Mountains of Abundance: A Fruit and Vegetable Walking Program in Central Appalachia

Introduction

On Thursday evenings, June through August, a main street leading into a small town in eastern Kentucky is closed off and tents erected. Participants in a fruit and vegetable walking program can be seen strolling into the county farmers’ market from the Tanglewood walking trail. Shoppers can browse an array of fruits, vegetables, honeys, breads, and other county-made goods then stick around for a nationally sponsored Levitt Amp concert on the hill beside the market (Levitt Foundation 2019). The sun sets behind a large outdoor stage and musicians from across the world perform for a growing crowd. The concerts contribute to the farmers’ Market’s lively and exciting atmosphere. “Being at the market,” one resident told me, “It’s just cool, it’s like everybody addicted going to Starbucks, you know, that vibe.”

Saturday mornings have their own distinct, frenzied vibe, as this is the only opportunity for FARMACY™ participants to turn in their fruit and vegetable prescriptions for market tokens. The hundreds of people who participate in FARMACY™ line up along Main Street and through the parking lot where the market is held. The market is kept strictly closed until 9 a.m., with people literally toeing the entry line, afraid that if they do not get to a particular farmer early, they will not get the produce they want. People mill about, eyeing their watches, and kids weave through the crowds, running and playing. The moment the market opens, everyone spills into the space, making a beeline for their favorite vendor. Lines quickly form and an excited chatter fills the air. Few farmers have many goods or produce to take home with them at the end of the day. Shoppers regularly purchase entire bushels of beans, multiple dozens of ears of corn, and carry home sacks delicately loaded with tomatoes or potatoes, food which they would consume, share with friends and families, and preserve.

The popularity of a farmers’ market in an eastern Kentucky town is not surprising. Research suggests that residents of central Appalachia, much like other parts of the United States, harbor an interest in consuming fresh produce (Dolstad, et al. 2016). Appalachia’s history of reliance on subsistence agriculture presupposes a food culture of consuming fresh fruits and vegetables that is also proudly and strongly linked to ideas of self-sufficiency and survival (Dolstad, et al. 2016). This set the stage for the recent steady increase in farmers’ markets and vendors in eastern Kentucky, a trend that since 2008 has similarly been experienced in other parts of the state (Map 1). Strikingly, reported sales statewide went from $7.67 million in 2008 to $13.0 million in 2015 (Spencer 2016). Despite urban “foodie” associations, consumers in rural areas tend to purchase more local produce, perhaps, some researchers suggest, as a way to support the local economy (Farmer and Betz 2016). What is unique to this market is the popularity of market support and incentive programs, including FARMACY™, the Levitt Amp Concert Series, and the Tanglewood to Table Walking Program (T2T).

Map 1:

Geographic Horticulture Directory of Kentucky (Center for Crop Diversification 2018). This map illustrates the current number of farmers’ markets in Kentucky.

FARMACY™ provides hundreds of qualifying individuals and families with farmers’ market vouchers, $2/day for the qualifying individuals and $1/day for each member of their household. Those who are eligible are: (1) women who are pregnant or people with type 1 diabetes regardless of income; or (2) people who have a diagnosis of obesity, type 2 diabetes, or hypertension and have an income of 100% at or below the federal poverty level. The Tanglewood to Table (T2T) program, which is the focus of this paper, seeks to engage community members in healthier lifestyle behaviors by providing $10 vouchers for anyone who signs up and walks approximately 1 mile to and from the market. Any adult over the age of 18 who signs up and walks to and from the market receives $10 to spend on fruits and vegetables at the Farmer’s Market. Diverse funding streams (including insurance corporations, medical institutes, universities, and private foundations) from both inside and outside the region support these and other market programs, with specific expectations about how the programs will run and what the (largely biomedical) outcomes will be.

Both FARMACY™ and T2T follow evidence-based medicine (EBM) approaches to program evaluation (details below). Helen Lambert’s research suggests that EBM is a methodological approach “for the evaluation and deployment of statistical measurements of outcomes derived from population research” but other (social and cultural) evidence is necessary for “ascertaining the value and relevance of such measurements in real world settings” (Lambert 2009). Further, Shore and Wright note, institutions encourage quantitative “reporting that bear scant resemblance to what people actually do in their everyday practice” (Shore, et al. 2011). Here I ask, in what ways do people engage with the T2T program that fall outside EBM’s narrow focus on the individual body as a data point?

Grappling with the nuances and complexities of everyday practice requires a brief look at eastern Kentucky’s agricultural and economic history, which shapes contemporary institutions (such as the farmers’ market) and practices. Despite a past punctuated by extractive industry and absentee landownership (Billings and Blee 2000, Black 2011), this paper argues, following others in the field of Appalachian Studies (Billings, et al. 1999, Billings and Kingsolver 2018, Hess, et al. 2018), that Central Appalachia is a region where hope, abundance, poverty, and decline remain layered and entangled. While EBM and socio-economic based figures provide information that is statistically legible, anthropological data, both ethnographic and bio-cultural, is necessary to comprehend “what people actually do.”

The results of interviews with twenty-five T2T participants, suggest that individuals joined and used the program for a number of diverse reasons, most commonly with the hope of improving their health. Participants also valued the abundance of food and social opportunities. Overall, participants enjoyed the program and utilized it in ways that funders and EBM methodologies of biometric and anthropometric data collection are not equipped to capture. Structural forces, such as a changing economy and food landscape, shape the choices and actions of individuals. However, this research illustrates how people within socio-economically marginalized regions such as Appalachia, use community-based networks of social and economic relations to exercise agency and maneuver around broader economic and political constraints. The goal of this paper is to challenge predominant stereotypes of eastern Kentucky and highlight the ways communities utilize resources in creative and unexpected ways.

Labor and Local Food

A report issued in June 2019 by the Appalachian Regional Commission identified 80 distressed counties within Appalachia (Appalachian Regional Commission 2019). Approximately half of these distressed counties are located in Kentucky. Local media outlets largely pointed fingers at plummeting per capita income and loss of jobs due to the receding coal industry (Anderson 2019, Wright 2019, WYMT News Staff 2019). The productivity of the coal industry declined throughout the latter half of the 20^th century due to the falling global use of coal and the shift of production to countries such as Russia and Colombia (Hansell 2016). Statewide, coal production decreased by 30 percent from 2015 to 2016 alone (Center for Business and Economic Research 2018); specifically, this eastern Kentucky county’s coal production fell from over 8.7 million tons in 1988 (Governor’s Office for Coal and Energy Policy and Kentucky Coal Association 1989) to just under 95,000 in 2018 (Office of Energy Policy 2018), an almost 92 percent decrease in only thirty years. In 2017, Kentucky’s poverty rate was 17.2 percent, while this eastern Kentucky county’s was 31.6 percent and median household income was $15,630 less than in the rest of the state (United States Census Bureau 2017). These numbers point to poverty and decline, but fixation on numbers flattens the textured fabric of everyday life.

Eastern Kentucky’s history of extractive industry and government incompetence fueled residents’ (re)production of social networks, particularly when it came to obtaining food. Throughout the early 19^th century, many communities resisted (or were barred from) large scale commercial food production and industrialization and relied on subsistence agriculture for household needs (Pudup 1990). Agricultural labor needs were met by the local community, particularly during the spring planting and autumn harvests. With the expansion of extractive industries (including salt, timber, and especially coal) after the Civil War, this history of sharing and exchanging subsistence agriculture goods (and labor) became an increasingly important survival strategy as capitalist forms of (food) production came to dominate (Billings and Blee 2000).

The influx of global products in the 19^th century – including flour, industrial cornmeal, meat, and other convenience foods – supplemented what could be grown, canned, and preserved (Billings and Blee 2000). Over time, gardens and plots shrank and communities consumed more imported food products, particularly in the wake of 20^th century government anti-poverty programs, such as food stamps. In general, ‘poverty time’ foods shifted from what could be grown and preserved to cheap, processed goods, often purchased with government-subsidies (Engelhardt 2018). Farming and gardening, however, did not completely disappear from the landscape. Farmers’ markets in particular have expanded across the region in recent years, and food growing and sharing is still a central component of community life (Quandt, et al. 2000). Appalachian food is increasingly celebrated on both a national (“the region’s cuisine reflects a dual reality of poverty and ingenuity” reads a subtitle from a 2017 article in The Nation (Jones 2017)) and local level (Hindman Settlement School 2017). The vibrancy of this farmers’ market illustrates how residents can reclaim their history of locally grown food through contemporary everyday practices, demonstrating the agency and abundance that exists in Central Appalachia, despite ongoing struggles with poverty.

Food, Health, and Farmers’ Markets

With the influx of corporate food chains including grocery stores and fast food restaurants eastern Kentucky experienced what public health scholars have labeled a “nutrition transition,” characterized by a shift from plant-based diets to refined foods (Yates-Doerr 2015). An additional aspect of nutrition transitions is a shift from high rates of infectious disease to increases in chronic diseases, such as cancer, diabetes, and heart disease. Mortality rates from diabetes, stroke, and liver disease are significantly higher in this eastern Kentucky county and other communities of eastern Kentucky than in the rest of the nation (Institute for Health Metrics and Evaluation 2015)¹. Research within the region has identified several barriers to consuming a balanced diet that incorporates a variety of fruits and vegetables. First, residents of rural Appalachia continue to experience their lives as busy, fast, and hectic, with the added barrier of the distance between locations and the mountainous terrain (Schoenberg, et al. 2013). Second, fast food restaurants are closer, easier, and cheaper (due, in part, to geography) than fresh food sellers, such as grocery stores (Schoenberg, et al. 2013). For example, in this county there are four grocery stores and fifteen fast food restaurants (United States Department of Agriculture 2014). Third, low income residents of rural areas are disproportionately located farther away from fresh food sellers, essentially increasing the price of food due to travel costs (Suarez, et al. 2015, United States Department of Agriculture 2014).

Farmers’ markets can “draw connections between food, empowerment, and identity [that can] serve to construct a…community capable of agency despite…marginalization” (Alkon 2012). As previously discussed, eastern Kentucky is experiencing a reclamation of its local food history, exemplified by the increase in and expansion of farmers’ markets. The popularity of farmers’ markets and market incentive programs tells us how individuals are engaged in strong social networks of care in a context of high rates of poverty and chronic disease.

Methods

In May 2018, eighty-two participants were enrolled into the sixteen-week T2T program that took place from June through September. The purpose of the T2T was to encourage people who frequent the Farmer’s Market to combine purchasing healthy fruits and vegetables with walking as a means of increasing physical activity. The overall goal of the program was to integrate into an established community initiative incentives to improve engagement in healthy lifestyle behaviors with the expectation that this would result in weight loss, decreased blood pressure, and improved cholesterol levels. A secondary focus of the program is to promote fruit and vegetable intake as a way to protect against the negative impacts of environmental pollution.

Baseline screenings took place at the Extension office and, following EBM methods to produce evidence of program efficacy, researchers collected height, weight, waist circumference, blood pressure, finger-stick hemoglobin A1c (A1c), finger-stick lipid panel (total cholesterol, high density lipoprotein [HDL], low density lipoprotein [LDL]), and carotenoid status (Pictures 2). A1c is a measure of blood glucose levels over the past three months. The Veggie Meter™, a noninvasive instrument utilizing light waves to detect vibrations of particular molecules measured participant carotenoids, an objective measure of fruit and vegetable consumption. Carotenoids are fat-soluble pigments found predominantly in fruits and vegetables, particularly red, orange, and dark green fruits and vegetables.

Picture 2:

Carotenoid scans (front) and blood pressure (back)

Additionally, participants completed a survey to assess knowledge of phytonutrients, self-reported physical activity, self-reported fruit and vegetable intake, self-reported health history, and demographics. Participants received a farmers’ Market t-shirt for participating in the baseline data collection as well as pedometers to track their steps and miles over the course of the program. The same data was collected in September 2018. This study was approved by the University of Kentucky (UK) Institutional Review Board. Funding for this project was provided by the UK Superfund Research Center (NIEHS P42ES007380), the UK Center for Clinical and Translational Science (NCATS UL1TR001998.), the Department of Dietetics and Human Nutrition, and the College of Agriculture, Food, and Environment Research Activity Award.

In early August, twenty-five in-depth, semi-structured interviews were conducted with participants (demographics, Table 1). The goal of these interviews was to assess program use, impact on food behavior, impact on the community, and potential areas for improvement. Recruitment occurred via word of mouth and snowball sampling, with initial interviewees contacted by the community T2T program leader. Interviews lasted between twenty minutes and one hour. The interviewer utilized the same interview script with all participants following a semi-structured approach, which allows for interviewees to discuss and elaborate on what they find to be the most important topics and issues.

Table 1:

Demographics for All T2T Participants and Interviewees

	All (n=75)	Interviewees (n= 25)
Mean age	48.4	48.3
White	96.30%	100%
Not Hispanic/Latino	86.60%*	100%
Female	73.20%	82.40%
Has a Garden	42.70%	35.30%
Employed full time	46.30%	5.90%
<$20,000	31.70%	41.20%
>$60,000	15.90%	17.60%
Married	64.60%	23.50%
Smoke/tobacco use	17.10%	23.50%

^*8.5% did not answer; 1.2% more than one race; 1.2% American Indian

All interviews were recorded and transcribed verbatim by the interviewer. Initial coding targeted concepts related to the interview goals - program use, impact on food behavior, and impact on the community. Focused coding compared codes across interview data to identify commonalities and contrast differences. Codes were then organized into four broad themes (discussed below). Biometric and anthropometric data are not included in this paper to maintain a focus on how participants themselves understood the program, with their own definitions of success, rather than on specific health outcomes. This paper interrogates what these numbers cannot – how participants utilized the program, and how it impacted food behavior (which is deeply social) and the community.

Results

Results are based on interviews with approximately one-third of all participants. Compared to all participants, interviewees were less likely to be employed full time, more likely to make less than $20,000, and less likely to be married (Table 1). Four main themes emerged from the interviews. First, participants were interested in joining the program as a health management strategy. Second, participants valued the freshness and quality of farmers’ market food and took pride in being able to support local growers. Third, participants approached the program and farmers’ market as a social opportunity, to either meet new people or spend time with friends and family. Fourth, participants viewed the T2T as a program that supported them to increase the variety of foods in their diets, to cook with more fruits and vegetables, and increased their access to enjoyable foods. Where applicable, anthropometric, biometric, and survey data collected at baseline (May 2018) and analyzed using SPSS v. 25 (SPSS Inc., Chicago, Illinois) is included to paint a more detailed picture of participants. This program exemplifies a potential way to think outside the confines of both an EBM approach to program evaluation and the stereotypes of decline common to eastern Kentucky.

Health Management Strategy

Interviewed individuals self-reported a similar overall health status to all participants (Figure 1). When compared to all participants, interviewees were slightly more likely to self-report having a diagnosis of diabetes (28% vs 20.7%), asthma (12% vs 8.5%), and chronic obstructive pulmonary disease (8% vs 2.4%), and slightly less likely to report having a diagnosis of high blood pressure (36% vs 42.6%), cancer (4% vs. 7.3%), and arthritis (16% vs 25.6%). The prevalence of diabetes in both the larger group of participants and subsection of interviewees is higher than the county rate of 17.5 percent (Institute for Health Metrics and Evaluation 2015), state rate of 14.5% (American Diabetes Association 2016), and national rate of 9.4 percent (Centers for Disease Control and Prevention 2017). The top two reasons for joining the program were to be physically active and to receive market tokens for fresh produce (as indicated on baseline survey data). Physical activity and fruit and vegetable consumption are correlated with a decrease in chronic disease complications (U.S. Department of Health and Human Services 2015) and widely advertised by public health organizations and initiatives, including the federal MyPlate program (United States Department of Agriculture 2018) and the more local university-community cooking project, AppalTree (Appalachians Together Restoring the Eating Environment) (Community Farm Alliance 2017).

Figure 1:

Self-Reported Health Status from Baseline Survey Data

Joining the T2T program with the hope of managing chronic diseases was a recurring theme in the interview data. Diabetes was discussed most commonly and affected the greatest number of interviewees. Fifty-six-year-old Erin Lambert (all names have been changed), when asked why she joined the program, responded in her quiet, stern voice, “I’m diabetic…so you know I wanted the exercise and stuff like that. It helps the A1c.” Not only does she make the connection between exercise and disease risk, but she also frames it in medical terms. Participants who reported a diagnosis of diabetes were more likely to use medical jargon, while family members and friends of those with diabetes would generally refer to diabetes as a struggle with “blood sugar.” For example, Kyle Haiser, a sixty-year-old, large, scraggly-bearded man with piercing eyes, initiated the conversation by explaining the health changes he was able to make over the course of six months in 2016. Among other health markers, including blood pressure and cholesterol, his A1c dropped by over 5 points – a change he credits entirely to the FARMACY™ program and increased fruit and vegetable intake. On the other hand, one mother and daughter shared their experience trying to help their husband/father “cut down on carbs” in order to “keep his blood sugar at a good number.” The use of the term “A1c” by interviewees with diabetes suggests an indoctrination into a biomedical understanding of disease, compared to the more colloquial term “blood sugar” used by participants who know someone who has been diagnosed.

While diabetes was the most commonly reported disease, other health complications individuals hoped to manage included high cholesterol, high blood pressure, liver disease, and cancer. Tara Wesley is a particularly animated example. She is forty years old and, at the time of the interview, on sick leave for cancer. In her interview, Tara repeatedly returned to the role of food, specifically organic, natural, locally-grown fruits and vegetables, in preventing disease, particularly cancer: “I know that I don’t want to try to do GMO, uh, stuff, because I know it’s worse for cancer. And so it’s really exciting to do this with the organic stuff.”

When asked what it is about the farmers’ market that makes the food “safer,” Tara responded that, “you know the people that’s growing it.” Other participants expressed similar distrust of distant farmers and implicit confidence in county farmers. Medical Anthropologist Yates-Doerr, during her fieldwork in Guatemala, observed doctors direct clinically overweight patients to consume fruits and vegetables heavily treated with pesticides, a fact that made these “healthy” foods, to the patients themselves, “unhealthy” (Yates-Doerr 2015). This paradox points to the ways in which, to paraphrase Yates-Doerr, clinicians see food as nutrients, and people see food as histories (Yates-Doerr 2014). Even though the majority of growers at this farmers’ market do not have organic certification, the facts that they grow locally, are known members of the community, and are often participants’ neighbors were perceived as just as good as certification.

Even participants who themselves were not struggling with health issues continued to participate with the hope that the program would benefit family members who also participated. Chloe Morris is a shy thirty-five year old, who, after her experience in the walking program in 2017, convinced her mother to sign up in 2018. When asked why she decided to join the program, Chloe said she enjoyed it last year and then immediately shifted the conversation to her mother:

[My mom] needed to lower her cholesterol and uhm she been trying she didn’t want to take extra medicine so that was kind of an incentive for her [to join this program].

Most participants understood the connections between what the program offered – physical activity and fresh fruits and vegetables – and a reduction in disease risk. As one middle-aged woman who I interviewed in October told me:

There was a time I did everything right including exercise an hour a day and it made a difference and I felt a lot better. And I wonder why my brain isn’t taking advantage of the knowledge that it has up there so I don’t know if getting additional information uh you know…uh…I don’t know….I don’t mind getting information but that isn’t it….

Although she moved the conversation towards the confusion she felt about the specifics of nutrition (“is turmeric a wonder food?”) she knew the fundamental, general habits that contribute to physical health. While she might not have been able to state the specific recommendations of government bodies (eat 5 fruits or vegetables a day; get 150 minutes of moderate physical activity a week (United States Department of Agriculture 2018)), she – and all interviewed participants – knew that eating fruits and vegetables and being physically active contribute to physical health and a reduction in chronic disease risk. That, after all, was why they were there, and why the program was so appealing, if not for themselves, then for someone they were supporting. This program is successful, in part, because it goes beyond giving information and teaching skills. “This program is saving lives,” Lucy told me, “whether they know it or not. I think it is. I think it’s saving lives.”

Value of Fresh Food

Access to and availability of fruits and vegetables does not measure the quality or freshness of the produce. Every interviewed participant was acutely aware of the differences in quality (and price) between the farmers’ market and the local grocery stores. They also had an abundant list of roadside produce sellers, both within the county and across the border in Virginia, where they could obtain fresher produce than what was found at the grocery in town.

Monica Jefferson, the mother of the mother/daughter duo I interviewed, told me:

You could tell a difference in the taste between what’s grown and what you get at the grocery store. And I hadn’t had any fresh strawberries like that somebody picked since I don’t know, ten years…you can tell a difference.

Hannah Cross, a middle aged schoolteacher, stated:

They’re usually prettier, the stuff at the farmers’ market, like the onions are generally kinda a little bit dirty but they’re uhm it’s very nice it’s very nice to buy ‘em off somebody that’s pulled them out of their garden.

Lucy Paxton, a fifty-year-old homemaker, also pointed out the difference, “[I joined the program] for the fresh vegetables…totally tastes totally tastes different from the store!” Erin Lambert, like Monica, was struck by the taste of the purchased vegetables, “Tomatoes taste like tomatoes, they don’t taste like…cardboard *laughs* And the corn tastes like corn not, hard and you know like get in the stores.”

As mentioned earlier, grocery stores in rural areas tend to be located further from residents, particularly lower income residents. The time it takes to get to the grocery store and the money associated with traveling the distance are both major barriers to produce intake. It is no wonder, given the ubiquity with which participants discussed the lack of quality of grocery store produce, that these barriers seem even more insurmountable. Why spend the time and money to travel more frequently for mediocre food? In other words, participants were willing and able to travel to the market for what they perceived to be an abundance of quality produce, which they often could not find at the grocery store in town. Participants value the sensory and aesthetic quality of their produce and feel this quality can only be found at the market, grown by the community. This valuing also provides a counterpoint to a food as medicine approach, as it implies a sensory enjoyment of the food that, in some cases, supersedes its value as a nutrition-delivery device or prescriptive consumable good.

Multiple participants also expressed frustration with the high cost of fresh fruits and vegetables at the grocery store. For example, Margaret Fanning, the cousin of another participant, has a challenging social life, with multiple family members addicted to opioids, complete responsibility for the care of her granddaughter, and a multitude of her own health conditions. Yet she is upbeat, and the only time she complained at all was to tell me, “By the time you get your basics you don’t got the extra money to get the fruits and vegetables.”

The market itself was another point of pride vocalized by many participants as the quotes below demonstrate:

• [Local farmers] supply just what we need….and we’re providing the money for them to have… (Kyle Haiser, 60-years-old)

• [I get excited about the market] knowing you’re there helping out local people. (Tara Wesley, 40-years-old)

• I like supporting the farmers. (Erin Lambert, 56-years-old)

• Yeah, I love supporting the farmers every bite I take. (Don Lambert, 50-years-old)

Of all T2T participants, 24.7 percent self-reported that they do not make enough to make ends meet, while 41.2 percent of interviewees reported this. Self-reported income was also lower among interviewees when compared to the larger group (Graph 1). Median household income in this eastern Kentucky county is $29,181 and the county poverty rate is 29.8 percent, over ten points higher than the overall rate in Kentucky (18.5%) (Data USA 2018). Interviewees who self-reported struggling to make ends meet were less likely to spend their own money at the market and were more likely to participate in other market programs, particularly FARMACY™. They were also more likely to state that they enjoyed the program because it supported local farmers. While higher income participants expressed joy in attending the market and viewed the program and market as sources of entertainment and a means to strengthen existing social networks (as Hannah Cross said, “A lot of teachers [joined the program] so it’s a lot of fun”), they did not mention supporting local farmers. Simultaneously, a few participants were cognizant of the precariousness of a market dependent on subsidized programs. “I hate that if you’re gonna [sell] at the market,” Don said in a moment of clarity, “you gotta get some coins to get through it.”

Graph 1:

Self-Reported Income from Baseline Survey Data

Social Opportunity

As Hannah Cross explained in the previous paragraph, all interviewed participants, across income level and health status, stated that the program and market provided opportunities to engage in an abundance of social relationships with coworkers, friends, farmers, and strangers.

Emma Carpenter, is a very quiet homemaker in her early forties. She was interviewed with her loud and outgoing sister, also a program participant. During the interview, Emma seemed more than happy to take the back seat; she sat almost perfectly still during the interview, hands clasped in her lap, while her sister gesticulated excitedly with her arms. Emma explained, “[I enjoy] meeting new people…you know when [my sister]’s sick, uh, I got others to walk with then I meet other people so that’s the fun part for me.”

Similarly, Monica seems to take the lead from Debra, her twenty-year-old daughter. Debra shared that she saw a Facebook post about the T2T program and thought it would be a fun activity for her and her mom to do together. While Monica, at first, was hesitant, during their interview she shared:

And I, uh, I didn’t want to walk by myself [at first] but I would because I’m comfortable now than in the beginning I wasn’t but I’m not now so after I met [some girls in the program], when I’m walking I talk to them. So yeah, I would go now. I would just come if [Debra] couldn’t, I would want to.

As Don explained

[This program] brings some people out of their shell. Course I broke my shell a long time ago, but you know some people the more interaction you get with other people the more that you are out…more…it makes you more outgoing.

Hannah, Cassie, and seventy-year-old Bev Kohler all commented on, in Hannah’s words, how “the program gets a diverse group of people together.” Cassie is not only the leader of the program and responsible for paperwork and signing participants in every week, but also a very kind, friendly individual. She laughed at how her number of Facebook friends grew over the course of the program. Bev, on the other hand, was sharply honest that she did not make new long-term friends during the program, but still met new people and enjoyed their company:

After hours or something would I be with [other participants of the program]? No. But that’s okay! That’s…they’re not in my inner circle but I love to speak to them out there and see that they’re interested in walking, that’s the big thing to me is everybody can get up off their…lazy butts and walk.

Increased Variety of Food Choices and Cooking

During fieldwork visits to the farmers’ market, it was rare to not have a conversation about food. Participants and non-participants would, unprompted, gush about the locally baked bread or share whose green onions were the best that week. Participants were always eager to explain new ways to cook mashed potatoes, the best way to eat summer squash, or encourage consuming raw corn on the cob. If given the opportunity, participants would have spent the entire interview discussing the abundance of foods they purchased at the market and the diverse ways they prepared them.

Chloe described trying kohlrabi for the first time, Emma tried swiss chard, and Don, who once swore up and down he would never eat greens, started eating kale and broccoli and spinach. Whitney Bell, a sixty-two-year-old newlywed, spoke to me with her husband, sixty-five-year-old Matthew. They were a quiet couple of few words, but Whitney perked up when I asked about recipes. She described a vegetable goulash she made for her husband, children, and grandkids: “I put peppers and green tomatoes and onion and squash and taters all in it and fry it together, it’s really good.”

The $10 participants received not only bolstered their ability to purchase food but also seemed to give them the freedom to purchase items they would not purchase with their own (often limited) income. Data from the 2017 walking program suggests that most participants reported purchasing a small, select number of particular fruits and vegetables every week (Graph 2). The majority of purchases were of the “Kentucky trinity” – corn, beans, and potatoes – along with tomatoes, peppers, and cabbage (Black 2015). Even if participants never purchased new items again, they discussed ways that they enjoyed the variety of foods available at the market.

Graph 2:

These results provide a counter-narrative to the stereotypical story of eastern Kentucky fatalism and decline. Participants joined and used the program for a number of diverse and overlapping reasons, including hope for better health and enjoyment in the abundance of both produce and social connections. This articulates with findings that even among people in Appalachia who did have high fatalism, there was high likelihood of engaging in healthy behaviors when motivated by health concerns and when able to access sufficient resources to support healthy behaviors (Mudd-Martin, et al. 2015). The program increased the variety of their diet as community networks were strengthened and new connections were formed among program participants and with local farmers. Overall, interviewed participants enjoyed the program and judged it to be valuable and successful.

Discussion

The research results illustrate the everyday realities of how program participants utilized and understood the T2T nutrition and physical activity program. The results resonate with Himmelgreen and Crooks’ argument that, “People eat food for a variety of reasons that have little, if anything, to do with nutrition, health, or survival” (Himmelgreen and Crooks 2005). Emergent themes point to a number of ways that individuals engaged in the program that went beyond personal nutrition and health and escape evaluation via EBM approaches. For example, while many participants joined the program to help them manage chronic health conditions, they did not consume the fruits and vegetables they purchased as medicine. Rather, they valued the freshness and quality of food produced by people they knew (or came to know through the course of the program), and consumed the food in a variety of tasty, enjoyable ways. This suggests that participants thought about and ate food as a way to engage with their community and experienced pleasure in snacks and meals.

Additionally, previous research (discussed above) highlights transportation and distance from fresh food sellers as a barrier to consumption. Transportation did prevent a few individuals from weekly participation, but this was rare. While this could be explained by self-selection into the program (only those who had a reliable form of transportation decided to join), the few individuals who did face the limitations such as broken-down cars called on friends and family to take them to the market. This might suggest that it is less the transportation that is the issue, but rather the quality of what is available. This resonates with what Monica, Lucy, Erin, Hannah, and countless others shared – that market produce looks, smells, and tastes better than what is available at grocery stores and fast food establishments. This also provides further evidence for the strength of social networks within this eastern Kentucky community.

The physical measurement data that was collected as part of the current study, while important, are better fit for a different, EBM-framed discussion, focused solely on nutrition or specific biometric health outcomes and their relevance to population statistics. Spending time with and talking to participants reveals the subtle but concrete strategies of resistance, hope, and abundance Appalachian communities have long employed in response to outside forces, in this case a diverse pool of research and health-related funding. For example, participants created diverse social spaces via the farmers’ market, a finding which defies quantitative analysis. By not including post-measurement biomedical data, this paper focuses on the “real world setting” of the farmer’s market and participants’ own definitions of what counts as a successful program. In short, fruit and vegetable prescription programs turn the language and expectations of funders and EBM on its head: through an individualizing practice (prescription), it feeds community bodies and relations.

Farmers’ market programs can also form the foundation for broader transitions in state and national spending. The diverse stream of funding that already supports multiple farmers’ market programs in this eastern Kentucky county should be expanded throughout the region. The fact that most participants joined the program for health-related reasons is striking and illustrates the Janus-headed nature of how health care is conceptualized in Western nations, particularly the United States. Individuals are increasingly responsible for self-managing their own health, often without the resources (healthcare and otherwise) necessary to do so (Trnka 2017, Mulligan and Castaneda 2018). The T2T program rests at the intersection of diet-related health and agriculture, two areas the United States Agricultural Act (Farm Bill) seek to address. In 2014, the Farm Bill allocated 80 percent of its $489 billion budget to addressing nutrition issues, through programs such as SNAP (United States Department of Agriculture 2018). Innovative, small-scale farmers’ market consumer subsidy programs seem a natural fit for future funding under the Farm Bill, as this program illustrates the potential for such programs to decrease food insecurity and provide the resources necessary to begin to support the health of both individuals and communities.

Conclusion

This paper seeks to contextualize a physical activity and nutrition program that largely relies on evidence-based medicine (EBM) approaches to evaluate and to illustrate what EBM fails to grasp; that individuals and communities engage with programs in disparate and creative ways. The history of local food production in eastern Kentucky forms the backdrop for understanding the hope expressed by individuals joining the program and the abundance of both food and community. While the T2T program relies on outside funding mechanisms, it provides a glimpse into what could be imagined for a post-coal, post-capitalist local food system. Given the broad acceptability of this program and the potential to improve both individual and community health, a key next step is exploring avenues to expand it both financially and geographically via policy initiatives.

Picture 1:

T2T Participants Signing in at the Market