Abstract
Background
Food insecurity and other unmet social needs can contribute to adverse outcomes for mothers and newborns. Food is Medicine (FIM) approaches are promising for improving nutrition and preventing chronic disease but have not been explored fully among rural-dwelling pregnant people. Our objectives were to (1) assess the potential of FIM programs to improve perinatal dietary quality; (2) assess patient satisfaction and self-reported health status with various FIM options; and (3) identify barriers to healthy eating among rural perinatal patients experiencing food insecurity.
Methods
Pregnant patients identified via a validated screener as experiencing food insecurity were referred to a community health worker (CHW), offered nutrition education, and connected to one or more FIM supports. A range of FIM programs developed through clinic-community partnerships provided tailored support to meet individual patient needs. We surveyed patients who received FIM support(s) from Dec 2023 - March 2024 regarding their satisfaction with and dietary changes related to FIM support. We collected qualitative data on challenges to healthy eating during pregnancy and opportunities for program improvement.
Results
In survey responses (n = 31), patients indicated high satisfaction with all FIM supports, especially more intensive options, and reported eating more vegetables, fruits, whole grains, and healthy proteins. 71% indicated a small positive change in diet quality, with home-delivered nutritionally tailored meals most likely to influence a larger positive change. The most common barriers to healthy eating included food preferences or aversions, transportation challenges, poor quality of available food, and limited time to cook or eat.
Conclusions
We identified strong potential for FIM interventions during pregnancy to improve diet quality and overall health. More research is needed to evaluate the effects of FIM programs on food security and dietary quality during pregnancy and to tailor the type and duration of food support.
Supplementary Information
The online version contains supplementary material available at 10.1186/s40795-025-01134-x.
Keywords: Perinatal care, Pregnancy, Food is medicine, Nutrition insecurity, Dietary quality, Food insecurity, Rural
Introduction
Food and nutrition security are critical social determinants of health (SDOH) that impact access to care and health outcomes. Those who experience food insecurity while pregnant are at higher risk of nutritional deficiencies [1]; gestational diabetes [2]; maternal stress and depression [3]; delivering a preterm infant, and greater inpatient and outpatient care utilization [4]. Adhering to perinatal nutrition and associated physical activity guidelines has been associated with reduced risk of adverse maternal and neonatal outcomes, including gestational diabetes, obesity, preterm delivery, and neonatal intensive care admission [5].
Pregnant people who live in rural areas are at increased risk of avoidable adverse outcomes compared to their urban counterparts, and disparities in the probability of severe maternal morbidity between rural and urban U.S. women may be worsening [6]. Additionally, rural communities in New Hampshire have high rates of substance-exposed pregnancies, a risk factor dually associated with food insecurity [7] and preterm birth [8].
Food is Medicine (FIM) approaches integrate food and nutrition into health care and are increasingly implemented to address a range of health issues. FIM programs show promise in reducing food insecurity [9], improving diet quality and preventing chronic disease [10], mitigating diabetes [11] and hypertension [12]; and are linked to lower rates of hospital utilization [13]. FIM approaches can help reduce common barriers to following dietary recommendations, including inability to pay for healthy foods or lack of nutrition and cooking education.
FIM approaches have not been adequately studied among pregnant people who live in rural areas, and there is a gap in knowledge about how patients engage with FIM options. Although there is literature on the positive impact of FIM approaches in addressing perinatal food insecurity and certain clinical outcomes, including reduced risk of preterm birth [14], reporting on patient characteristics, implementation context and motivation, program quality and effectiveness, sustainability, and overall health impacts of these programs (e.g., food insecurity status, diet quality, birth outcomes) varies widely, limiting effective comparison between programs [15]. Integration of FIM programs into perinatal care settings should assess patient and clinical staff perspectives to ensure the acceptability, feasibility, and fidelity of FIM implementation [16].
Our team previously described perinatal patients’ acceptance of being screened for food insecurity and accessing resources through prenatal care [17]. Here, we describe the implementation of five tailored food and nutrition support options for perinatal patients at a rural northern New England hospital. Our objectives were to (1) explore the potential of different FIM options to improve perinatal dietary quality (2), assess patient satisfaction and self-reported health status with various FIM support options, and (3) identify barriers to healthy eating.
Methods
Participants & setting
Perinatal patients at a rural New England hospital were identified as experiencing food insecurity via the Hunger Vital Sign metric [18] embedded in universal social determinants of health (SDOH) screening. Patients were referred to a community health worker (CHW), provided with pregnancy-specific nutrition education materials, and connected to one or more FIM supports based on individual needs. Some patients were referred to a dietitian for additional nutrition guidance specific to pregnancy or other health conditions.
FIM programs (Fig. 1)
Fig. 1.
FIM supports provided to pregnant and postpartum patients; adapted from Mozaffarian et al., 2024 [19]
All FIM options (supported by a mixture of grant and operational funding) were developed through clinic-community partnerships over five years. Onsite food and nutrition programs, including shelf-stable food bags (food for a family of up to four for up to two days; patients could receive 1–5 bags depending on family size at every visit), nutritionally tailored meals (NTMs; prepared meals developed by registered dietitians to adhere to pregnancy-specific nutrition guidelines), farm shares (a selection of fruits and vegetables from both a local farm and on-site “farmacy” garden provided weekly during the growing season), and essential cooking equipment (e.g. can openers, blenders), offered immediate support. Home-delivered NTMs (14 refrigerated meals delivered weekly) were available for those with functional challenges, including housing and transportation barriers. Healthy food prescriptions (food rx; shelf-stable food and fresh produce designed by an OB/GYN dietitian and tailored to a patient and family’s medical needs; food for the family for up to a week with refills available monthly; picked up offsite at a food pantry or delivered to the patient by a CHW) were provided to transition from more to less intensive support. The type, duration, and number of FIM supports patients received depended on patient preference and the CHW’s perception of what would be most helpful based on their current context (e.g., whether the patient had a medical condition, access to transportation, stable housing, cooking equipment, etc.). Patients received FIM support for up to six months.
Data collection
A one-time electronic survey was used to assess participant satisfaction, barriers to healthy eating, trends in dietary quality, and self-reported health status [20]. We collected dietary intake data using an abbreviated food frequency questionnaire that asked whether people had eaten “more,” “less,” or “no change” for 11 food groups. The survey included qualitative (open text) questions regarding challenges to healthy eating during pregnancy and opportunities for program improvement (Appendix 1). Given our rural setting, small sample size, and the homogeneity of our population’s demographics, we did not ask patients to report identifying information.
A multi-disciplinary team, including a CHW, a social worker, a nurse midwife, and a plain-language expert, provided feedback that informed survey development. We piloted the survey with three patients (included in the full sample).
Patients who received FIM supports between Dec 2023 - Mar 2024 (representing the time period when all five FIM supports were available to patients) were invited via email to complete the survey between April - May 2024. Following the first outreach, we sent three reminder emails to each participant. A $25 incentive was provided for completing the survey.
Data analysis
We descriptively analyzed survey questions and compared findings for each FIM option. We assessed the change in consumption of 11 food groups (Appendix 1) related to receiving FIM options and assigned a diet quality score that we adapted from the validated Prime Diet Quality Score [21, 22] (scoring of 1 point if the respondent selected “I ate more” for: vegetables, fruits, dairy, whole grains, poultry, fish, beans; -1 point if the respondent selected “I ate less” for: vegetables, fruits, dairy, whole grains, poultry, fish, beans; 0 points if the respondent selected “No change” for any nutrition items; 1 point if the respondent selected “I ate less” for: red meat, processed meat, food from outside the home, sweets/ processed snacks; -1 point if the respondent selected “I ate more” for: red meat, processed meat, food from outside the home, sweets/ processed snacks). We summarized themes from qualitative responses. The Dartmouth Health Institutional Review Board determined this project non-human subjects research.
Results
Approximately 225 (9.0%) of OB/GYN patients experienced food insecurity in 2024, including 9.3% among Hispanic/Latino and 17.1% among Black and African American patients. Between Jul 2022 - May 2024, we provided approximately 4,000 NTMs, food prescriptions, farm shares, and food bags to 300 patients. The most common FIM supports received were shelf-stable food bags (77%), followed by home-delivered NTMs (48%), food rx (35%), on-site NTMs (10%), and farm shares (6%). 55% received one FIM support, and 39% received either two or three supports. The most common combination of FIM supports was shelf-stable food bags, food rx, and home-delivered NTMs (16%).
We emailed 55 patients (representing those who received one or more FIM support from December 2023 through March 2024), of whom 31 (56%) completed the survey. The total number of responses was originally 35, but we excluded three responses because they were duplicates (we kept the first survey response) and one response because the respondent only completed the first question of the survey. 60% of people who received FIM support and responded to the survey were New Hampshire residents, and 38% were Vermont residents. Respondents ranged from 16 to 50 years old. 5% of respondents identified as Hispanic or Latino; 87% of respondents identified as White, 7% as Black or African American, 4% as Asian, and 2% chose not to disclose their race. 45% of respondents received more than one FIM support, with the most common supports being shelf-stable food bags (77%), followed by home-delivered NTMs (48%), food rx (36%), frozen NTMs (10%), and farm share (3%).
Diet quality
Most patients (71%) reported a small positive change in diet quality (score of 2 to 4 points) influenced by receiving one or more FIM options (Fig. 2). Home-delivered NTMs were most likely to influence a large positive change (score of 5 to 7) in diet quality.
Fig. 2.
Dietary quality scores for each FIM option
All FIM options except the shelf-stable food bags helped patients eat more vegetables and less food from outside the home. Farm shares, home-delivered NTMs, and on-site NTMs corresponded with the greatest vegetable and fruit intake increases. Patients who received these supports also reported eating more whole grains and healthy proteins. Among respondents who received home-delivered NTMs, 60% indicated eating more food overall.
Most respondents indicated that FIM options, except the shelf-stable food bags, helped them eat the foods recommended by their care team. Notably, five participants reported that they did not discuss their food needs during pregnancy with their care team, despite this being the standard prerequisite to receiving FIM support.
Participant satisfaction and self-reported health status
Overall, respondents were satisfied with the FIM option(s) they received and were likely to use them again, with higher satisfaction levels for more intensive food support (Table 1). Patients indicated the highest satisfaction (either “somewhat” or “extremely” satisfied) for the farm share (100%), home-delivered NTM (94%), and in-clinic NTM (67%) options.
Table 1.
Heat map showing the range of average satisfaction for each FIM option. Darker colors represent higher scores
*Based on a Likert scale (1–5; extremely dissatisfied to extremely satisfied)
Over 50% of respondents selected “I felt healthier” when asked how the FIM option(s) they received impacted their health for every resource except shelf-stable food bags.
Barriers to healthy eating
When asked about specific challenges to healthy eating, 16 (52%) participants endorsed at least one challenge. Of these responses, barriers from most to least common were: specific food preferences or aversions (40%), transportation barriers (25%), poor quality of available food (25%), lack of time to cook or eat (20%), unstable housing (10%), language barrier (10%), health limitations (10%), lack of access to essential cooking equipment (5%), and lack of cooking education (5%). When asked about additional challenges related to pregnancy, six people (19%) reported morning sickness.
In qualitative (open text) responses (all optional), respondents identified communication with care teams about healthy eating and available options as areas for improvement. When asked what they would change about FIM supports, some indicated that they would like greater “variety,” “selection,” and “options” (especially for the shelf-stable food bags). A few people requested specific food item additions, and one person requested “as many types of food as possible.” Other respondents wanted FIM support to extend in duration (e.g., “sign up for a longer period,” “getting fresh food sent to your home up to a year postpartum”).
Many expressed positive sentiments, including that the FIM supports were “decent” and “helpful.” One patient said she was “grateful for the guided support throughout this journey [pregnancy].” Another specified that the “resource [she] got through postpartum care helped [her family] through a hard time while [her] baby was in the intensive care nursery and [she had] two toddlers at home.” Most of those who commented positively about receiving FIM support received home-delivered NTMs.
Discussion
Our findings add to the growing exploration of FIM to promote healthy eating during pregnancy. We found increasingly positive trends in dietary change and satisfaction with more intensive food support. These results are indicative of the nature of our shelf-stable food program, which provides a minimal quantity of food and no fresh produce. Additionally, FIM support is intended to be supplemental and does not provide the full amount or diversity of foods needed for a healthy diet. FIM supports may have influenced dietary change through several pathways, including direct provision of food, exposure to new foods and dishes, and changes encouraged through nutrition education. Seasonality of food availability likely also impacted our findings; farm shares, for example, were only available during the growing season (generally June-September).
Strengths of our perinatal FIM program include integration with SDOH screening, food support in tandem with nutrition education, strong reliance on community assets, and the ability to tailor options for a range of needs.
There are several barriers to the implementation of these programs in rural settings. Clinical barriers include workforce shortages, specifically resource specialists (e.g., CHWs) and social workers to connect patients to FIM, and unsustainable funding sources [15]. Community-level barriers include lack of transportation and secure housing.
To help address these challenges, we included gas cards with food prescriptions and offered on-site food support. We also provided essential cooking equipment, including a pot that can be used over an open flame, to facilitate cooking in insecure housing situations. Home-delivered and prepared foods can further ameliorate challenges for those with the most significant needs, including lack of cooking facilities/equipment and transportation or complex medical conditions. Additionally, we identified variety and choice as important components of FIM options to address challenges like food preferences and morning sickness.
Balis and colleagues (2024) [15] assessed organizational factors impacting perinatal FIM programs through interviews with 26 implementation and support staff, who identified persistent gaps in “program adoption, consistent implementation, and long-term maintenance,” indicating a vital opportunity for standard evaluation to inform our ability to adapt and scale perinatal FIM programs. Stronger evidence could also help garner more sustainable funding for perinatal FIM programs. There is strong potential for federal and state policy to support the equitable scale-up of FIM programs, following the example of Massachusetts, California, and other states with Medicaid 1115 waivers, which have allocated funding for FIM programs geared toward socially vulnerable patients [23].
A limitation of this analysis is the small sample size; FIM supports were integrated at different time points, and thus, we excluded patients from our survey outreach who received FIM support before all five options were available. Additionally, we surveyed patients from one rural clinic location, meaning our findings are limited in transferability. We were unable to conduct a pre-survey; therefore, we do not know the full impact of these FIM programs in improving perinatal diet quality or the effect of potential confounding variables (e.g., receipt of other material supports), and we cannot determine associations between FIM and diet and health outcomes. Our findings may overstate the impact of FIM supports as we did not track whether patients utilized FIM supports as intended (e.g., whether a patient picked up their food rx on time). Despite these limitations, these data offer compelling insights into the acceptability of and opportunities to expand FIM programs specific to rural perinatal patients.
Conclusions
Our findings add to growing evidence on the potential for FIM interventions during pregnancy to improve diet quality and overall health. More research is needed to evaluate the effects of FIM programs on nutrition security and dietary quality during pregnancy and to determine the right kind and duration of food support among perinatal patients. Additional data on patient and clinical provider perspectives would add important context to the relative advantage of FIM supports and help refine workflows for FIM integration. Finally, there is a critical gap in evidence on the effective implementation of FIM strategies specific to rural communities.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
We thank Daisy Goodman, Alka Dev, Katie Robie, Megan Adams, Theresa Estrada, Bea Ngugi, Krista Duval, Greg Norman, and Amber Bissonnette for their help with developing and facilitating Food is Medicine programs for the Dartmouth Health OB/GYN clinics.
Abbreviations
- FIM
Food is medicine
- SDOH
Social determinants of health
- CHW
Community health worker
- food rx
Food prescription
- NTM
Nutritionally-tailored meal
- OB/GYN
Obstetrics and gynecology
Author contributions
Conceptualization: Canavan CR, Allen SE, Bielaski, T. Data curation: Allen SE. Formal analysis: Allen SE. Funding acquisition: Canavan CR. Methodology: Allen, SE, Canavan CR. Project administration: Bielaski T, Allen SE. Visualization: Bielaski T, Allen SE. Writing - original draft: Allen SE. Writing - review & editing: Canavan CR, Bielaski T. All authors read and approved the final manuscript.
Funding
This work was supported by the Cigna Foundation’s Healthier Kids For Our Future initiative (proposal: “Healthy Food Healthy Births”).
Data availability
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The Dartmouth Health institutional review board determined this project non-human subjects research. We obtained informed consent from all survey respondents.
Consent for publication
NA.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.