Education Columns

By Elena Rosenbaum, MD and Angela Antonikowski, PhD, MA

Introduction
Treatment and prevention of obesity have centered on healthy lifestyle counseling, and this approach has been the focus of teaching for our medical students and family medicine residents. Research shows that environmental, financial, and social factors contribute to dietary habits^1,2,3; cost is often cited by families as a major barrier to healthy eating.¹ According to the American Academy of Family Physicians member survey, 85% of physicians state they believe unmet social needs are directly related to worse health, but 80% are not confident in their ability to address these needs.⁴ Our residency and medical school training practice is working to shift perspectives and address social factors that impact chronic health issues. We hypothesized that reducing the financial barriers to healthy eating by providing produce coupons redeemable in a local mobile market will increase consumption of vegetables and fruits.              

Methods

A pilot study was performed at Albany Family Medicine, the site of a residency and medical school training program. Eighteen families with 6month-old infants were recruited and randomized to intervention and control groups. Participants in the intervention group received 3 months of weekly $21 coupons to the local mobile produce market at four well-child checkups over the span of 9 months. Both groups filled out surveys assessing infant and family intake of fresh vegetable consumption at their 6, 9, 12, and 15-month well-child visits, and received routine nutritional counseling and well-child anticipatory guidance at each visit. Medical students and residents involved in the study were asked to read educational material that included information on infant solid food introduction, food safety, and baby food preparation.  

Results

The study had a high dropout rate (39% of all participants) and low well-child visit attendance rate (33% of participants attended all well-child visits and 22% completed surveys during the study period). Coupon redemption rate was low (60% of participants attempted redemption on at leastone occasion and 20% of participants redeemed more than 8% of the coupons provided). Reasons cited for low redemption included families moved to zip codes that were inaccessible to the mobile food market and one family moved into a shelter where a kitchen was unavailable. Families stated that the mobile food market schedule or location were not convenient, that they forgot to go, or did not have enough time or knowledge for food preparation.

Conclusions

Despite addressing financial constraints on healthy eating, some families were not able to use the coupons. Time constraints, transportation, and other stressors related to caring for infants were barriers to picking up the free vegetables and fruits. Targeting food access in isolation of other social factors was not successful in our practice, although the number of participants and length of the study were both limited. These results may differ in other patient populations or where more supportive services are available, as demonstrated in a community health center study of adult patients with diabetes.⁵

Further medical student, resident, and practicing physician education on social determinants of health is important because many have not been trained to incorporate plans to mitigate these disparities into their clinical practice.⁴ As we attempt to introduce routine clinical screening for social determinants of health, we should also consider the role of physicians within the existing infrastructure of community and public health resources. Most importantly, we need to teach our students and residents about community participatory interventions and research. If we truly want to reduce health disparities, we must incorporate participants’ points of view when planning and implementing interventions.⁶

References

1. Taylor JP, Evers S, McKenna M. Determinants of healthy eating in children and youth. Can J Public Health. 2005: 96: S20-6, S22-9.
2. Sallis JF, Glanz K. The role of built environments in physical activity, eating, and obesity in childhood. Future Child. 2006;16(1):89-108. https://doi.org/10.1353/foc.2006.0009
3. Pearson N, Biddle SJ, Gorely T. Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review. Public Health Nutr. 2009;12(2):267-283. https://doi.org/10.1017/S1368980008002589
4. American Academy of Family Physicians. Social Determinants of Health (SDoH): Family Physicians’ Role. https://www.aafp.org/dam/AAFP/documents/patient_care/everyone_project/sdoh-survey-results.pdf. Accessed May 8, 2019.
5. Cavanagh M, Jurkowski J, Bozlak C, Hastings J, Klein A. Veggie Rx: an outcome evaluation of a healthy food incentive programme. Public Health Nutr. 2017;20(14):2636-2641. https://doi.org/10.1017/S1368980016002081
6. Macaulay AC. Promoting participatory research by family physicians. Ann Fam Med. 2007;5(6):557-560. https://doi.org/10.1370/afm.755