Abstract
BACKGROUND: Food insecurity, poor nutrition, and diet-related diseases create major intersecting health challenges. The Veterans Health Administration (VHA) has identified food insecurity as a high-priority problem and established regular clinical screening. Veterans with identified food insecurity and diet-sensitive cardiometabolic health conditions will benefit from the successful implementation of effective Food is Medicine interventions. METHODS: This pragmatic, quasi-experimental intervention study of effectiveness and implementation of a produce-prescription program is conducted in 2 VA hospital health systems in Salt Lake City, Utah, and Houston, Texas. Eligible Veterans have (a) a diet-sensitive cardiometabolic health condition (obesity, hypertension, and/or diabetes) identified in the electronic health record (EHR) by diagnostic codes (ICD-10) and/or lab values and (b) low-income identified by priority status in administrative data. Program enrollment is pragmatically integrated within the VA clinical care process of food security screening and service referrals. Eligible Veterans who screen positive for food insecurity during clinical care processes are referred to the intervention. The Veterans Affairs FreshConnect Produce Prescription (VA FCPRx) intervention program includes 12 months of a produce prescription allowance for purchasing fresh fruits or vegetables, provided as $100 monthly on a pre-paid card for use at local grocery stores. The program also includes culinary education through cooking courses provided by VA nutritionists or nutritional consults provided one-on-one by a VA dietitian. Process and outcome measures will be evaluated using the PRISM RE-AIM framework. Health outcomes related to diet-sensitive chronic conditions (e.g., HbA1c levels for patients with diabetes) and healthcare costs (e.g., outpatient costs) are assessed using EHR data. VA FCPRx participant outcomes are assessed in comparison to a group of similar Veterans using intention-to-treat analyses. Patient-reported outcomes, implementation strategies and outcomes, and staff and Veteran experience are assessed with a combination of surveys, focus groups, and program administrative data. DISCUSSION: This pragmatic quasi-experimental intervention study will provide important new evidence about the impact of a produce prescription program for U.S. Veterans on health outcomes, healthcare costs, and patient-reported outcomes. The assessment of effectiveness and implementation processes and outcomes will inform the design and scaling of impactful, pragmatic, cost-effective programs for food insecure Veterans with diet-sensitive cardiometabolic conditions.