A total of 62 participants agreed to participate in the study. Over the course of the study, five participants dropped out; two moved away from the region, one felt they no longer needed the food support provided by the program, and two felt the program did meet their needs. A total of 57 participants completed pre-intervention data collection, of which 46 completed the mid-point survey and 49 completed post-intervention data collection. The overall follow-up rate was 79.0% after accounting for dropouts and non-responses. A total of 197 household members were captured in the program, although data collection occurred only with one participant meeting eligibility criteria from each household. Descriptive characteristics of participants is provided in Table 1. More women (n=42) than men (n=15) were captured by the program, and half (50.9%) of participants were between the ages of 40 and 59. The most common self-reported health outcomes were depression and anxiety (68.4%), hypertension (56.1%), dyslipidemia (40.4%), and vitamin deficiencies, including iron deficiency anemia (35.1%). Over 88% of the value of vouchers was redeemed by participants, who were provided on average $1,340 each to spend at Groceries from the SEED over the 52-week period. Twenty-five (43.8%) participants redeemed all of the vouchers they were provided.
Table 1: Descriptive characteristics of participants in a fresh food prescription program in Ontario, Canada based on pre-intervention survey and voucher usage (n=57)
Characteristic
|
No. (%), proportion, or mean (95% confidence interval)
|
Gender
Man
Woman
|
15 (26.3)
42 (73.7)
|
Age at enrolment in years
|
50.1 (46.6, 53.6)
|
Age group at enrolment
20 – 39 years
40 – 59 years
60+ years
|
15 (26.3)
29 (50.9)
13 (22.8)
|
Race/ethnicity
White
Black
Indigenous to Turtle Island
Asian (including Arabic, East Asian, South Asian, or Southeast Asian)
Latin American
Chose not to respond
|
23 (40.4)
6 (10.5)
1 (1.8)
16 (28.1)
1 (1.8)
12 (21.1)
|
Smoker Yes No
|
22 (38.6) 35 (61.4)
|
Self-reported health outcomes
Prediabetes
Diabetes
Hypertension
Chronic obstructive pulmonary disorder
Dyslipidemia
Chrons’ disease, irritable bowel syndrome, or Celiac disease
Depression and/or anxiety
Anorexia, bulimia, and/or eating disorder
Iron deficiency anemia
Other vitamin deficiency
|
6 (10.5)
16 (28.1)
32 (56.1)
5 (8.8)
23 (40.4)
8 (14.0)
39 (68.4)
5 (8.8)
20 (35.1)
25 (43.9)
|
Household size
|
3.2 (2.7, 3.8)
|
Household size group
1-2
3-4
5-6
7+
|
24 (42.1)
21 (36.8)
8 (14.0)
4 (7.0)
|
Household income group ($CAD)
0 – 19,999
20,000 – 39,999
40,000 +
Don’t know / prefer not to answer
|
32 (56.1)
16 (28.1)
9 (15.8)
5 (8.8)
|
Receiving Ontario Disability Service Support Program
Yes
No
|
27 (47)
30 (53)
|
Adequacy of appliances in home for food preparation
Inadequate
Adequate
Very adequate
|
14 (24.6)
30 (52.6)
13 (22.8)
|
Place where most foods are purchased
Grocery store
Farmer’s Market
Food Bank
Groceries from the SEED
|
51 (83.9)
0 (0)
6 (10.7)
2 (5.4)
|
Appointments with healthcare professional during study period
|
12.9 (10.0, 15.8)
|
Value of vouchers redeemed
|
$1,340 (1136, 1543)
|
Proportion of vouchers redeemed
|
88.2%
|
Pre-intervention, midpoint, and post-intervention food security, food consumption, and self-reported health are presented in Table 2. Although all participants initially screened as food insecure based on the one-item food security screener, there were two participants who were categorized as food secure in the pre-intervention survey and were included in the study. Adult food insecurity score improved (i.e., was reduced) from pre-intervention to mid-point (p<0.001), then worsened between the midpoint and the post-intervention survey. However, the mean post-intervention adult food insecurity score was still lower (p<0.001) than the mean pre-intervention food insecurity score. The proportion of participants categorized as severely food insecure was reduced from 47.4% to 24.5% from pre-intervention to post-intervention. Consumption of fruit, dark green vegetables, orange vegetables, and other vegetables increased during the intervention (p<0.05). Results from pre-intervention and post-intervention blood pressure measurements and blood cardiometabolic and nutrition biomarker analyses are presented in Table 3. Fasting insulin (Δ=-52 pmol/L; p<0.001) and ascorbic acid (Δ=4 μmol/L; p<0.05) were the only two health measures that showed a statistically significant improvement from pre-intervention to post-intervention data collection.
Table 2: Pre-intervention, mid-point, and post-intervention food security, food consumption, and self-reported health among participants in a fresh food prescription program based in Ontario, Canada
Characteristic
|
Pre-intervention mean (95% CI) or proportion
|
Mid-point mean (95% CI) or proportion
|
P-value
|
Post-intervention mean (95% CI) or proportion
|
P-value
|
Adult food insecurity score
|
5.0 (4.4, 4.4)
|
2.4 (1.7, 3.1)
|
<0.001
|
3.3 (2.6, 3.9)
|
<0.001
|
Child food insecurity score
|
2.7 (1.8, 3.7)
|
1.0 (0.4, 1.6)
|
0.16
|
2.3 (1.2, 3.3)
|
0.16
|
Food security categories
|
|
|
<0.001
|
|
0.061
|
Food secure
|
3.5%
|
25.6%
|
|
10.2%
|
|
Marginal food insecurity
|
5.3%
|
16.3%
|
|
14.2%
|
|
Moderate food insecurity
|
43.9%
|
46.4%
|
|
51.0%
|
|
Severe food insecurity
|
47.4%
|
11.6%
|
|
24.5%
|
|
Food consumption (servings per week)
|
|
|
|
|
|
Fruit
|
4.7 (3.5, 5.8)
|
8.9 (7.3, 10.4)
|
<0.001
|
7.3 (5.9, 8.7)
|
0.019
|
Fruit juice
|
1.0 (0.5, 1.5)
|
1.8 (0.9, 2.6)
|
0.016
|
1.4 (0.5, 2.2)
|
0.32
|
Dark green vegetables
|
3. (2.6, 4.2)
|
4.3 (3.5, 5.2)
|
0.12
|
4.9 (3.8, 5.9)
|
0.046
|
Orange vegetables
|
1.5 (1.1, 1.9)
|
3.3 (2.6, 40)
|
<0.001
|
3.0 (2.0, 3.9)
|
0003
|
Potatoes
|
1.7 (1.1, 2.3)
|
2.7 (2.0, 3.4)
|
0.017
|
2.7 (1.6, 3.8)
|
0.16
|
Other vegetables
|
2.9 (2.2, 3.7)
|
4.5 (3.6, 5.3)
|
0.0069
|
4.3 (2.9, 5.8)
|
0.033
|
Red meat
|
2.1 (1.6, 2.6)
|
1.7 (1.2, 2.2)
|
0.029
|
1.7 (1.0, 2.4)
|
0.19
|
Other meat
|
6.4 (5.3, 7.6)
|
5.9 (4.6, 7.2)
|
0.69
|
6.3 (4.7, 7.8)
|
0.72
|
Dairy products
|
8.9 (6.9, 10.9)
|
8.1 (6.2, 9.8)
|
0.57
|
8.3 (6.5, 10.1)
|
0.49
|
Eggs
|
2.5 (1.8, 3.2)
|
3.8 (2.8, 4.7)
|
0.027
|
3.1 (2.3, 3.9)
|
0.28
|
Sugar-sweetened beverages
|
2.1 (0.9, 3.2)
|
1.3 (0.5, 2.2)
|
0.14
|
2.4 (0.6, 4.2)
|
0.38
|
Alcohol
|
0.6 (0.2, 2.0)
|
0.2 (0.0, 0.6)
|
0.06
|
0.3 (0.0, 0.8)
|
0.21
|
Total fruits and vegetables
|
13.5 (10.9, 16.0)
|
22.9 (19.9, 25.8)
|
<0.001
|
20.8 (16.8, 24.9)
|
0.005
|
≥5 servings fruits and
vegetables per day
|
3.5%
|
9.5%
|
0.12
|
8.3%
|
0.40
|
Self-reported health scores
|
|
|
|
|
|
Physical health
|
3.7 (3.4, 3.9)
|
|
|
3.4 (3.1, 3.7)
|
0.16
|
Psychological and emotional health
|
3.4 (3.2, 3.7)
|
|
|
3.3 (3.0, 3.6)
|
0.67
|
Emotional health
|
2.7 (2.4, 3.0)
|
|
|
2.9 (2.6, 3.3)
|
0.032
|
P-value based on paired two-tailed t-tests or Fisher’s exact tests for proportions compared to pre-intervention
Table 3: Pre-intervention, mid-point, and post-intervention cardiometabolic and nutritional measures and biomarkers among participants in a fresh food prescription program based in Ontario, Canada.
Biomarker
|
Pre-intervention mean (95% CI)
|
Post-intervention mean (95% CI)
|
P-value
|
‘Healthy’ reference value
|
Systolic blood pressure (mmHg)
|
125.9 (119.8, 131.9)
|
126.7 (122.0, 131.4)
|
0.49
|
<120a
|
Diastolic blood pressure (mmHg)
|
78.9 (74., 83.1)
|
80.1 (76.9, 83.4)
|
0.25
|
<80a
|
Cholesterol (mmol/L)
|
4.7 (4.4, 5.0)
|
4.7 (4.3, 5.1)
|
0.85
|
<5.2b
|
HDL cholesterol (%)
|
1.27 (l.12, 1.42)
|
1.19 (1.09, 1.28)
|
0.33
|
men: >1; women: >1.3b
|
LDL cholesterol (mmol/L)
|
2.56 (2.26, 2.85)
|
2.60 (2.26, 2.95)
|
0.50
|
<3.5b
|
Trigylcerides (mmol/L)
|
2.21 (1.74, 2.7)
|
2.05 (1.69, 2.410
|
0.082
|
<1.7c
|
Fasting glucose (mmol/L)
|
6.9 (5.8, 7.9)
|
6.2 (5.6, 6.9)
|
0.24
|
<6.1d
|
Fasting insulin (pmol/L)
|
192 (138, 245)
|
140 (109, 170)
|
0.007
|
<174e
|
HbA1c (%)
|
6.4 (5.9, 6.9)
|
6.5 (6.0, 7.0)
|
0.71
|
<5.7f
|
Hemoglobin (g/L)
|
137 (13, 142)
|
138 (133, 143)
|
0.35
|
men: ≥130; women: ≥120g
|
Serum ferritin (μg/L)
|
94 (62, 125)
|
99 (60, 138)
|
0.23
|
>15h
|
Ascorbic acid (μmol/L)
|
31 (25, 37
|
35 (29, 42)
|
0.41
|
>0.7i
|
Vitamin A (μmol/L)
|
2.3 (2.1, 2.5)
|
2.4 (2.1, 2.6)
|
0.41
|
>0.7j
|
Vitamin B12 (pmol/L)
|
374 (289, 459)
|
303 (242, 363)
|
0.11
|
>250k
|
P-value based on paired two-tailed t-tests comparing post-intervention mean to pre-intervention mean
aChobanian et al., 2003 (23)
bPearson et al., 2021(24)
cStatistics Canada, 2023 (25)
dPublic Health Agency of Canada, 2011 (26)
eChevenne et al., 1999 (27)
fCenters for Disease Control and Prevention, 2022 (28)
gWorld Health Organization, 2011(29)
hIannou et al., 2002 (30)
iRowe et al., 2020 (31)
jWorld Health Organization, 2009 (32)
kSelhub et al., 2008 (33)
Self-reported health did not show improvement over the course of the FFRx program. Indeed, participants’ self-reported physical, emotional, and psychological health was unchanged, and social relationships were worse, after the program (p<0.05) in comparison to before when ranked on a 5-point Likert scale from “excellent” to “terrible”. Despite this, however, during the post-intervention survey, 75.5% of respondents stated that their health was “much better”, “somewhat better”, or “about the same” compared to a year prior (Table 4).
Table 4: Responses to the surrey question, “Compared to one year ago, how would you say your health is now?” from participants of a fresh food prescription program in Guelph, Ontario, Canada
Response
|
N (%)
|
Much better
|
9 (18.4)
|
Somewhat better
|
10 (20.4
|
About the same
|
18 (36.7)
|
Somewhat worse
|
8 (16.3)
|
Much worse
|
3 (6.12)
|
Don’t know / prefer not to say
|
1 (2.0)
|
Sixty-five percent of participants reported increased total fruit and vegetable consumption (including fruits, fruit juice, dark green vegetables, orange vegetables, and ‘other’ vegetables) over the course of the program. The overall mean (±SD) change in total fruit and vegetable consumption was 6.4 ± 15.3 servings per week from pre- to post-intervention. In other words, on average, participants consumed 6.4 additional servings of fruits and vegetables following FFRx. We assessed factors associated with change in weekly servings of fruits and vegetables using linear regressions adjusted for age and sex (Table 5). Higher food insecurity score (i.e., worse food insecurity) at baseline was associated with a greater change in fruit and vegetable consumption. Lower fruit and vegetable consumption at baseline was also associated with a greater change in fruit and vegetable consumption over the course of the study (p<0.005). Finally, the number of visits with a healthcare professional (including a physician, nurse practitioner, social worker, dietitian, or service access coordinator) was associated with a greater change in fruit and vegetable consumption (p=0.026).
Table 5: Linear regression assessing factors associated with change in frequency of fruit and vegetable consumption post-intervention (vs. pre-intervention)
Covariate
|
Beta coefficient (95% CI)a
|
Standard error
|
P-value
|
Age (years)
|
-0.15 (-0.51, 0.20)
|
0.18
|
0.39
|
Gender
Male
Female
|
[Ref]
-4.28 (-15.1, 6.5)
|
5.4
|
0.43
|
Household size
|
-0.6 (-2.7, 1.5)
|
1.0
|
0.57
|
Household income
|
-0.09 (-3.4, 3.3)
|
1.7
|
0.96
|
Receiving Ontario Disability Service Support Program
Yes
No
|
[Ref]
-8.2 (-17.0, 0.61)
|
4.4
|
0.067
|
Body mass index at baseline in kg/m2
|
0.04 (-0.5, 0.6)
|
0.3
|
0.90
|
Cardio-metabolic health outcome (prediabetes, diabetes, hypertension, dyslipidemia)
No
Yes
|
[Ref]
1.9 (-12.0, 15.8)
|
6.9
|
0.80
|
Auto-immune (Chrons’ disease, IBS, Celiac)
No
Yes
|
[Ref] 2.6 (-9.9, 15.0)
|
6.2
|
0.68
|
Depression and/or anxiety
No
Yes
|
[Ref]
1.9 (-7.9, 11.8)
|
4.9
|
0.68
|
Vitamin or micronutrient deficiency
No
Yes
|
[Ref]
3.0 (-7.1, 13.1)
|
5.0
|
0.55
|
Adequacy of appliances in home for food preparation
Inadequate
Adequate
|
[Ref]
-0.98 (-11.8, 9.9)
|
15.3
|
0.86
|
Food insecurity score at baseline
|
2.2 (0.04, 4.3)
|
1.1
|
0.04
|
Fruit and vegetable consumption at baseline (servings per week)
|
-0.67 (-1.10, -0.25)
|
0.21
|
0.003
|
No. of appointments with healthcare professionals during study period
|
0.43
|
0.19
|
0.026
|
Coupon usage (as a percentage of coupons issued)
|
-9.9 (-40.1, 20.3)
|
15.0
|
0.51
|
aAdjusted for age and sex only
Next, we assessed potential factors associated with coupon usage as a percentage of coupons issued while controlling for age and sex (Table 6). No assessed characteristics were associated with this outcome.
Table 6: Linear regression assessing factors associated with coupon usage (as a percentage of coupons issued)
Covariate
|
Beta coefficient (95% CI)a
|
Standard error
|
P-value
|
Age (years)
|
-0.001 (-0.005, 0.003)
|
0.0018
|
0.56
|
Gender
Male
Female
|
[Ref]
-0.04 (-0.06, 0.15)
|
0.053
|
0.43
|
Household size
|
-0.005 (-0.03, 0.02)
|
0.01
|
0.66
|
Household income
|
|
|
|
Receiving Ontario Disability Service Support Program
Yes
No
|
[Ref]
0.04 (-0.06, 13.0)
|
0.04
|
0.46
|
Body mass index at baseline in kg/m2
|
-0.0006 (-0.006, 0.004)
|
0.003
|
0.81
|
Cardio-metabolic health outcome (prediabetes, diabetes, hypertension, dyslipidemia)
No
Yes
|
[Ref]
0.10 (-0.03, 0.23)
|
0.07
|
0.14
|
Auto-immune (Chrons’ disease, IBS, Celiac)
No
Yes
|
[Ref] 0.10 (-0.03, 0.24)
|
0.07
|
0.14
|
Depression and/or anxiety
No
Yes
|
[Ref]
-0.004 (-0.11, 0.10)
|
0.05
|
0.93
|
Vitamin or micronutrient deficiency
No
Yes
|
[Ref]
0.026 (-0.078, 0.13)
|
0.05
|
0.62
|
Adequacy of appliances in home for food preparation
Inadequate
Adequate
|
[Ref]
-0.023 (-0.13, 0.09)
|
0.056
|
0.69
|
Food insecurity score at baseline
|
-0.01 (-0.03, 0.009)
|
0.011
|
0.25
|
No. of appointments with healthcare professionals during study period
|
0.002
|
0.002
|
0.36
|
Fruit and vegetable consumption at baseline (servings per week)
|
0.005 (0.0, 0.010)
|
0.002
|
0.052
|
aAdjusted for age and sex only