Instead of pills, doctors prescribe fruits and vegetables through program that unites health care with local food systems.
Photographs by Josh Scott
At the Mercado farmers market in southwest Detroit, Cynthia Ketz zeroes in on a box brimming with collard greens, one of her favorite vegetables. She doesn’t find a bunch that she likes, so she moves on.
She picks up produce she’s familiar with — onions, a green pepper — but then pauses at the eggplants. As she picks one up, she asks the vendor, “What are these, honey?”
The vendor says they’re eggplants and shares how she likes to eat them: breaded and baked. She offers a few recipe suggestions such as baba ghanoush, the Middle Eastern dip. Ketz has never heard of it but decides she’ll try it. She throws in peaches and plums and a pint of blueberries, bringing her total to $9. She pulls out a debit card, part of her “prescription” (see table below). But instead of pills for her high blood pressure, her doctor at CHASS (Community Health and Social Services) Center, a health care facility that focuses on African-American and Hispanic populations in Southwest Detroit, has given her a referral to a program offered in partnership through CHASS, the site of the Mercado farmers market every Thursday, and the Ecology Center, a Michigan-based environmental organization.
Ketz tried taking pills for the high blood pressure, but “it made me sick to my stomach, just made me want to throw up. I called the doctor, ‘Can you give me something else?’”
Growing up in Wisconsin where her dad had a garden, she ate fresh fruits and vegetables on a regular basis. Now she’s come full circle, except this time she’s eating to improve her health.
Eat 2 and Call Me in the Morning
Diet-related diseases are increasingly becoming more of a public health concern in the U.S. The CDC says more than one-third (or 78.6 million) of U.S. adults are obese. The story is similar for youths. In 2012, more than one-third of children and adolescents were overweight or obese.
Obese youths are likely to be at risk for cardiovascular diseases such as high cholesterol or blood pressure. Long term, they are more at risk for adult health problems such as heart disease, type 2 diabetes, several types of cancers, and stroke.
The typical idea of treating diseases in this country consists of seeing a doctor, who then prescribes medication, says Dr. Richard Bryce, a senior staff physician in the Department of Family Medicine at Henry Ford Hospital who works full time at CHASS.
With Health Rx, he has the option of telling patients, “Here are meds. These are good meds but there’s a lot of side effects that go along with them, and if we can fix this problem with just nutrition and exercise you’ll feel better and you’ll be helping your health in general overall.”
The concept of leafy greens instead of Lipitor is gaining traction across the country as nutrition incentive programs have grown. For example, the 2014 Farm Bill rolled out the Food Insecurity Nutrition Incentive Program, which provides $100 million in grants over the next five years.
Connecticut-based nonprofit Wholesome Wave, founded by a James Beard award-winning chef in 2007, created the Fruit and Vegetable Prescription Program that reached more than 5,000 low-income families between 2010 and 2014.
At CHASS, Bryce says the top three preventable, diet-related conditions for which he refers patients to the program include high blood pressure, high cholesterol, and diabetes.
“Just making a few diet changes makes a huge difference,” Bryce says. He has seen patients make improvements in dealing with chronic diseases thanks to nutrition and emphasizing healthy habits. The program might not completely eliminate insulin for a diabetes patient or medication for someone with high blood pressure but what it does is build confidence. They see positive results in their lab tests such as lower cholesterol levels so they keep the ball rolling, he says.
“That kind of keeps them motivated to keep exploring more natural ways to improve health,” he says.
An Environmental Approach
Health Rx, a partnership between the Ecology Center and CHASS, aims to increase consumption of fruits and vegetables as a way to manage chronic diseases. CHASS, which piloted the program last year, had 45 participants in 2013. This year, they have the capacity to reach 140 people who receive a total of $40, distributed through debit cards, to be used in $10 increments at the farmers market held every Thursday at CHASS.
This year, the program has been expanded to two other sites: American Indian Health and Family Services, which will be using a fresh produce box model, similar to shares offered through community supported agriculture programs; and the Joy-Southfield Community Development Corporation, which is using the same model as CHASS at the Sowing Seeds Growing Futures Farmers Market in partnership with Henry Ford Health System. The produce box model will help address the issue of farmers markets being open for only a few months of the year, says Nicki Milgrom, Healthy Food in Health Care Organizer at the Ecology Center.
Health Rx is modeled after Washtenaw County Public Health’s Prescriptions for Health Program, which began in 2008 as a pilot project. It has continued with funding from the Kresge Foundation.
The program is based on the idea of forming a three-way relationship between a local health department, health clinics serving low-income residents, and farmers markets, says Sharon Sheldon, Washtenaw County Health Promotion/Disease Prevention program administrator.
Sheldon says there was a relationship between areas in the county with the lowest rate of consumption of vegetables and fruits and the highest chronic disease rate. They saw an idea emerging in areas like California where farmers markets and health care systems were partnering up, prompting the county to take that environmental approach to disease prevention.
With Prescriptions for Health, Sheldon says the program aims to help people over time access more fruits and vegetables that are affordable and teach them how to prepare them.
In 2013, consumption of fruits and vegetables increased by one full cup per day post-program compared to their habits before starting the program, and 89 percent reported being able to manage a health condition better, according to a telephone survey of Prescriptions for Health participants.
In its first year, Health Rx received positive feedback from participants, including 94 percent reporting eating more fruits and vegetables, with 75 percent of their family members eating more produce. Participants also reported a 19 percent decrease in consumption of unhealthy foods during the week, and 94 percent said they were able to manage their conditions better after participating in the program.
One of these patients is Bernie Juozapaitis, who lives in Southwest Detroit and is a self-described “meat and potatoes man.” One day last year, he was experiencing “all kinds of pain,” including in his shoulder due to his days working as a machinist.
Since he didn’t have any insurance, he came to CHASS, and found out he was at the “height of everything: diabetes, cholesterol — I had more medical problems than I thought.”
He was referred to the Health Rx program and has lost 57 pounds since coming to the center, using the health advice from the CHASS staff. He’s also started exercising.
“You wouldn’t be talking to me right now if it weren’t for that one visit,” he says. These days, he uses less insulin for his diabetes, and has tried many vegetables he never had before, including squash, tomatillos, and cabbage, which he didn’t know “was coleslaw. Now I make my own coleslaw.”
Eating ‘Nature’s Candy’
It’s one thing to say eat more fruits and vegetables, and it’s another to actually apply that when faced with tables of unfamiliar produce.
The Health Rx program also entails nutrition education and cooking tips. During a recent market day at CHASS, chef Michael Schram and registered dietitian Tricia Bischoff from Henry Ford Health System’s Generation With Promise program led a cooking demo to help new Health Rx patients cook their new prescriptions.
Schram prepares corn salsa, using what’s in season. He goes over the proper care of corn. He tells the small group gathered at his table to look at the corn in the husk as he peels it away. “Look for ears that have kernels all the way to the top. If it’s not all the way to the top, it’s underripe.”
As he chops and dices, Bischoff explains corn can be either a grain (dried) or a vegetable (fresh).
Schram then tells the group that corn is “nature’s candy,” as it’s very sweet when raw and fresh. To control fat, he puts a teaspoon of oil in a bag to coat the ears.
The two go over how to save the scraps for vegetable stock as well as unsaturated versus saturated fat.
Bischoff remarks how colorful the meal is and goes over the different benefits of each color: dark green is best; white is high in potassium and is good for heart health; yellow, orange, and red-colored produce are beneficial for outside the body such as hair, skin, and vision; and purple is good for the brain.
And all helps reduce risk of cancer, she says.
At the nutrition education table, registered dietitian Tamara Landazuri meets with market shoppers and Health Rx participants to answer their questions. Every week she goes over a different theme and health topic. This week it’s fats so her table is full of processed foods found in Southwest Detroit: Gansito, Takis, and Barritas Pinas. These favorite treats are loaded with trans fats.
“We can prevent chronic diseases and manage diseases by eating more fruits and vegetables than processed foods,” she says.
People come back and tell her how they’ve changed their shopping habits, opting for whole grains than enriched or buying less processed foods.
A New Health Care System
Health Rx bridges the health care and food systems, leveraging the expertise of both, says Milgrom of the Ecology Center.
What the health care systems are purchasing drives demand so they are able to shift the system with their buying power, she says.
Sheldon in Washtenaw County says the benefit of having clinic partners involved is that they sustain relationships with patients year-round so they can keep coaching them during the winter months when the farmers market isn’t open.
It’s also about helping participants make the connection between what they’re eating and how they’re feeling because “not everything is solved by a pill. We give them the tools and experiences to get them there,” says Denise Pike, development coordinator at CHASS.
These programs are grant-funded but organizers are looking for more sustainable funding models. For now, insurance is not part of the picture — yet.
“That’s one of the things we hope to be able to start having more conversations [about] with hospitals in the area. Programs like this are very much a part of the language in the new Affordable Care Act … it really talks about importance of clinics taking an active role in trying to help their patients manage chronic diseases and looking for better outcomes when they come to follow-up visits,” Sheldon says.
The long-term vision for Health Rx is “to have health care sites where any doctor can write a prescription and anyone can fill the prescription at any market,” says Milgrom.
“It’s about changing the traditional medical system.”