About every other patient who walks up to Abid Nadeem’s counter at Dyckman Pharmacy in the Inwood section of Manhattan is picking up prescription medication to treat high blood pressure — losartan, telmisartan, beta blockers like metoprotolol, bepridil and other calcium channel blockers. But Nadeem’s favorite prescription to hand out to these patients is the one they can use to get $30 worth of fresh fruits and vegetables at the nearby Inwood Greenmarket, for free.
In May, Nadeem, the supervising pharmacist at Dyckman, was selected to join New York City’s Pharmacy to Farm program, which provides extra money each month for fresh produce to people who receive Supplemental Nutrition Assistance Program (SNAP) benefits and are on medication for hypertension. One in five New Yorkers is on SNAP; one in four has high blood pressure. Eating a diet high in fruits and vegetables can lower blood pressure and reduce a person’s risk of heart disease and stroke.
Nadeem was so enthusiastic about introducing the program to the residents of the neighborhood he’s served for 25 years that he spent his own money to design, print and mail 4,000 promotional flyers. Just a few days after dropping off the last batch at the post office, he was already seeing new faces coming in to sign up.
“I’m excited to join and tell my patients how important this program is,” Nadeem told HuffPost. “They are understanding what it all means, how the city is spending money on them, for their health. They are eager to get vouchers.”
He’s already enrolled 80 patients and is expecting many more now that all the flyers have gone out.
Pharmacy to Farm started as a New York City Health Department pilot program in the spring of 2017, funded by the USDA’s Farm Bill. When patients pick up their blood pressure medication at participating pharmacies, they’re handed a “prescription” for $30 in coupons, redeemable for fruits and vegetables at any of the city’s 142 farmers markets.
What started out as a very small pilot in just a few pharmacies has been so popular with patients, pharmacists and farmers markets that it’s rapidly expanded, first to 10 pharmacies, then to 16, many in low-income neighborhoods in Manhattan, Brooklyn and Queens, explained Jeni Clapp, director of nutrition policy and programs at the NYC Health Department.
“There has been a lot of interest in the clinical environment to figure out how doctors can connect their patients to healthier food,” Clapp said. Doctors and registered dietitians often recommend eating better to treat or reverse health conditions such as hypertension and diabetes, but then have no good way to help patients change their diets. “For people who have fewer resources, a lot of clinicians were interested in actually connecting patients to those resources.”
Food inequity researchers have found time and again that healthy foods, such as fruits, vegetables, whole grains and lean protein, are more expensive and harder to find for low-income families, who often end up relying on cheaper, more convenient, more calorically dense and less healthful options. Research also shows that when you make healthy food cheaper, people buy more of it.
In most states, SNAP recipients already get some financial incentives, such as coupons or rebates, to buy healthy food. In New York City, these incentives take the form of Health Bucks, which can be used to buy fresh produce at farmers markets across the city. For every $5 in SNAP benefits recipients spend at the market, they get a $2 Health Bucks coupon. Studies have shown that these incentives increase fruit and vegetable consumption, said Alyssa Moran, assistant professor of health policy and management at Johns Hopkins University. Fruit and vegetable prescription programs are emerging as a way to expand incentives and get more people using them to improve their health.
Often people are forced to make tradeoffs that no one should have to make between paying for your medication or paying for food for your family.
Alyssa Moran, assistant professor of health policy and management at Johns Hopkins University
By signing up for the Pharmacy to Farm program (and picking up their prescription medications), low-income adults with high blood pressure get extra Health Bucks for foods that can help them manage their condition. Since launching in May 2017, Pharmacy to Farm has distributed over $80,000 in Health Bucks to more than 850 participants. It’s a way for the city to simultaneously address two pressing public health issues: low food access and chronic high blood pressure.
“The food we eat really can change our health. That’s what makes it so unjust that people’s access to healthy food is influenced by their income,” New York City health commissioner Oxiris Barbot said in a statement. “We’re making it easier for New Yorkers who need it most to afford more fresh produce. This is good for New Yorkers’ wallets and good for their health.”
Research shows that people who are dealing with chronic diseases are especially vulnerable to food insecurity. Moran, who is not involved in Pharmacy to Farm, described the relationship as a vicious cycle: “If you’re already low-income and food insecure and struggling to make ends meet, and you’re now diagnosed with a chronic disease, you now likely have increased expenses, because you’re paying for transportation to appointments, you may have higher out-of-pocket medical expenses, you need to pay the cost of medication. Often people are forced to make tradeoffs that no one should have to make between paying for your medication or paying for food for your family.”
She added, “What’s really cool about this program is that it’s actually incentivizing you to be able to do both. You go to pick up your medication and you’re receiving money that can be spent on healthy food that can be used to help you better manage your chronic disease.”
Moran estimates that dozens of fruit and vegetable prescription schemes have been tried in different states, including the pioneering Wholesome Rx program, Geisinger Health’s Fresh Food Farmacy in Pennsylvania, and the Preventive Food Pantry at Boston Medical Center. But this is the first being administered at pharmacies, rather than in hospitals and doctors’ offices.
“Clinicians actually don’t have a ton of time with patients. So having a program like that be sustained and be something that can be scaled can be challenging,” said Clapp. Plus it’s hard to get a doctor’s appointment and easy to walk into your local drug store.
After talking to New Yorkers in low-income neighborhoods, Clapp and her team learned that people really trusted and relied on their pharmacists. And the pharmacists were eager to find new ways to help their patients afford and implement lifestyle changes, such as eating better and being more active. “They saw this program as a way to remove a barrier for their patients to be able to access healthier foods.”
Nadeem knows the families in the neighborhood well. He loves when he sees customers he knew as children, now grown up and married, coming into Dyckman Pharmacy with kids of their own. Along with medication, he dispenses guidance and advice. But there’s only so much he can do on his own.
“I can tell them, ‘Eat healthy,’ but how are they going to buy healthy food? Everything is so expensive and they don’t have enough [money] to buy [it]. It’s very difficult to tell them to change their diets,” he said. “With this program, they don’t have to spend a single penny. They are coming to the pharmacy, we are giving them the voucher … they are getting the medicine and they’re getting fruits and vegetables, which otherwise they don’t buy.”
He says patients tell him they love the program and that they are buying — and eating — more fresh produce. He’s also happy that the lure of the voucher is getting people who were lagging behind on refills to come in regularly for their medications.
Beryl Benbow, 67, picks up her atenolol, a beta blocker, once a month from Whitman Pharmacy in Fort Greene, Brooklyn — and always puts her $30 in Health Bucks to use at the farmers market on the corner of Washington and DeKalb. A community chef and self-described flexitarian, Benbow has always eaten a lot of vegetables, but since joining near the start of the Pharmacy to Farm program, she’s eating even more.
“It was like a true payday because I was really able to take advantage of being able to buy more at the greenmarket. I feel I eat fresher and more vegetables definitely,” she said. “It tastes 100% better and lasts for the most part much longer than the vegetables I’ve bought in the supermarket.”
Whereas before she was limited by her budget in what she could buy, now she’s able to spend money on fresh herbs and try vegetables she’s never had, such as Jerusalem artichokes and kohlrabi. Cheng Lin, the supervising pharmacist and owner of Whitman Pharmacy, said other participants also report being exposed to new foods. The Health Department offers nutritional education and cooking demonstrations focused on budget-friendly recipes at 15 markets in the city to teach people how to pick and prepare foods that might not be familiar to them.
I can tell patients, ‘Eat healthy,’ but how are they going to buy healthy food? Everything is so expensive.
Abid Nadeem, supervising pharmacist at Dyckman Pharmacy
It’s too early to know if Pharmacy to Farm is increasing consumption of fresh produce for all participants or having a measurable effect on their health. (Nor is there a clear threshold for exactly how much fruit and veg a person needs to eat to lower high blood pressure.)
Anecdotally, people working the SNAP booths at the markets say they’re seeing new faces picking up Health Bucks with Pharmacy to Farm prescriptions. At markets where the health department runs healthy cooking workshops and hands out recipes, featured products are selling out.
Participants are required to fill out a short multiple-choice survey when they pick up their prescription, reporting, for instance, how often they ate fruit in the past month. Clapp is aiming to publish that data in the next year or two, and use the results to expand the program further.
She’s also looking into adding supermarkets, which can be complicated because different stores have different protocols for processing rebates. It would be easier if the vouchers could be loaded onto the SNAP debit cards, Moran suggested.
“The more you can meet people where they are, the better,” she said. “If people are already spending most of their food dollars in supermarkets, if this type of program can be implemented in supermarkets, I think we’d see greater utilization and greater effects. But working in farmers markets is a great first step.”
It’s also, Clapp stressed, a great way to support local farmers. And since Health Bucks increases the food budgets of people in areas of low access to healthy food, it draws more vendors to low-income neighborhoods.
Moran would love to see fruit and vegetable prescription programs be funded by health providers and insurers, which would benefit if those programs can be shown to lower total health care costs. “We know that food insecurity for patients with chronic diseases increases health care utilizations and cost of care,” she said. “I think there’s really huge potential for these types of preventive programs to lead to better health outcomes for patients and better financial outcomes for the health care system.”
“Any way we can make these types of programs financially appealing for other types of payers, I think they’re more likely to be sustained and more likely to reach a larger number of people,” Moran said.
For now, Nadeem put it simply: “I hope the city doesn’t stop this.”
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