Factors associated with produce prescription program enrollment and benefit use among patients with diabetes and at risk for food insecurity

BACKGROUND: Food insecurity exacerbates Type 2 Diabetes (T2D) by limiting access to nutritious foods and worsening glycemic control. Produce Prescription (PRx) programs subsidize fruits and vegetables to improve food security and diet quality, yet factors associated with PRx engagement patterns remain understudied. 

OBJECTIVE: To evaluate factors associated with enrollment and benefit use in a PRx program among patients with T2D at risk for food insecurity. 

METHODS: This observational cohort study analyzed participants from a pragmatic randomized trial in a large integrated health system. Eligible adults (≥18 years) had recent HbA1c measurements and food insecurity risk based on Medicaid enrollment, high area deprivation index (ADI ≥7), or documented unmet social needs. Of 9,644 contacted, 2,177 enrolled and were randomized 2:1 to receive the EatWell PRx program, receiving a reloadable debit card providing $80/month for 12 months to purchase fruits and vegetables. We examined predictors of: (1) study enrollment, (2) any spending (>$0), (3) high spending (>$53/month median), and (4) highest spending (>$70/month). Multivariate logistic regression included demographic, socioeconomic, and clinical covariates. 

RESULTS: Of the 9,644 contacted, 2,177 enrolled (22.6%),1,450 were assigned to the PRx arm, and 1,148 (79.2% of enrollees) activated their cards. Enrollment was lower among older adults (per 10-year increase: OR 0.75; 95% CI 0.72-0.77), males (OR 0.57; 0.51-0.63), Medicaid enrollees (OR 0.61; 0.53-0.69), high-ADI (OR 0.62; 0.55-0.70), and non-Hispanic White (OR 0.76; 0.68-0.85) and Hispanic/Latino (OR 0.72; 0.57-0.90) participants compared with Black participants. Among card activators, high spending was associated with older age (OR 1.15; 1.04-1.27), while highest spending was associated with being married (OR 1.43; 1.03-1.96) and Black compared to White race (OR 1.56; 1.09-2.22). 

CONCLUSIONS: Demographic and socioeconomic factors were significantly associated with PRx enrollment and utilization. Multimodal outreach strategies and targeted implementation approaches may be necessary to ensure equitable program reach and effectiveness.