This post explores the healing power of fruits and vegetables and the need for clinicians to become more involved in national strategies that encourage Americans to eat more of them.
Research shows that eating more fruits, vegetables, whole grains, and seeds as part of a broader lifestyle medicine strategy – especially combined with weight loss – can slow down the development of, or put in remission, chronic conditions such as heart disease, type 2 diabetes, and hypertension. The success of this strategy depends heavily on replacing modern factory food “creations” with foods that are closer to their natural state.
While fruits and vegetables have been central to the human diet for millennia, the typical American diet today is dominated by highly processed foods and sugar-sweetened drinks that promote inflammation; disrupt normal satiety and immune, gut, and neuroendocrine systems; and weaken our physical and mental health.
Meanwhile, plants are much more than the sum of their parts – fiber, vitamins, minerals, phytochemicals, and antioxidants (anthocyanins, carotenoids, isothiocyanates, and flavonoids). There is much to learn about their health benefits of plants and what we have lost as a result of modern commercial food processing.
US dietary guidelines recommend that we fill half our plate with fruits and vegetables, but only 10% of Americans get the minimum daily recommended amount of 1.5-2 cups of fruit, plus 2-3 cups of vegetables. Of course, this is much less than the amount needed to get the full health benefits of plants, based on recent research in this area.
Given this problem, should US clinicians step up and actively encourage their patients to replace highly processed foods and fast food with fruits and vegetables in their diet? Can “prescribing” fresh produce become a routine treatment that helps motivate patients to change habits? Also, can doctors and other clinicians become activists who strive to improve their patients’ access to local fresh fruits and vegetables as part of new focus on the “upstream” causes of chronic diseases?
The case for promoting healthy fruits and vegetables
The health benefits of a diet mostly of plants, including fruits and vegetables, is well documented, but it also makes economic sense. For example, Fast Company magazine highlighted research showing that if doctors were permitted to prescribe fruits and vegetables, similar to the way they prescribe expensive drugs and procedures, the country would save an estimated $40B annually in healthcare costs. They estimate that if clinicians were also allowed to prescribe seafood, whole grains, and healthy plant oils, the saving would grow to $100B.
Prescribing healthy foods to treat chronic conditions is not futuristic; in the US we already have successful pilot programs. An important benefit of these programs is that they can stimulate a shift in clinician thinking towards a routine use of lifestyle medicine to complement or replace drugs and medical procedures. Clinician involvement in fruit and vegetable prescription programs may also help clinicians consider certification in lifestyle medicine as a new skillset, or becoming role models by adopting “plant-strong” diets themselves and witnessing a personal health transformation that they share with their patients.
Social, political, and legislative barriers to national fruit and vegetable intake
But there are headwinds to these types of initiatives. To start, clinicians get just a few hours of training in nutrition during medical school and post-grad. This typically focuses on the biochemistry of nutrients and related deficiency states (e.g., niacin deficiency and pelagra), rather than on the quality of our US food supply or how our national eating habits are driving the chronic disease epidemic. Another barrier is that the US healthcare system currently reimburses acute care procedures very well, but pays much less for prevention.
Cost, availability, consumer convenience, and ingrained consumer preferences are well-known, practical barriers to wider fruit and vegetable consumption. But less well known is that while farmers who grow corn to feed cattle, make corn syrup, or create biofuel additives, are heavily subsidized by the federal government (as much as $7.3B annually), fruits and vegetables are classified as “specialty crops”. Farmers dedicated to growing these crops receive less than 10% of federal subsidies. This gap exists even though the federal government recommends that fruits and vegetables occupy half of a healthy plate. These policies reduce access to fruits and vegetables and discourage marketplace innovation and investment in getting fresh fruit and vegetables to consumer dining tables in the form of ready-to-eat, accessible, affordable, and desirable meals – the sweet spot for fast food corporations.
Tackling this misalignment of food guidelines with farming subsidies could help our healthcare system address chronic conditions. For example, fruit and vegetable farmers could be greatly helped if physician champion groups supported a restructuring of the Farm Bill. This effort, combined with legislation that supports targeted low taxes on healthy foods and drinks, would help shape the behavior of stakeholders whose products actively promote obesity and chronic conditions along the entire food chain.
Clinician champions could also help revamp our federal public “safety net” feeding programs, including the Supplemental Nutrition Assistance Program (SNAP) and the School Meals Program to stress health and the promotion of delicious, affordable foods. But this needs a sophisticated multistakeholder approach. For example, a recent federal mandate that more fruits and vegetables be included in the School Meals Program was implemented with little student input, resulting in high waste when many students threw their fresh produce in the trash. Program advocates believed that “getting kids healthy foods” was the primary goal and that “lack of time to eat at lunchtime” was the main barrier. But, in contrast, the $570B fast-food industry uses careful market testing, looks for “bliss points”, and uses effective messaging and product positioning to generate high demand for quick meals. There have been promising pilot programs for healthier school meals that are plant strong led by passionate chefs with commercial experience satisfying student palates and age group preferences. Progressive US physician groups could add their voice to a program of legislative, marketing, and culinary expertise that grows in both scale and impact. The American College of Lifestyle Medicine is a prime example that other national physician groups could look to for inspiration.
Waste in the US fruit and vegetable supply chain
It is not widely appreciated, but approximately 50% of fruits and vegetables produced in the US are wasted along the supply chain from farm to wholesaler to retailer when products are judged as visually “imperfect”, such as having uneven shapes, minor blemishes, or color variations. These fruits and vegetables are rejected by buyers along the supply chain for natural imperfections and variations in size, despite good quality otherwise. The waste that is the result of these unrealistic industry and consumer standards could be tackled through effective education. In fact, innovative digital food delivery companies are starting to educate US consumers on this important food waste issue. They buy up and distribute conventional and organic imperfect fruits and vegetables to consumers and pass the savings to consumers as their business model.
A related consumer education issue is that household food costs are at a low point historically. Consumers may believe that fresh fruit and vegetables are not affordable, but they can fit within consumers’ current budgets when consumers use seasonal availability and buy in bulk, as many can be stored for later use. Also, meals based on fruits and vegetables are on average cheaper than for highly processed foods or fast foods. For example, a national survey of 156 fruits and vegetables showed that it cost $2.10 to $2.60 daily, per person, to meet the federal recommended intake, not including the cost of the time and effort for cooking. By comparison, families on average spend $6 per person for a fast food meal and more at family chain restaurants. With an effort to provide patients with a bit of education and resources, clinicians can not only prescribe fruits and vegetables but can reassure their patients that many healthy and tasty options are also affordable.
Motivating patients to replace junk foods with fruits and vegetables
Personal attitudes, cultural beliefs, shopping habits, cooking skills, and family dining habits and celebrations are important to understand and build from clinically. The Fast Company article, “Prescribing” fruits and veggies would save $100 billion in medical costs, featured an attractive, colorful photo of fruits and vegetables as they might be on display at a supermarket shelf or at a local farm stand.
But this image of “a rainbow of healthy produce” is illustrative of another problem: The “marketing” of raw fruits and vegetables often shows them in their raw format, rather than as eye-catching, mouthwatering meals. Raw plants are not seen by most consumers as ready-to-eat breakfast, lunch, or dinner options. These images compete with those from highly processed food companies and fast-food restaurants that are painstakingly designed to scream “flavor” and “convenience”.
Just like any prescription a physician would write for their patient, there are barriers that can get in the way of patients using their fruit and vegetable prescription as intended. Right now, we do not have a large and thriving “clean” fast food industry, so there are practical steps that people must take to turn most raw produce into meals. Some people don’t like to cook, or their neighborhood lacks healthy produce. Some people don’t know how to prepare a variety of vegetables, or they have had negative childhood experiences with them (bland and mushy). These are all barriers to adopting a diet that is higher in fruit and vegetables.
A critical need is for clinicians who serve as patients’ healthcare guides to assess each person’s individual needs and barriers and connect them with new resources, successful peers, and programs that provide positive new experiences around healthy food options. At Silver Fern, our in-depth assessments are designed to specifically assess the current diet behaviors, goals, and barriers of each individual and then offer specific, tailored actions for working with each person to improve their meal plan. Data from our Behavior Diagnostic Platform also offers insights into the most common behaviors and barriers for different populations, enabling physicians and the extended care team to tailor education and support to those populations.
How can clinicians promote more fruit and vegetable consumption in their daily practice?
- Connect with the American College of Lifestyle Medicine and use their practice resources and professional networks to help integrate lifestyle medicine into routine clinical practice.
- Build an integrated team of dietitians, care management nurses, health coaches, community health workers, and other extenders of your core team. Blend telehealth with traditional in-person patient education and care coordination. Work with local healthcare administrators to hardwire these new referrals into existing clinical dashboards, team processes, and billing.
- Raise patient awareness of our US diet and lifestyle and its connection to patient health and quality of life. Provide patients with fresh information and messaging around whole person care.
- Help patients identify healthy vs. unhealthy food choices, including replacing highly processed foods and fast foods with fruits and vegetables using handouts, web videos, and other links.
- Meet patients “where they are” and take time to understand their typical day and habits. Ask them about their goals and help them start with positive changes in meal choices that could be maintained over the long term.
- Recommend “flexitarian” eating for most people. Simple messages could include, “Eat more plants and fewer animal products.” And, “Fill your cart with foods around the perimeter of the grocery store, avoiding highly processed foods and filling up on minimally processed foods”.
- Help patients use the internet, social media, and aps to explore herbs, spices, and healthy cooking techniques from different global cuisines to find deep flavors, variety, and enjoyment in meals made of plant-based and whole-food ingredients.
- Track clinical data and fruit and vegetable intake changes and share with patients the impact on their health as measured by blood glucose, blood lipids, blood pressure, inflammation markers, and insulin resistance.
- Consider being a role model for your patients or an activist for US food system change.
Garry Welch, PhD is an expert in the area of behavior medicine for chronic disease care. He has extensive experience leading clinical research on behavior change strategies for people with diabetes and other chronic diseases. Dr. Welch’s 30+ years of clinical research led to co-founding Silver Fern Healthcare. He leads research and development at Silver Fern.