Dear Editor:
We thank Coskun and Oz for their letter on additional lifestyle risk factors for cardiovascular disease (CVD), such as physical activity, stress, smoking, and alcohol, that could be considered in evaluating effects of produce prescription interventions. We note that suboptimal diet is an established major risk factor for CVD, by itself accounting for up to 45% of attributable risk (1), with downstream influences on physiologic risk factors that are both established (e.g., blood pressure, adiposity, glucose, blood cholesterol) and emerging (e.g., inflammation, endothelial function, gut health). Thus, any intervention that successfully contributes to increased intake of healthy foods will meaningfully impact CVD risk, as shown in the PREDIMED (Prevention with Mediterranean Diet) trial (2). This highlights the promise of Food is Medicine interventions like healthy food prescriptions, which integrate food and nutrition into health care systems.
In our systematic review of healthy food prescriptions, only 1 study included stress-reduction techniques and physical activity coaching (3), and none included guidance on smoking or alcohol. Yet, improving food and nutrition insecurity through the provision and subsidizing of healthy foods could also plausibly reduce stress, improve quality of life, and thus indirectly improve other lifestyle behaviors such as around exercise and alcohol.
In response to the letter by Coskun and Oz, we have reviewed all studies in our systematic review to assess how many reported effects on smoking, alcohol, exercise, or psychosocial stress. Of the 13 studies, only 2 reported on exercise: the multicomponent intervention found a significant increase in time spent exercising from 83 min to 129 min/wk (3), whereas another study found an increase in the number of days of moderate activity from 1.5 d to 3 d/wk (4). Only 1 study reported on depressive symptoms, finding an improvement of 2 points on the Patient Health Questionnaire-9 (3). None of the studies reported on changes in smoking or alcohol.
In sum, the significant improvements we identified in fruit and vegetable intake, BMI, and glycated hemoglobin (HbA1c) provide evidence for important clinical benefits of healthy food prescription programs. The additional findings on exercise and depression should be considered hypothesis-generating and require further confirmation. Given the highly interrelated nature of nutrition, food security, and other cardiovascular and metabolic risk factors, we agree with Coskun and Oz that future healthy food prescription studies could aim to assess the impact of such interventions on additional lifestyle habits, cardiometabolic risk factors, and other patient-centered outcomes.
Notes
Author disclosures: The authors report no conflicts of interest.
Contributor Information
Saiuj Bhat, From the School of Medicine, the University of Western Australia, Crawley, Australia.
Daisy H Coyle, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
Kathy Trieu, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
Bruce Neal, The George Institute for Global Health, University of New South Wales, Sydney, Australia; School of Public Health, Imperial College London, London, United Kingdom.
Dariush Mozaffarian, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA.
Matti Marklund, The George Institute for Global Health, University of New South Wales, Sydney, Australia; Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
Jason H Y Wu, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
References
- 1. Micha R, Peñalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA. 2017;317(9):912–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Estruch R, Ros E, Salas-Salvadó J, Covas M-I, Corella D, Arós F, Gómez-Gracia E, Ruiz-Gutiérrez V, Fiol M, Lapetra Jet al. Primary prevention of cardiovascular disease with a Mediterranean diet. N Engl J Med. 2013;368(14):1279–90. [DOI] [PubMed] [Google Scholar]
- 3. Emmert-Aronson B, Grill KB, Trivedi Z, Markle EA, Chen S. Group medical visits 2.0: the open source wellness behavioral pharmacy model. J Altern Complement Med. 2019;25(10):1026–34. [DOI] [PubMed] [Google Scholar]
- 4. Forbes JM, Forbes CR, Lehman E, George DR. “Prevention produce”: integrating medical student mentorship into a fruit and vegetable prescription program for at-risk patients. Perm J. 2019;23:18–238. [DOI] [PMC free article] [PubMed] [Google Scholar]