Advancing Food is Medicine research: An EPIS-informed qualitative study of stakeholder views

Introduction: Diet quality in the United States remains poor and contributes to chronic disease. Food is medicine (FIM) interventions integrate healthy foods into health care to manage or treat diet-related illness. Although evidence supports the nutrition-health link, less is known about how to implement FIM programs effectively in real-world settings or how to design FIM research across complex delivery systems. Guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework, this qualitative study examines early implementation experiences from the American Heart Association's Health Care by Food™ (HCXF) initiative to inform future FIM research.

Methods: We conducted five virtual focus groups with HCXF-funded FIM researchers and community-based organization (CBO) partners and interviewed one food vendor. Discussions explored lessons learned, evidence gaps, methodological improvements, implementation barriers, motivations for participation, and future research priorities. We performed thematic analysis and mapped themes to the EPIS framework.

Results: Themes spanned all EPIS phases. In Exploration, participants described a fragmented evidence base, measurement gaps, and uncertainty about payer requirements amid shifting policy. In Preparation, they emphasized earlier engagement of CBOs and vendors, limited partner research capacity, and tensions between standardization and cultural tailoring. In Implementation, unclear roles, logistical complexity, and variable capacity affected feasibility; recruitment and retention relied on trust-based engagement, and technology was helpful but constrained by access and use. In Sustainment, participants highlighted outcomes beyond clinical measures, payer-specific communication and champions, and the need for stronger national coordination to support scale and coverage.

Conclusions: Early HCXF implementation experiences suggest that advancing the FIM evidence base will require larger, more coordinated studies and clearer approaches to partnership governance, measurement, cultural adaptation, and trust-based engagement. Aligning implementation science-grounded study designs with payer needs, capturing outcomes beyond clinical endpoints, and strengthening national coordination may accelerate translation into scalable models and sustainable coverage.