WASHINGTON (THE WASHINGTON POST) - Ms Adrienne Dove pulled up to the checkout line of the Giant grocery store in Washington with a cart filled with cabbage, bananas and bagged string beans.
The register rang US$20.60 (S$28.37). Instead of cash or card, Ms Dove paid with a Produce Rx voucher from the store pharmacy.
The Giant in the most impoverished part of the District of Columbia is the latest frontier in the "food as medicine" movement.
Hospitals and local governments across the country have been writing and filling prescriptions for healthy food in an attempt to address the root causes of diabetes, hypertension and other costly illnesses.
The federal farm Bill that was passed late last year included more than US$4 million in grants for the US Department of Agriculture (USDA) to distribute to governments that run prescription produce programmes, but the money has not yet been distributed.
The goal, backed by some research, is to improve health and reduce costs by subsidising fresh produce such as broccoli and grapefruit in addition to insulin and beta blockers.
"What we are hoping to find is there is a return on investment for the health-care system: a reduction in ER visits, medication compliance," said Ms Lauren Shweder Biel, executive director of DC Greens, a nonprofit group that is managing the District's Produce Rx pilot.
"That's the holy grail for systems like this."
Improved diet is also a target.
"I was trying to manage my patients' diabetes and high blood pressure, but when they were telling me they were eating Top Ramen, doughnuts and bagels because it keeps them full, all I could say was 'That's too bad, here's some more drugs', " said Dr Rita Nguyen of the San Francisco Department of Public Health, who now oversees an expanding produce prescription programme at six clinics.
In the nation's capital, the Produce Rx programme started last month and provides 500 Medicaid patients US$20 weekly vouchers for produce at the Giant in Ward 8 through the end of the year.
Ward 8 is the poorest, sickest part of the city and has the highest rates of death for diabetes and heart disease. It is also a food desert, and the Giant is the only full-service grocery store.
The Produce Rx programme, which includes the costs of vouchers and evaluating patient outcomes, has received US$500,000 from the District government and about US$150,000 from AmeriHealth Caritas, a Medicaid-managed care organisation.
AmeriHealth Caritas patients are the only ones now eligible for the Produce Rx pilot. DC Greens is seeking additional funding from the USDA to expand the programme.
Council member Mary Cheh is urging lawmakers to increase the sales tax on sweetened beverages by 1 per cent to create a permanent revenue source for the Produce Rx initiative, among other programmes.
Ms Dove, 43, found out about the programme while at a health clinic for a check on the state of her hypertension and anaemia.
Medical professionals often urge Ms Dove to eat better, but she was surprised when a clinic official called the grocery store pharmacy to secure produce vouchers for her the same way doctors would call in a prescription for drugs.
"I was just mainly eating fried chicken wings and french fries. I grew up on McDonald's and I got high blood pressure," said Ms Dove, who lives with her mother and two children near the grocery store.
"Now I tell my son, 'don't be like Mommy', and he asks for broccoli and spinach."
In 2001, Boston Medical Centre launched one of the first food pharmacies with its preventive food pantry in the basement of the safety net hospital, which treats patients regardless of their ability to pay.
In San Francisco, health officials found that patients were more likely to pick up food from weekly events at neighbourhood clinics than at the public hospital. At the clinics, patients can choose their own meats, whole grains and vegetables, as well as watch cooking demonstrations by nutritionists - who sometimes give out cutting boards and knives.
Dr Nguyen, the San Francisco health official, said that proponents of food as medicine are still trying to figure out the best way to set up such programmes.
"We don't know what dose of food is enough to make a difference," Dr Nguyen said.
"Is food by itself enough? Or do you need the nutritionist, do you need the cooking supplies, the recipes?"
In Pennsylvania, the Fresh Food Farmacy initiative by regional health insurer and provider Geisinger provides produce, cooking demonstrations and diabetes management lessons to 700 patients in the northeast and central parts of the state.
In the first two years of the programme, officials found that diabetics who received food saw their blood sugar levels decline, as opposed to those who were not given any.
Ms Allison Hess, a Geisinger executive, said the Fresh Food Farmacy costs about US$3,500 per family annually, and drops in blood sugar would result in greater savings from less medication.
"It's kind of a no-brainer," Ms Hess said. "We are going to either pay for this medical expense or pay for this food and education that's going to be more of a lifelong benefit."
The District's approach differs still. Instead of a new pantry or offering food at the doctor's office, the city is nudging residents to buy fruits and vegetables at a grocery store that is already part of their weekly routines.
City health officials said that earlier efforts to connect residents in food deserts to produce at corner stores ran into trouble because the retailers could not always find enough customers. The Produce Rx programme builds on a more limited subsidy programme that already exists at farmers markets.
"Most people are going to come to the grocery store, while farmers markets and pop-ups are at certain places at certain times of year," said Dr Lavdena Adams Orr, the chief medical officer at AmeriHealth Caritas.
Ms Ciera Price of Washington was distraught when she was diagnosed this winter with hypertension, diabetes and high cholesterol. She left the doctor's office with an admonition to eat healthier and a prescription for the produce programme.
Ms Price was at the grocery store, on her first shopping trip with her produce vouchers, looking at melons and strawberries when she met the supermarket's in-house nutritionist, Ms Jillian Griffith, and scheduled an appointment for a free consultation.
The Produce Rx programme does not require consultations, but patients picking up their produce vouchers are encouraged to meet with Giant's nutritionist.
Giant has them across the Washington region, and they usually rove between stores and offer US$25 consultations, a fee offset by US$25 in vouchers for products. The Ward 8 Giant does not charge for consultations with nutritionists and is the only store in the supermarket chain with an in-store wellness centre. It offers diabetes management classes and one-on-one coaching.
"When they tell you to eat healthy, what does that mean to you?" Ms Griffith asked Ms Price from behind her desk in the store's wellness centre on a recent afternoon.
Ms Price winced.
"Leaving everything that I love and sticking to the greens," she replied.
Ms Griffith offered a more optimistic answer.
"Maybe you can learn to love new things," she said. "We want to be in the middle and mindful of the things we are eating and how to eat foods that make us happy."
Over the next hour, they talked about what Ms Price likes to eat (pasta and mac and cheese) and what she does not like (chicken and apples). They ended with two concrete goals: bigger vegetable sides and smaller pasta portions during dinner, and adding fresh strawberries and bananas to her breakfast oatmeal.
Before she left, Ms Price asked to pose for a selfie with Ms Griffith as photographic evidence that she was meeting a nutritionist.
One of the biggest challenges for prescription produce programmes is ensuring that access to healthier foods will make a difference in what a person chooses to eat.
Ms Griffith said that it is not uncommon to hear from patients who, like Ms Price, are overwhelmed by the thought that they have to change everything about their meals. She instead tries to steer them towards new options rather than restricting their diet.
"Either they've been struggling with diabetes a long time or never received information beyond 'eat healthier'," Ms Griffith said. "Especially on this side of town, there's not a lot of opportunities for people to receive one-on-one time they need."