski, a registered dietitian working in the Prescription for Health program.  Evaluation criteria measured "whether patients were experiencing readiness to change their eating habits; something they were thinking about or active doing that could make them a good fit for the program. Even more practical than that, some of our clinic would find during the first year, part-way through the season, that some of the folks enrolled in the program weren't actually going."
 
Program staff learned that transportation, or work schedules, were major barriers to getting to the market when it was open. Packard Health, another participating health center, developed a pilot project with Food Gatherers that provided people with transportation problems a box of produce. 
 
"In the second year we tried to emphasize with our clinics to make sure they were digging a little deeper in that actual consultation to see if going to the farmer's market was realistic for this particular patient," Mankowski says. "You didn't want to exclude people who are willing but you have to be practical in the sense that if you work on Tuesday afternoons then this particular market isn’t going to be a good fit for you."
 
"What we were trying to do is change the dialogue and the emphasis in the health care visit and look at the broader situation that the patient is dealing with, particularly we focused on low income clinics serving folks that might be dealing with chronic illness, lack of resources, and for all those reasons they're struggling to maintain a healthy diet and manage chronic illness," Ringler Cerniglia says. "By working directly with the health clinic we wanted some of that advice to come from them. We wanted to support that advice in the medical setting. We also wanted to make it realistic for folks, offering them the resources to spend at what is already a viable source of produce - local farmer's markets."
 
Originally, many people came to the farm market not because they were making a "grand lifestyle change," but because they needed food and the voucher paid for food they wouldn't have gotten otherwise. But once they learned about the many different types greens, and the multiple colors of fruits, they added them to their diet - many as much as a cup per day, Mankowski says. 
 
In fact, half of the patients continued going to the market after the vouchers ran out. 
 
"For them that really was a lifestyle change," she says. "They realized that they benefited from getting these fruits and vegetables and after they stopped having the financial incentive of going, they continued to go." 
 
Going to a farmer's market was a new experience for many. "They might have known about it but never considered it as a routine food source, Ringler Cerniglia says. "A lot of folks were pleasantly surprised to see what was available there; that there were fresh foods, foods that they hadn't tried, and by having the coupons and tokens to try it out took away the risk for them, in terms of having to spend food dollars on something they might like. It helped folks try something different, in terms of their behavior that could fit into their lives with extra resources and extra support."
 
The challenge, Ringler Cerniglia says, is funding the program so it allows for four-season access.While Prescription for Health was designed to promote public health, there also is an economic benefit for the farmer's markets. Program participants spent $26,246 at the markets. It also reinforced the sense that the grower and the consumer were from the same community.  
 
"One of the things I found surprising in our first year when we asked people more open-ended in our evaluation what they appreciated or what they really got from going to the market, we had a lot of comments from patients how much they appreciated that the produce was local," Ringler Cerniglia says. "They were getting it from the grower; they got to talk to the grower, the farmer, right there, and that the quality was good. That had value to them. We sometimes think of the farmer's market as more of suburban, higher income type of thing."
 
While many patients altered their diet to include fresh produce every day, and some even dug their own backyard garden, most continue to struggle with the temptation of the convenience stores and the long winter between growing seasons. The challenge, Ringler Cerniglia says, is funding the program so it allows for four-season access. 
 
Sometimes, as with kitchen chemistry, change can be measured by the cup. "We definitely saw that if someone visited the market at least three times or more, that was where we saw change in consumption... a measurable difference," Ringler Cerniglia says. 
 
When offered a choice, and the financial incentive to take a risk on it, motivated people do the right thing. But it's only as sustainable as the grant funding. Until the health system accepts nutritional behavioral change as essential as pharmacology, public health innovators will be going up against the "extraordinary" force of the junk food economy.

Dennis Archambault lives in Detroit and writes for Concentrate, Metromode and Model D. His previous story was Five Really Cool Technologies Being Developed Here.

All photos by Doug Coombe

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