Nutrition prescriptions
Nutrition prescriptions are one way for physicians and other health care providers to outline a healthy, balanced eating plan and provide healthy food for patients. Based on U.S. Dietary Guidelines for adults, children, and adolescents1, nutrition prescriptions establish achievable dietary goals for patients and their families. Health care providers check progress at each office visit and a nutrition specialist is consulted for dietary advice as needed. Nutrition prescription programs typically partner with local farmers markets or grocery stores (through produce prescription or fruit and vegetable prescription (FVRx) programs). Prescriptions for fruits, vegetables, and other healthy staples such as lean proteins and whole grains2, 3 are redeemed at participating markets through vouchers, are provided as preselected food boxes or bags, or are delivered directly to patients. Nutrition prescriptions typically support purchase of at least one serving of produce per day for each patient and their family members4. Some programs additionally provide nutrition education including handouts with health information, recipes, and storage information5, 6, 7.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased fruit & vegetable consumption
Increased food security
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Improved health-related knowledge
Improved dietary habits
Improved nutrition
Improved health outcomes
Reduced emissions
What does the research say about effectiveness?
There is some evidence that nutrition prescriptions that include access to fresh produce increase consumption of healthy foods including fruits and vegetables and reduce food insecurity2, 3, 5. Healthy eating and nutrition counseling, advice, and information given by physicians and other health care providers influences patient behavior8, 9. Nutrition prescriptions increase access to healthy foods when they provide vouchers for fresh fruits and vegetables, redeemable at local farmers markets or grocery stores, or pre-selected food for pick up or delivery2, 3, 5, 10. In general, subsidies and financial incentives for healthy foods have been shown to increase healthy food purchases11, 12, 13, 14, 15, 16, which enables increased healthy food consumption11, 15, 16. Additional evidence is needed to determine the long-term effects of enrollment in nutrition prescription programs17.
Nutrition prescriptions may improve health outcomes3, 18, 19, improve quality of life7, reduce stress6, improve mental and physical health20, and improve sleep, mood, and pain18. Pediatric nutrition prescription programs may increase fruit and vegetable consumption among children10, increase food security10, 21, and improve self-reported health outcomes among children and adults in the household21.
Nutrition prescriptions may increase fresh produce consumption and cooking from scratch, which may reduce emissions from fossil fuels used to produce, process, and transport food22, 23, 24. Nutrition prescriptions may also reduce the energy intensity of an individual’s diet if more plant-based foods are consumed in place of animal products22.
Nutrition prescription programs may focus on helping populations with diet-related diseases or with managing chronic diseases2. Nutrition prescriptions may generate community co-benefits, for example, nutrition prescriptions can increase demand for fresh produce, so community grocery stores may increase the amount of fresh produce available25. Family members of nutrition prescription recipients may experience dietary improvements when shared meals include more healthy foods25. Farmers markets, often locations for voucher redemption or food pick up, may offer additional opportunities to increase social connection and reduce isolation7.
Interviews with health care providers suggest that participation in nutrition prescription programs changes the way providers talk with patients about healthy eating26, improves patient health outcomes26, improves provider knowledge of the burden of food insecurity27, and increases provider desires to screen for food insecurity27. Several challenges for implementing these programs in a medical setting were identified by providers and patients, including limited time with patients, limited training, and the need for follow-up to encourage continued patient engagement26. Additional barriers to the implementation of nutrition prescription programs include limited transportation to clinics or farmers markets6, 28, 29, communication issues between retailers, providers, and patients5, potential for patients to feel stigmatized5, 30, and difficulty sustaining changes to lifestyle or diet after the program ends or when farmers markets seasonally close29.
Nutrition prescriptions and supports for access to healthy foods may be a cost-effective way to manage chronic diseases2, for example, among adults with diabetes31.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact nutrition prescriptions alone may have on disparities in healthy food consumption and health outcomes.
Some nutrition prescription programs have increased fruit and vegetable consumption43, reduced food insecurity43, and improved health outcomes among Black participants with low incomes44, 45. Programs targeting Latino/a adults have reduced food insecurity and improved health outcomes19. Participant interviews suggest that nutrition prescription programs in these communities may be more effective if they include trust building efforts46, culturally relevant education46, culturally relevant dietary choices46, 47, and bidirectional feedback46. One theoretical model of national implementation of nutrition prescriptions for adults with diabetes and low incomes suggests that targeted nutrition prescriptions may have the potential to reduce racial disparities in cardiovascular disease, since they could prevent more cases of cardiovascular disease among Hispanic and Non-Hispanic Black populations under 65 years old than among Non-Hispanic white populations31. Black and rural communities are also typically underserved by farmers markets, one of the more common redemption points for vouchers17.
Some nutrition prescription programs have targeted rural areas where poverty and food insecurity rates are higher than in urban areas7. At the beginning of the Partnerships to Improve Community Health (PICH) Produce Rx program in rural eastern North Carolina, 48.0% of participants reported that they did not have fresh fruits and vegetables available in their neighborhood48. Nutrition prescription programs that support farmers markets in rural areas can provide community opportunities to strengthen existing connections, build new ones, and prevent individuals from experiencing severe social isolation7. Local farmers markets also provide a space to celebrate community resources and change the narrative of scarcity in rural areas with limited access to grocery stores7.
What is the relevant historical background?
Throughout U.S. history, discriminatory housing, lending, and exclusionary zoning policies entrenched racial residential segregation and concentrated poverty49, 50. This systemic disinvestment and exclusion by both government and private entities created and maintains community environments with limited resources, deteriorating infrastructure, hazardous industries and waste disposal sites, and many other factors that lead to poorer health outcomes for people of color and people with low incomes51, 52, 53, 54. Communities shaped by discriminatory policies are often areas that have limited access to healthy and affordable food, formerly known as “food deserts”55, 56. Individuals who live in these communities face higher food costs, fewer store options, and must travel further to purchase healthy food than those who live in well-resourced communities55. Residents also have increased exposure to high calorie foods that have little nutritional value which often leads to worse health outcomes56.
Disparities in access to health care are associated with delays in disease diagnosis and treatment of health conditions, fewer preventive health visits, shortages of behavioral health clinicians, and larger Medicaid or uninsured populations in neighborhoods that are primarily Black and low income57. People with one or more chronic diseases are at greater risk for disability, death, poor functional status, unnecessary hospitalizations, and many other challenges58. Individuals from minoritized racial backgrounds59, from rural areas60, and those with low incomes are disproportionately more likely to have one or more chronic diseases61. Rural areas also lack adequate access to physicians; approximately 20% of the U.S. population resides in rural areas, but only 10% of physicians provide care there62.
Nutrition prescription programs have evolved as part of the growing Food is Medicine movement, an approach that centers access to nutritious food as an essential part of health and well-being63. Food is Medicine programs, including nutrition prescriptions, facilitate access to and support the production of healthy foods in a variety of settings across the country63. Food is Medicine programs are working to overcome existing structural barriers that have created communities where access to nutritious food is limited and improve the health of individuals who are disproportionately living in areas where access to healthcare is limited. In 2023, the U.S. Department of Health and Human Services began organizing a federal Food is Medicine strategy through the funding established by the 2023 Omnibus Appropriations Bill, with the goals of reducing food insecurity and nutrition-related chronic disease64.
Equity Considerations
- What populations are you aiming to enroll in your nutrition prescription program? Have you adequately invested time in this community to build a culture of trust and an open line of communication? Have you considered cultural norms when choosing the food or education you want to include in the program?
- What barriers exist that might impede a nutrition prescription program in your community? Are there adequate spaces (e.g. farmers markets, grocery stores) that will partner with you to provide access to fresh produce? Will transportation be an issue for your population? How could your program support local healthcare providers so healthy food boxes could be offered on-site or establish food delivery programs to make program participation easier?
- Are there local coalitions or partnerships that can champion expanded appointment times so health care providers can offer counseling and follow-up care with nutrition prescriptions? Which groups have the power to influence health insurance policies to pay for physician’s time and any additional costs associated with nutrition prescriptions?
Implementation Examples
The 5-2-1-0 childhood obesity prevention program is an example of a program that allows health care provider partners to give patients nutrition and physical activity prescriptions. Prescriptions encourage daily habits that include five servings of fruits and vegetables, two hours or less of screen time, one hour or more of physical activity, zero sugary drinks, and increased water consumption. Providers also administer healthy habits questionnaires and monitor patients’ BMI. The 5-2-1-0 program started in Maine32 and has expanded to cities and states all over the country, including Florida33; New Hampshire34; and Palo Alto, California35.
Through Gorge Grown Food Network’s Veggie Rx program participating health care providers prescribe $30 worth of vouchers for one month to families who screen positive for food insecurity to redeem at 30 local groceries, farms stands, or farmers markets36. Wholesome Wave’s produce prescription (Rx) programs allow doctors and other providers around the country to prescribe fruits and vegetables to prevent or manage diet-related illnesses37, with programs including Augusta Georgia Food for Health38, the FARM Rx program of Athens, GA39, and the Food4Moms program in Hartford, CT40. In New York, the Choosing Healthy & Active Lifestyles for Kids (CHALK) obesity prevention program connects patients facing food insecurity with healthy groceries and social services41.
The Navajo Fruit & Vegetable Prescription (FVRx) program enrolls Navajo families with pregnant parents or children under six to attend monthly health classes and receive prescriptions with whole food vouchers42. COPE (Community Outreach & Patient Empowerment), a Native-controlled non-profit organization, reports 53% of health facilities serving the Navajo Nation have implemented this FVRx program42.
Implementation Resources
‡ Resources with a focus on equity.
WW-Rx - Wholesome Wave (WW). What we do: Produce prescription (Rx) program, healthy choice initiatives, and SNAP doubling.
GGFN-Veggie Rx - Gorge Grown Food Network (GGFN). Veggie Rx Program.
MBC-Health care toolkit - Mary Bridge Children’s (MBC) Hospital-Clinics-Foundation. Family wellness toolkit: Ready, set, go! 5210.
ISU-Food and sustainability resources - Iowa State University (ISU), Sustainable Food Processing Alliance. Online resources for food and sustainability.
Footnotes
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1 US DHHS-DG - U.S. Department of Health and Human Services (U.S. DHHS). The dietary guidelines for Americans.
2 Haslam 2022 - Haslam, A., Gill, J., Taniguchi, T., Love, C., & Jernigan, V. B. (2022). The effect of food prescription programs on chronic disease management in primarily low-income populations: A systematic review and meta-analysis. Nutrition and Health, 28(3), 389–400.
3 Bhat 2021 - Bhat, S., Coyle, D. H., Trieu, K., Neal, B., Mozaffarian, D., Marklund, M., & Wu, J. H. Y. (2021). Healthy food prescription programs and their impact on dietary behavior and cardiometabolic risk factors: A systematic review and meta-analysis. Advances in Nutrition, 12(5), 1944–1956.
4 TFAH-Levi 2014 - Levi J, Segal L, St. Lauren R, Rayburn J. The state of obesity: Better policies for a healthier America 2014. Washington, D.C.: Trust for America's Health (TFAH); 2014.
5 Little 2022 - Little, M., Rosa, E., Heasley, C., Asif, A., Dodd, W., & Richter, A. (2022). Promoting Healthy Food Access and Nutrition in primary care: A systematic scoping review of food prescription programs. American Journal of Health Promotion, 36(3), 518–536.
6 Stroud 2023 - Stroud, B., Jacobs, M. M., Palakshappa, D., & Sastre, L. R. (2023). A rural delivery-based produce prescription intervention improves glycemic control and stress. Journal of Nutrition Education and Behavior, 55(11), 803–814.
7 Joseph 2023 - Joseph, C. A., & Seguin, M. L. (2023). “Something fun to look forward to”: Lessons from implementing the prescription for health farmers’ market initiative in rural Upper Michigan. Health Promotion Practice, 24(5), 903–910.
8 Bhattarai 2013 - Bhattarai, N., Prevost, A.T., Wright, A.J., Charlton, J., Rudisill, C., & Gulliford, M.C. (2013). Effectiveness of interventions to promote healthy diet in primary care: Systematic review and meta-analysis of randomised controlled trials. BMC Public Health, 13, 1203.
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10 Muleta 2024 - Muleta, H., Fischer, L. K., Chang, M., Kim, N., Leung, C. W., Obudulu, C., & Essel, K. (2024). Pediatric produce prescription initiatives in the U.S.: A scoping review. Pediatric Research, 95(5), 1193–1206.
11 Gittelsohn 2017 - Gittelsohn J, Trude ACB, Kim H. Pricing strategies to encourage availability, purchase, and consumption of healthy foods and beverages: A systematic review. Preventing Chronic Disease. 2017;14(E107):170213.
12 Grech 2015 - Grech A, Allman-Farinelli M. A systematic literature review of nutrition interventions in vending machines that encourage consumers to make healthier choices. Obesity Reviews. 2015;16(12):1030-1041.
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14 Kocken 2012 - Kocken PL, Eeuwijk J, Van Kesteren NMC, et al. Promoting the purchase of low-calorie foods from school vending machines: A cluster-randomized controlled study. Journal of School Health. 2012;82(3):115-122.
15 An 2013 - An, R. (2013). Effectiveness of subsidies in promoting healthy food purchases and consumption: A review of field experiments. Public Health Nutrition, 16(7), 1215-1228.
16 AHA-Mozaffarian 2012 - Mozaffarian, D., Afshin, A., Benowitz, N.L., Bittner, V., Daniels, S.R., Franch, H.A., Jacobs, D.R., Kraus, W.E., Kris-Etherton, P.M., Krummel, D.A., Popkin, B.M., Whitsel, L.P., & Zakai, N.A. (2012). Population approaches to improve diet, physical activity, and smoking habits: A scientific statement from the American Heart Association (AHA). Circulation, 126(12), 1514-1563.
17 Cafer 2023 - Cafer, A., Rosenthal, M., Smith, P., McGrew, D., Bhattacharya, K., Rong, Y., Salkar, M., Yang, J., Nguyen, J., & Arnold, A. (2023). Examining the context, logistics, and outcomes of food prescription programs: A scoping review. Research in Social and Administrative Pharmacy, 19(1), 57–68.
18 Kerr 2020 - Kerr, D., Barua, S., Glantz, N., Conneely, C., Kujan, M., Bevier, W., Larez, A., & Sabharwal, A. (2020). Farming for life: Impact of medical prescriptions for fresh vegetables on cardiometabolic health for adults with or at risk of type 2 diabetes in a predominantly Mexican American population. BMJ Nutrition, Prevention & Health, 3(2), 239–246.
19 York 2020 - York, B., Kujan, M., Conneely, C., Glantz, N., & Kerr, D. (2020). Farming for Life: Pilot assessment of the impact of medical prescriptions for vegetables on health and food security among Latino adults with type 2 diabetes. Nutrition and Health, 26(1), 9–12.
20 PCORE-Royal 2016 - Royal N, Brown K, Rodriguez F, Fernandez B, Valle L, Bello E. Harvesting health: A community-based participatory evaluation of the Veggie Rx program. Providence Center for Outcomes Research & Education (PCORE), The Next Door, Inc. 2016.
21 Hager 2023 - Hager, K., Du, M., Li, Z., Mozaffarian, D., Chui, K., Shi, P., Ling, B., Cash, S. B., Folta, S. C., & Zhang, F. F. (2023). Impact of produce prescriptions on diet, food security, and cardiometabolic health outcomes: A multisite evaluation of 9 produce prescription programs in the United States. Circulation: Cardiovascular Quality and Outcomes, 16(9).
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25 Virudachalam 2023 - Virudachalam, S., Kim, L. S.-H., & Seligman, H. (2023). Produce prescriptions and a path toward food equity for children. JAMA Pediatrics, 177(3), 225.
26 Stotz 2022 - Stotz, S. A., Budd Nugent, N., Ridberg, R., Byker Shanks, C., Her, K., Yaroch, A. L., & Seligman, H. (2022). Produce prescription projects: Challenges, solutions, and emerging best practices – perspectives from health care providers. Preventive Medicine Reports, 29, 101951.
27 Johnson 2023a - Johnson, S., Fischer, L., Gupta, S., Lazerov, J., Singletary, J., & Essel, K. (2023). “I felt like I had something I could do about it”: Pediatric clinician experiences with a food insecurity-focused produce prescription program. Clinical Pediatrics, 62(9), 1018–1026.
28 Thomson 2022 - Thomson, S., Ugwuegbu, J., Montez, K., Langdon, S., Best, S., Sostaita, D., Franklin, M., & Zimmer, R. (2022). Qualitative perceptions of an anticipated fresh food prescription program. Health Behavior and Policy Review, 9(1).
29 Newman 2022 - Newman, T., Lee, J. S., Thompson, J.J., & Rajbhandari-Thapa, J. (2022). Current landscape of produce prescription programs in the U.S. Journal of Nutrition Education and Behavior, 54(6), 575–581.
30 Johnson 2023 - Johnson, J. K., Vingilis, E., & Terry, A. L. (2023). Patients’ experiences with a community fruit and vegetable box program prescribed by their health provider. BMC Public Health, 23(1), 869.
31 Wang 2023 - Wang, L., Lauren, B. N., Hager, K., Zhang, F. F., Wong, J. B., Kim, D. D., & Mozaffarian, D. (2023). Health and economic impacts of implementing produce prescription programs for diabetes in the United States: A microsimulation study. Journal of the American Heart Association, 12(15), e029215.
32 MH-Let’s go - MaineHealth (MH). Let's go!
33 FL DOH-5210 - Florida Department of Health (FL DOH), FloridaHealth Lee County. The 5-2-1-0 plan for a healthier active lifestyle.
34 FHC-5210 - Foundation for Healthy Communities (FHC). 5-2-1-0 Healthy NH.
35 PAMF-5210 resources - Sutter Health Palo Alto Medical Foundation (PAMF). 5-2-1-0 Resources.
36 GGFN-Veggie Rx - Gorge Grown Food Network (GGFN). Veggie Rx Program.
37 WW-Rx - Wholesome Wave (WW). What we do: Produce prescription (Rx) program, healthy choice initiatives, and SNAP doubling.
38 Augusta-Rx - Augusta Georgia Food for Health Program. (n.d.). The Georgia Food for Health Program: Augusta’s vegetable prescription program. Retrieved October 21, 2024.
39 FARM-Rx - Athens Farmers Market. (n.d.). The FARM Rx Program. Retrieved October 21, 2024.
40 Food4Moms-Rx - Wholesome Wave. (n.d.). Empowering Latina moms: The Food4Moms Produce Prescription Program. Retrieved October 21, 2024.
41 NYP-CHALK - New York-Presbyterian Ambulatory Care Network. (n.d.). CHALK Choosing Healthy & Active Lifestyles for Kids. Retrieved October 21, 2024.
42 Navajo-FVRx - COPE (Community Outreach & Patient Empowerment). (n.d.). Food access: Navajo Fruit & Vegetable Prescription Program. Retrieved October 21, 2024.
43 Saxe-Custack 2021a - Saxe-Custack, A., LaChance, J., Jess, J., & Hanna-Attisha, M. (2021). Influence of a pediatric fruit and vegetable prescription program on child dietary patterns and food security. Nutrients, 13(8), 2619.
44 Cook 2021 - Cook, M., Ward, R., Newman, T., Berney, S., Slagel, N., Bussey-Jones, J., Schmidt, S., Sun Lee, J., & Webb-Girard, A. (2021). Food security and clinical outcomes of the 2017 Georgia fruit and vegetable prescription program. Journal of Nutrition Education and Behavior, 53(9), 770–778.
45 Cook 2023 - Cook, M. A., Taylor, K., Reasoner, T., Moore, S., Mooney, K., Tran, C., Barbo, C., Schmidt, S., Stein, A. D., & Webb Girard, A. (2023). Participation in the Georgia food for health programme and CVD risk factors: A longitudinal observational study. Public Health Nutrition, 26(11), 2470–2479.
46 Suh 2024 - Suh, C. K., Huliganga, A., Collymore, J., Desai, N., Mora, M., & Hatchett, L. (2024). Participants’ experiences with a community based participatory research produce prescription program: Findings from a qualitative study. American Journal of Health Promotion, 38(4), 522–527.
47 Jones 2020 - Jones, L. J., VanWassenhove-Paetzold, J., Thomas, K., Bancroft, C., Ziatyk, E. Q., Kim, L. S.-H., Shirley, A., Warren, A. C., Hamilton, L., George, C. V., Begay, M.-G., Wilmot, T., Tsosie, M., Ellis, E., Selig, S. M., Gall, G., & Shin, S. S. (2020). Impact of a fruit and vegetable prescription program on health outcomes and behaviors in young Navajo children. Current Developments in Nutrition, 4(8), nzaa109.
48 Lyonnais 2022 - Lyonnais, M. J., Rafferty, A. P., Spratt, S., & Jilcott Pitts, S. (2022). A produce prescription program in eastern North Carolina results in increased voucher redemption rates and increased fruit and vegetable intake among participants. Nutrients, 14(12), 2431.
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