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Advancing the Science of Integrative Health Equity-Original Article
Global Advances in Integrative Medicine and Health
Volume 14: 1–15
© The Author(s) 2025
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DOI: 10.1177/27536130251316535
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Implementing Food as Medicine During
COVID-19: Produce Prescriptions and
Integrative Group Medical Visits in
Federally Qualified Health Centers
Ariana Thompson-Lastad, PhD
1,2
, Denise Ruvalcaba, BA
1
, Wei-Ting Chen, PhD
3
,
Patricia Rodriguez Espinosa, PhD, MPH
3
, Dorothy T. Chiu, PhD, MSPH
1
, Lan Xiao, PhD
3
,
Lisa G. Rosas, PhD, MPH
3,
*, and Steven Chen, MD
4,
*
Abstract
Background: Food as Medicine is a rapidly developing area of health care in the United States, aimed at concurrently ad-
dressing nutrition-sensitive chronic conditions and food and nutrition insecurity. Recipe4Health (R4H) is a Food as Medicine
program with an integrative health equity focus. It provides prescriptions for locally grown produce (‘Food Farmacy’) with or
without integrative group medical visits, alongside training for clinic staff.
Objectives: To describe the initial implementation of R4H in four Federally Qualified Health Centers in Northern California,
using a convergent mixed-methods approach.
Methods: We used the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) implementation science
framework to assess the first two years of R4H (2020-2022). We draw from 40 interviews (26 partner organization staff,
14 patients) and program data on reach and adoption. Qualitative data were analyzed using codebook thematic analysis.
Results: Reach: From January 2020 to August 2022, 3255 patients were referred to the program; 1997 of those referred (61%)
enrolled in the Food Farmacy only (N= 1681) or Food Farmacy + integrative group medical visits (N= 316). Participating
patients included a wide range of ages (mean age 41.4, [SD 20]; 18% < 18 years old) and racial and ethnic backgrounds (3%
American Indian or Alaska Native, 6% Asian or Pacific Islander, 19% Black, 57% Hispanic/Latine, 7% white). 69% were female;
43% primarily spoke Spanish. Adoption: 84% of trained clinic staff referred two or more patients to R4H. Implementation:
Elements of successful implementation included: (1) support from county government leadership, (2) centralized coordination
of the multi-sector partnership, and (3) a flexible approach responsive to organizational and COVID-related shifts. R4H
implementation informed statewide Medicaid policy changes. Maintenance: To date, all four clinics continue to participate
in R4H.
Conclusion: Centralized implementation, training, and administration of Food as Medicine programs can strengthen com-
munity health centers’capacities to concurrently address chronic conditions and food insecurity. Multi-sector partnerships can
support Food as Medicine program sustainability.
1
Osher Center for Integrative Health, University of California San Francisco, San Francisco, CA, USA
2
Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA
3
Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, USA
4
Alameda County Health, San Leandro, CA, USA
*Lisa G. Rosas & Steven Chen are equally credited last authors of this manuscript.
Corresponding Author:
Ariana Thompson-Lastad, PhD, Osher Center for Integrative Health, University of California San Francisco, 1545 Divisadero Street, 4th Floor San Francisco, CA
94115, USA.
Email: Ariana.thompson-lastad@ucsf.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the originalwork is attributed as specified on the SAGE and
Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
Keywords
food as medicine, food insecurity, group medical visits
Received October 2, 2024; Revised December 2, 2024. Accepted for publication January 10, 2025
Introduction
Food as Medicine is a rapidly developing area of health care
in the United States,
1,2
and one of multiple approaches to
concurrently addressing medical and social needs (eg, the
connections between chronic conditions and food insecurity).
Federally Qualified Health Centers (FQHCs) are primary care
settings with longstanding roles in acknowledging and ad-
dressing social and structural determinants of health.
3
They
are an important site for implementing Food as Medicine
programs. Food as Medicine programs have the potential to
align with broader efforts for integrative health equity, de-
fined as “optimal health for all through a whole-person ap-
proach that explicitly recognizes cultural, social, and
structural determinants of health”.
4
Produce prescriptions are one approach to addressing
nutrition-sensitive chronic conditions and food and nutrition
insecurity
5
and fall within a broader category of medically
supportive food interventions focused on preventing and
treating chronic conditions.
2
The US Department of Agri-
culture (USDA) has been a leader in funding produce pre-
scriptions through the GUSNIP program, funded through the
Farm Bill, COVID relief funds, and the American Rescue
Program Act.
5
Many produce prescription programs have
been implemented in safety-net primary care settings, in-
cluding FQHCs.
6,7
In produce prescription programs, health
care workers ‘prescribe’fresh vegetables and fruit to patients
with chronic conditions and/or food insecurity. Depending on
the program, participating patients can use produce pre-
scriptions in home delivery programs, farmers markets, or
grocery stores. USDA-funded produce prescription programs
have shared goals of supporting health equity, improving
community health, and contributing to local economies.
5
During the COVID pandemic, increased federal funding
allowed produce prescription programs to rapidly expand,
alongside other public and private responses to food inse-
curity, such as the pandemic EBT program and food banks.
8
A rising number of states, including California, now have
waivers from the federal government allowing them to use
Medicaid funds to pay for medically supportive food and
nutrition programs including produce prescriptions.
9,10
Produce prescriptions are being implemented amidst
broad efforts to advance health equity in the United States.
Notable advocacy and policy change efforts in recent years
have aimed to increase food and nutrition security using
multiple approaches. These endeavors include the White
House Conference on Hunger, Nutrition, and Health
11
;a
growing number of states offering universal free school
meals, in an expansion of federally funded school meal
programs originally modeled on those initiated by the Black
Panthers
12,13
; advocacy to maintain and expand SNAP and
WIC food benefits after the end of the COVID public health
emergency
14
; and efforts to increase the number of Black
farmers by redressing harms done by past federal policies
15
.
Qualitative research on the implementation of produce pre-
scription programs highlights the importance of tailoring
programs to local conditions and communities,
16
as well as
the need for organizational infrastructure to support such
programs. Interview studies with clinicians involved in
produce prescription programs have emphasized the need for
training and staff time to implement and evaluate produce
prescription programs,
17
as well as support for integrating
programs into clinical workflows.
18
A recently developed
theory of change for produce prescription programs high-
lights the key roles played by health care organizations,
patients, farmers, and food retail sites (eg, farmers’markets
and grocery stores).
5
Research on produce prescription im-
plementation is an important companion to quantitative
clinical research on health outcomes associated with par-
ticipation. Non-randomized, quantitative studies of produce
prescription programs have demonstrated clinically signifi-
cant improvements in food insecurity, fruit and vegetable
consumption, and cardiometabolic health among adults with
chronic conditions, as well as cost-effectiveness.
2
Random-
ized trials and other research on health outcomes, health care
utilization, and cost of health care use among people re-
ceiving produce prescriptions are ongoing, with multiple
efforts to use electronic health records to collect clinical data
for research.
19
Group medical visits are a rapidly expanding model of
care delivery that many see as an important model for ad-
dressing health care inequities.
20-22
Group visits have been
implemented in primary care settings, particularly FQHCs,
23
to provide care for diabetes, prenatal care, and chronic pain,
among other conditions. Group medical visits bring multiple
patients into the same physical or virtual space with one or
more clinicians for billable medical care, peer support, and
health education. Integrative group medical visits (IGMVs)
also include integrative therapies such as mind-body practices
(eg, mindfulness, yoga) or acupuncture. Nutrition education,
cooking, and health coaching have also been commonly
integrated into IGMVs.
23,24
Telehealth IGMVs were un-
common before the COVID pandemic but have been growing
rapidly, with many organizations continuing to offer virtual
IGMVs.
25,26
Clinical research on IGMVs has demonstrated a
wide variety of benefits for chronic conditions,
21,24,27
and
qualitative evidence consistently points to their promise for
reducing social isolation and loneliness.
28-30
2Global Advances in Integrative Medicine and Health
Recipe4Health (R4H), a Food as Medicine initiative,
addresses food insecurity and nutrition-sensitive chronic
conditions among patients in FQHCs in Alameda County, CA
(see Figure 1). R4H includes: (1) produce prescriptions for
locally grown fruit and vegetables (‘Food Farmacy’); (2)
IGMVs that include medical care, peer support, health
coaching, nutrition and movement, and mind-body practices;
and (3) training for FQHC clinicians and staff to implement
Food as Medicine. Alameda County Health, an arm of the
County government, was the lead agency for developing the
program and coordinating the partners. R4H partners during
the period discussed in this article included Dig Deep Farms,
a local farm led by Black farmers that grows food for the Food
Farmacy using organic and regenerative approaches; Open
Source Wellness, a local non-profit that provides health
coaches and curriculum for IGMVs; Community Health
Center Network, a county-wide consortium of FQHCs; Al-
ameda Alliance for Health, a local Medicaid managed care
plan; four multi-site FQHCs, and multi-disciplinary re-
searchers at Stanford and University of California San
Francisco (see Table 4). The program has been funded by the
USDA, local Medicaid managed care, local government, and
philanthropic sources. Quasi-experimental quantitative
evaluation of R4H effectiveness has found improvements in
produce consumption and clinical outcomes, and has been
described elsewhere.
31,32
Recipe4Health works concurrently towards multiple
goals. First, the program strives to prevent, treat and reverse
chronic conditions, using broad eligibility criteria that include
people of any age living with food insecurity or a range of
nutrition-sensitive chronic conditions. Second, it increases
access to vegetables and fruit. Third, R4H works to advance
health equity through implementation in FQHCs, which serve
racially and ethnically diverse, low-income populations
primarily insured through Medicaid. The program trains a
wide range of health care workers to ‘prescribe’produce and
IGMV participation. Finally, R4H contributes to local
economies, with a focus on climate and soil health and
employing people from the communities it serves. Partner
organization Dig Deep Farms is led by BIPOC farmers and
was originally an affiliate of the Alameda County Sheriff’s
Office. Dig Deep Farms provides job training to people in re-
entry from incarceration and uses regenerative agriculture
approaches focused on improving soil health as well as
nutrient density of food.
This article focuses on the initial implementation of
Recipe4Health (2020-2022). We used a mixed methods ap-
proach informed by the RE-AIM implementation science
framework to assess reach, adoption, implementation and
maintenance of the program
33,34
with a focus on under-
standing the roles of participating partner organizations in this
multi-sector partnership.
Methods
Setting
Alameda County is a large region in Northern California, with a
high cost of living in urban and suburban areas. In 2022 (when
this analysis ended), nearly 10% of county residents were ex-
periencing food insecurity, but notably half of those had incomes
too high to qualify for SNAP nutrition benefits.
8
A recent
analysis demonstrated that food insecurity in the county is al-
most three times as high in formerly redlined neighborhoods as
in neighborhoods that were not redlined.
35
The county has eight
FQHCs, each with multiple primary care sites.
Figure 1. Recipe4Health model ingredients.
Thompson-Lastad et al. 3
Intervention
Recipe4Health was planned prior to the COVID pandemic
with the intention of offering in-person integrative group
medical visits at each site, as well as onsite produce stands
(“Food Farmacies”) staffed by Dig Deep Farms staff. In this
planned implementation, R4H participants would receive
produce using their prescriptions, and other patients and staff
could purchase produce using cash or SNAP benefits. Due to
COVID, R4H quickly adapted in the first two months of
implementation. During the period discussed in this article,
the program provided telehealth IGMVs for adults and
doorstep delivery of produce to both adults and children. Staff
and clinicians at participating FQHC sites referred patients to
R4H if they screened positive for food insecurity, and/or
because of diagnosis with one or more nutrition-sensitive
chronic conditions (including diabetes, hypertension, pre-
diabetes, hyperlipidemia, depression and anxiety, chronic
kidney disease, irritable bowel disease, and others). The
program provided doorstep delivery of produce with or
without IGMV participation depending on patient preference.
All enrolled patients received 16 weeks of produce delivery,
and adult participants who chose to participate in the IGMV
attended 16 weekly sessions co-facilitated by a primary care
provider with trained health coaches. The R4H Food Farmacy
and IGMV (sometimes called a ‘Behavioral Pharmacy’) have
been described in detail in prior publications.
31
Clinics also
assessed whether participating patients were enrolled in
SNAP/CalFresh (colloquially known as ‘food stamps’)to
support ongoing food access.
Formal data-sharing agreements between partner organi-
zations allowed (1) clinic staff to refer to R4H through the
EHR, (2) Dig Deep Farms and Open Source Wellness staff to
receive and process referrals for the Food Farmacy and IGMV,
and (3) researchers to receive anonymized EHR and survey
data for quantitative evaluation of program effectiveness.
Study Design & Recruitment
This research is part of a larger mixed-methods, longitudinal
evaluation of R4H effectiveness and implementation. The
present analysis used the RE-AIM implementation science
framework to assess R4H reach, adoption, implementation
and maintenance (effectiveness is reported in a separate
publication currently under review).
33
RE-AIM typically
includes individual-level data on a program’s reach and ef-
fectiveness, as well as program-level data on adoption, im-
plementation and maintenance. All research procedures were
approved by the Institutional Review Boards at UCSF (#19-
28766, #21-34511) and Stanford University (#57239).
Measures and Data Sources
Reach. Reach is generally defined in the RE-AIM framework
as the number and characteristics of program participants, as
compared with broader populations in the same settings. We
compare demographic data for patients referred to and par-
ticipating in R4H with overall patient populations at the same
FQHCs. Demographics for people referred to R4H were
collected from FQHC electronic health records with formal
data sharing agreements, while broader demographic data
from R4H clinics were publicly available online through the
Community Health Center Network.
Adoption and Maintenance. The Recipe4Health coordinating
hub in county government provided data on program
adoption and maintenance. We defined adoption as number of
clinic staff trained to refer to R4H who referred at least two
patients. This data was only available for 2022. We defined
maintenance as whether an FQHC continued participating in
R4H (as of fall 2024).
Implementation. Implementation was evaluated qualitatively
through interviews. Interview guides were developed by our
interdisciplinary team and informed by the RE-AIM
framework. A total of 40 interviews were conducted with
patients and R4H partner organization staff from Spring
2020-Spring 2022. Researchers fluent in Spanish and English
(DR and ATL) conducted interviews using Zoom video-
conferencing, phone calls, or in-person, and informed consent
was obtained from all participants. All interviewees received
a $50 gift card. Additionally, researchers attended weekly
meetings of R4H partner organization leadership as
participant-observers in program implementation. These
meetings included detailed discussion of program reach,
adoption, implementation and maintenance that informed our
analysis.
Staff interviews. Staff members were recruited from partner
organizations including three FQHCs, Dig Deep Farms, Open
Source Wellness, and Recipe4Health staff from county
government. All staff involved in R4H and employed by one
of these organizations were invited via email and staff
meetings to participate in an interview.
Patient interviews. We conducted interviews with patients
participating in IGMV with concurrent Food Farmacy de-
liveries. A researcher attended virtual IGMV sessions at three
R4H sites to observe and meet patients before inviting them to
participate. Interviews were conducted in Spanish or English
according to patient preference.
Data Analysis
All interviews were audio recorded and professionally
transcribed. Interviewers wrote summary memos after each
interview, and quality checking of interview transcripts was
completed by listening to recordings while reviewing tran-
scriptions. A team of five researchers with qualitative
research experience conducted data analysis using a
4Global Advances in Integrative Medicine and Health
codebook thematic analysis approach and Dedoose qualita-
tive data management software.
36
The analysis team devel-
oped an initial codebook using inductive and deductive
approaches. Interviews were coded in their original language
(Spanish or English). We met regularly to refine inductive
codes, reconcile coding differences, and ensure accuracy,
while simultaneously participating in weekly meetings with a
larger R4H evaluation team. Themes were then reviewed and
refined through discussion with the interdisciplinary author
team, which includes the R4H Chief Medical Officer, as well
as researchers with backgrounds in sociology, epidemiology,
psychology, food systems, group visits, nutrition, and health
equity. Interview data on referral processes, patient per-
spectives on participation in Food Farmacy and IGMVs and
other programmatic insights were shared as feedback for
program optimization using the lightning report method.
37
Results
In alignment with the RE-AIM implementation science
framework, we discuss the reach, adoption, implementation,
and maintenance of the Recipe4Health program. Data sources
include demographics of participating patients, program
implementation data, and 40 qualitative interviews. Patient
interviewees (N= 14) were all participants in the Food
Farmacy + IGMV program. The majority were women
(93%), Black (29%) or Latine (43%), and had hypertension
(57%) and/or chronic pain (50%) as well as other chronic
conditions (see Table 1). Staff interviewees (N= 26) worked
for partner FQHCs, Open Source Wellness, or Dig Deep
Farms in a variety of roles including clinicians, medical
assistants, health coaches and farmers. The majority were
women (92%) and identified as Latine (35%) or white (54%);
46% spoke Spanish (see Table 2).
Reach
Recipe4Health was implemented at four FQHC sites between
January 2020 and January 2022. From January 2020 to
August 2022, 3255 patients were referred to the program, and
1997 or 63% of those referred enrolled. The majority of these
participated in the Food Farmacy only (1681 patients). Adults
18 and over could additionally participate in the integrative
group medical visits, which were available in English at all
sites and in Spanish at some sites; 316 people participated in
IGMVs during the analysis period.
Table 3 provides descriptive demographics for all patients
referred to and enrolled in Recipe4Health, relative to all
patients at the FQHCs with sites participating in R4H. Par-
ticipants in R4H were fairly representative of the overall
patient populations in participating FQHCs, with some no-
table demographic differences.
Patients enrolled in R4H included a wide range of ages
(mean age 41.4 years, [SD 20]; 18% < 18 years old) and
racial/ethnic backgrounds (19% Non-Hispanic Black, 57%
Hispanic/Latine, 6% Asian/Pacific Islander, 7% Non-
Hispanic white, 3% American Indian or Alaska Native).
Compared to overall FQHC demographics, R4H participation
generally mirrored patient age breakdown, although the
percentage of children served by R4H was smaller than the
percentage of children served by FQHCs overall (18% vs
29%). By gender, more R4H participants were female (69%)
than the percentage of females served by FQHCs overall
(57%). Compared to FQHCs overall, R4H referrals and
enrollees included more non-Hispanic Black participants
(19% of those enrolled in R4H vs 12% of clinics overall),
Hispanic/Latine participants (57% of those enrolled vs 53%
served in clinics overall), and mixed race participants (3% of
those enrolled vs 1% served in clinics overall). Fewer Asian/
Pacific Islander patients participated in R4H (6% of those
enrolled vs 14% served in clinics overall). Among patients
referred to R4H, 43% of participants spoke Spanish; language
data was not available for the full FQHC population.
Comparing those enrolled in the Food Farmacy only
(which was also available to children) to those enrolled in the
Food Farmacy + IGMV, those enrolled in Food Farmacy +
IGMV tended to be older (mean age 48.6 vs 40.1 years) and
were predominantly female (81% vs 69% of Food Farmacy
only participants). There were dramatically fewer Hispanic/
Latine participants in the Food Farmacy + IGMV program
(29% vs 63% of Food Farmacy-only participants), likely
because few clinics offered Spanish-language IGMVs during
this period. Only 13% of Food Farmacy + IGMV participants
spoke Spanish as their primary language, compared with 52%
of Food Farmacy only participants.
Adoption
Four clinic sites, each from a different FQHC organization,
implemented R4H between January 2020 and August 2022.
R4H intentionally developed a very inclusive definition of
which staff could ‘prescribe’produce and IGMV participa-
tion. R4H ‘prescribers’included all primary care clinicians,
as well as mental health clinicians, pharmacists, nutritionists
and dieticians, Certified Diabetes Educators, nurses and
community health workers.
As each clinic prepared to launch R4H, all staff received at
least two hours of experiential training in which they ex-
perienced an IGMV session and also received training in R4H
workflows, including food insecurity screening and referring
to R4H programs through the electronic health record. Pri-
mary care and mental health clinicians, nurses, health edu-
cators, dieticians and nutritionists all received an additional
eight hours of training on food and nutrition, focused on the
prevention and treatment of chronic conditions (see Rosas
et al. 2023 for a more detailed description of training).
31
In
interviews with clinic staff, many mentioned that high rates of
staff turnover meant that not all clinicians and support staff
were trained in R4H, and this affected consistency of re-
ferrals. In 2021, a primary care clinician described how half
Thompson-Lastad et al. 5
of the clinicians at their site had left over the course of a year
and been replaced by new clinicians who were not present for
the initial R4H training. She said, “we’ve told them about
Recipe for Health, but they didn’t get the same introduction.
And I don’t know if it’s possible to [provide the full training
again] but some version would probably be good to get them
bought in.”
Despite challenges with staff turnover at multiple sites,
adoption of the program was high in 2022, the year for which
quantitative data was available. Of clinic staff trained to refer
patients to R4H, in 2022 84% referred 2 or more patients.
With rare exceptions, produce was delivered to all partici-
pants for all 16 weeks (exact adherence data is not available).
IGMVattendance was evenly divided, with about one-third of
participants attending fewer than 50% of sessions, one-third
attending 50%-75% of sessions, and one-third attend-
ing >75% of sessions.
Implementation
After quickly adapting planned implementation at the be-
ginning of the COVID-19 pandemic, R4H consistently
provided doorstep home delivery of produce and telehealth
IGMVs throughout the early years of the COVID pandemic.
Qualitative analysis identified multiple implementation in-
gredients that facilitated the success of R4H. These included:
(1) political will and material support from multiple levels of
government; (2) a multi-sector partnership with centralized
coordination; (3) a flexible, pragmatic approach to program
implementation. Recipe4Health also faced multiple im-
plementation challenges including: (1) clinics’frequently
shifting priorities due to the ongoing COVID pandemic; (2)
communication challenges, intensified by remote collabo-
ration due to COVID; and (3) limited access to land to grow
food for the produce prescription program.
Implementation Strengths
(1) Political will and material support: Recipe4Health
was initiated as part of ALL IN Alameda County, a
broad effort to implement county-level anti-poverty
initiatives developed by the late County Supervisor
Wilma Chan.
38
Federal funding from the USDA
GUSNIP produce prescription program allowed the
ALL IN team to initially implement the program, with
additional funding from the county government, a
local Medicaid managed care plan, and philanthropic
Table 1. Patient Interviewee Demographics.
(N= 14)
Nor mean % or SD
Gender
Female 13 92.9
Age (years; range: 32-65) 52.7 11.0
Race/ethnicity (self-identified)
Black/African American 4 28.6
Hispanic/Latine 6 42.9
American Indian/Native American 2 14.3
White 2 14.3
Highest level of education
Completed college 4 27.5
Some college or vocational school 3 20.4
High school graduate or GED 3 21.4
Less than high school or GED 4 27.5
Primary language
English 9 64.3
Spanish 5 35.7
Health conditions (self-reported)
Pre-diabetes or diabetes 6 42.9
Hypertension 8 57.1
Mental health condition 3 21.4
Chronic pain 7 50.0
Other (eg, heart disease, hypothyroidism) 9 64.3
Interview year
2020 7 50.0
2021 2 14.3
2022 5 35.7
6Global Advances in Integrative Medicine and Health
foundations. Multiple sources of COVID-related
funding supported R4H expansion. Additionally,
Dig Deep Farms, as part of the Alameda County
Sheriff’sOffice, received support from the county
government. One Dig Deep staff member explained
that it was founded “because we wanted to create jobs
for people coming out of jail. And we wanted the job
to be connected to doing something healthy for the
environment and the world first. So, we started the
farm. That was 10 years ago…. We basically are
calling our work, the community capital model of
public safety.”In addition to collaborating with local
government, Recipe4Health leadership participated
in efforts to make Food as Medicine programs a
covered service through California’s Medicaid pro-
gram, which were ultimately successful in 2022 as
part of CalAIM statewide Medicaid reform efforts.
(2) Multi-sector partnership with centralized coordina-
tion: Recipe4Health partner organizations repre-
sented health care, government, non-profit
organizations, agriculture, and research, each holding
distinct roles (see Table 4). A small team based in the
county’s health care services department served as the
convenors, trainers, and implementers of R4H. Clinic
staff at FQHCs had the essential role of identifying
and referring patients to participate in R4H. In in-
terviews, staff and patients alike shared that patients
were more likely to participate when referred by a
trusted member of a health care team. One IGMV
facilitator said that it was “powerful for a health care
provider to tell a patient, ‘I’ve got to write your
prescription, but it’s not for medication, it’s for
participation in the community.’And so patients take
it seriously, they are primed to feel like this is the real
deal, and to commit to it in a way that I think is really
supported by having the provider there.”Dig Deep
Farms held the key role of growing and delivering
food for the produce prescription program, and their
contract with R4H supported the organization’s
overall growth. A Dig Deep staff member explained,
“We’re not a huge farm site so our salaries are
subsidized by Recipe4Health and other governmental
agencies that support Dig Deep Farms.”Represen-
tatives of partner organizations met weekly to discuss
program implementation and evaluation in a process
that one staff person described as “really supportive,
and it can also just be a little bit convoluted or la-
borious to figure out who needs to be involved and
what decisions and where are both the accountabil-
ities, and decision-making power?...it’s just been a
learning process.”During the rapid transitions of
program implementation during the COVID pan-
demic, frequent communication was an essential and
complex aspect of creating a multi-sector partnership.
(3) Flexible,pragmatic approach to program im-
plementation: R4H has consistently provided ser-
vices since March 2020, throughout all stages of the
COVID pandemic. It carefully selected FQHC sites
based on clinic leadership support, County Board of
Supervisors priorities, and the R4H team’s capacity to
provide training and technical assistance. The pro-
gram built on strong relationships between the
Community Health Center Network and individual
FQHC sites (eg, use of a shared electronic health
record). The substantial roles played by partner or-
ganizations meant that patients could continue ac-
cessing R4H services even as clinics navigated
shifting priorities due to COVID. For example, Open
Source Wellness health coaches co-facilitated IGMVs
with clinic-based primary care providers. Health
coaches were able to focus fully on IGMV im-
plementation, with roles that included helping pa-
tients navigate telehealth—described by one as,
“going the extra mile to help [patients] get onto
Zoom….Everyone’s kind of split into a million ways
and asking them to spend a little extra time helping
out their parents or their sibling or whoever it is to get
them onto Zoom is sometimes a little bit tough to
navigate.”From the patient perspective, many
Table 2. Staff Interviewee Demographics.
(N= 26)
Nor mean % or SD
Professional role
Integrative group medical visit health
coach
623
Farmer 2 7.7
Organizational administrator 4 15.4
Primary care clinician 4 15.4
Clinic-medical assistant 5 19.2
Mental health clinician 5 19.2
Gender
Female 24 92.3
Male 2 7.7
Age (years; range: 21-67)
a
39.04 13.0
Race/ethnicity
Black/African-American 2 7.7
Asian/Pacific Islander 2 7.7
Hispanic/Latine 9 34.6
American Indian/Native American 3 11.6
White 14 53.9
Languages spoken
English 26 100
Spanish 12 46.15
Interview year
2020 10 38.46
2021 15 57.69
2022 1 3.85
a
One staff interviewee’s age was missing.
Thompson-Lastad et al. 7
Table 3. Demographics of Patients Referred and Enrolled to Recipe4Health (R4H), Compared With all Patients at R4H Partner FQHCs N(%), Unless Otherwise Noted.
Demographic
characteristic
Referred to R4H Enrolled in R4H All patients of R4H partner FQHCs
a
All referrals (Jan
2020 –Aug
2022) (n= 3255)
Food
farmacy only
(n= 2074)
Food farmacy +
integrative group
medical visits (n=
1181)
All enrolled
(n= 1997)
Food
farmacy only
(n= 1681)
Food farmacy +
integrative group
medical visits (n=
316)
All
clinics
Tiburcio
Vazquez
Health Center
LifeLong
Medical
Care
Native
American
Health Center
Bay Area
Community
Health
Total patients served
(2022)
28 592 57 082 8224 64 157
Age (years), mean
(SD)
43.0 (19.6) 39.9 (21.0) 48.4 (15.3) 41.4 (20.0) 40.1 (20.8) 48.6 (13.6) --
b
--
b
--
b
--
b
--
b
Age category
<18 years 483 (14.8) 451 (21.7) 32 (2.7) 359 (18.0) 359 (21.4) 0 (0.0) 29.1% 42% 25% 44%
c
25%
18-44 years 1090 (33.5) 651 (31.4) 439 (37.2) 657 (23.9) 530 (31.5) 127 (40.2) 59.2% 52% 61% 49%
c
62%
45-64 years 1277 (39.2) 738 (35.6) 539 (45.6) 765 (38.3) 614 (36.5) 151 (47.8)
65+ years 405 (12.4) 234 (11.3) 171 (14.5) 216 (10.8) 178 (10.6) 38 (12.0) 11.8% 6% 14% 7%
c
13%
Gender
Female 2192 (67.3) 1347 (64.9) 845 (71.5) 1368 (68.5) 1113 (66.2) 255 (80.7) 57.2%
d
59%
d
57%
d
61%
d
56%
d
Male 1060 (32.6) 725 (35.0) 335 (28.4) 628 (31.4) 567 (33.7) 61 (19.3) 42.8%
d
41%
d
43%
d
39%
d
44%
d
Not binary 2 (0.1) 2 (0.1) 0 (0.0) 1 (0.1) 1 (0.1) 0 (0.0) --
d
--
d
--
d
--
d
--
d
Race/ethnicity
Hispanic/Latine 1786 (54.9) 1202 (58.0) 584 (49.4) 1142 (57.2) 1052 (62.6) 90 (28.5) 52.9% 70% 39% 58% 57%
White (non-
hispanic)
292 (9.0) 179 (8.6) 113 (9.6) 147 (7.4) 116 (6.9) 31 (9.8) 10.5%
e
6%
e
13%
e
4%
e
11%
e
Black (non-
hispanic)
601 (18.5) 339 (16.3) 262 (22.2) 381 (19.1) 254 (15.1) 127 (40.2) 11.8%
f
4%
f
25%
f
15%
f
3%
f
Asian or pacific
Islander (non-
hispanic)
235 (7.2) 135 (6.5) 100 (8.5) 111 (5.6) 102 (6.1) 9 (2.8) 13.5%
g
7%
g
6%
g
7%
g
24%
g
American Indian or
Alaskan native
(non-hispanic)
73 (2.2) 42 (2.0) 31 (2.6) 50 (2.5) 35 (2.1) 15 (4.7)
Mixed race 73 (2.2) 49 (2.4) 24 (2.0) 56 (2.8) 39 (2.3) 17 (5.4) 1.2%
h
--
h
2%
h
2%
h
1%
h
Unknown/other 195 (6.0) 128 (6.2) 67 (5.7) 110 (5.5) 83 (4.9) 27 (8.5) 9.9% 13% 15% 10% 4%
Preferred language
English 1758 (54.0) 1036 (50.0) 722 (61.1) 1037 (51.9) 763 (45.4) 272 (86.7) --
b
--
b
--
b
--
b
--
b
Spanish 1396 (42.9) 962 (46.4) 434 (36.7) 906 (45.4) 866 (51.5) 40 (12.7) --
b
--
b
--
b
--
b
--
b
Other 101 (3.1) 76 (3.7) 25 (2.1) 54 (2.7) 52 (3.1) 2 (0.6) --
b
--
b
--
b
--
b
--
b
a
For all clinic level statistics, we relied on publicly available 2022 data provided by Community Health Center Network. Only percentages were available.
b
This data was not reported in publicly available Clinic data.
c
Note, Native American Health Center’s public data for age was only available as categorized in the following groupings: 0-19 years, 20-64 years, 65 years+.
d
Publicly available data for clinics was only provided for sex assigned at birth, not gender.
e
Clinic data was only provided as “White.”
f
Clinic data was only provided as “African American.”
g
Clinic data was only provided as “Asian.”
h
Clinic data was only provided as “More than 1 race.”
8Global Advances in Integrative Medicine and Health
appreciated the details of how R4H was im-
plemented. For example, multiple patients found the
doorstep produce delivery to be a more flexible and
person-centered approach than in-person pickup of
produce would have been. One patient said, “I love it.
Well, I don’t have any complaints. Because they text
you and say we’re on our way…. And so I text back
and …There’s your bag and it’s right there!...I want to
find that farm too. I want to see the location [where
the food is grown].”
Implementation Challenges
(1) COVID Pivots: During the implementation period
described, clinics needed to make what several re-
ferred to as ‘constant pivots’to respond to the COVID
pandemic. At many points, clinic staff needed to
prioritize COVID vaccination campaigns or shifting
safety protocols for in-person care. In interviews,
staff described relief that Recipe4Health could ad-
dress patient needs related to food security, social
support, and care for chronic conditions. For some
staff and at some time points, R4H felt like a support
that made their jobs easier. One medical assistant
shared a sense of relief that food insecurity screening
could lead to an R4H referral: “When I’m doing
different screening tools and asking [patients] dif-
ferent questions, I think that it’s a nice surprise, that at
the end of one of them, they get free produce….that
feels like a really valuable resource, being able to just
ask somebody, ‘Are you hungry? Oh, here’s some
food.’It feels like just a very direct way to support
somebody in a really simple, but really important
way.”For other staff and in other moments, priori-
tizing consistent food security screening and program
referrals felt like one more challenge to deal with.
Early in the pandemic, one clinic staff member said:
“Our medical assistants are supposed to be screening
for food insecurity and then immediately recom-
mending that patients get a referral to the Food
Farmacy. I don’t feel like that’s happening consis-
tently. I’m not really sure why. Maybe it’s because of
the way telemedicine visits are structured compared
to when patients are coming in person. I think a lot
more things are falling through the cracks [because of
COVID].”Over a year later, another staff person
described creative approaches like texting patients
who were eligible for R4H and using the program as a
way to motivate attendance at medical visits. Re-
gardless of shifting COVID safety protocols, R4H
was able to continue due to its development as a
program that did not require in-person, face-to-face
interaction.
(2) Partnership communication: Due to COVID, com-
munication between organizational partners took
place almost entirely remotely (via videoconference,
email, and phone) despite most partners being in the
same county. At times this led to communication
challenges between organizations, and between pa-
tients and those providing R4H services. Clinic staff
sometimes were confused about how R4H operated,
and whether they should truly refer all eligible pa-
tients. One said, “They keep telling us ‘Send more
referrals, send more referrals!’I’m assuming they
have bandwidth to take on more patients. I don’t
know if there’s a limit to how many patients…But I
would hope that if it’s working that they would
continue to do it.”Clinic staff attempted to support
patient enrollment in R4H but sometimes were unsure
how to reach partner organizations. Early in the
program’s implementation, a clinician wished they
could “directly call Open Source Wellness and talk to
somebody about the group, if it was like the [patient]
wasn’t getting calls or I’ve referred, but nobody had
followed up. Sometimes that happens where there’s just
not a follow-up and probably what happens is they call
the patient and don’t get through until they close the
referral.”During the implementation period, partner
organizations worked to strengthen communication
with patients via telehealth, as well as provide direct
communication channels between clinics and other
partner organizations through the Electronic Health
Record and other standardized communications.
Offering IGMVs via telehealth made the program more
accessible for some people, and addressed social iso-
lation worsened by COVID. One patient called the
IGMV “practically a social gathering and it’s like time
for us, spending time for ourselves.”For other patients,
Internet access, low tech literacy, and limited literacy
overall made telehealth IGMVs challenging to access.
In spring 2020, an IGMV staff member explained that
“some people dropped off because of [the virtual
format]. They just decided I’ll go back when it’sin
person, but they didn’t know it was going to last this
long.”In the IGMV program, staff sought to align dis-
cussions of cooking and nutrition with the specific foods
that were delivered through the Food Farmacy. However,
this was not always possible, and sometimes led to pa-
tients feeling confused or embarrassed about their lack of
knowledge about certain foods. One said, “In the
group…I should bring the bag out and say, ‘Hey, can you
tell us all what this is?’Because I think it’s purple kale. I
think it’s Swiss chard, but it doesn’t have a name, and I
don’t normally eat like that.”This kind of discussion of
food was straightforward in an in-person group, but more
challenging to coordinate for virtual group visits. Over
time, the Dig Deep Farms team began providing addi-
tional information about the food provided.
(3) Land,delivery and food needs: The doorstep delivery
format of the Food Farmacy provided access to
people with transportation and scheduling challenges
Thompson-Lastad et al. 9
that would have kept them from picking up food at
clinics. However, clinic staff noted that the Food
Farmacy did not support “people that don’t have an
address”or were unhoused, as well as those who
could not receive food delivery or did not have access
to cooking facilities. Additionally, the doorstep delivery
allowed for limited discussion and education about the
food itself. For some patients, the specificandlimited
kinds of produce available (particularly in the winter)
were confusing; some wanted food like avocados that
are not widely grown in the region, or foods that were
not in season. Others noted that because only produce
was delivered, recipes provided included ingredients that
they might not have at home. These issues highlighted
the complex nature of food insecurity, and the challenges
of a produce prescription program in addressing it.
Table 4. Recipe4Health Partner Organizations.
Organization Type of organization Role in R4H Strengths identified
Alameda County Health Local government
agency
Central convener, lead training &
implementation
Recipe4Health leadership embedded
in local government made it
possible to implement
Dig Deep Farms Local farming non-
profit
Grow vegetables for the Food Farmacy,
and deliver to patients’home
-Local sourcing of produce using
regenerative and organic farming
with benefits for human & soil
health
-Supports local economy through
job training focused on BIPOC
farmers & re-entry population
Open Source Wellness Local non-profit
organization
Contract with FQHCs to provide IGMV
program (health coaches &
curriculum), survey patients for clinical
research on R4H
-Skilled in virtual & in-person IGMV
facilitation
-Multilingual health coaching staff,
majority BIPOC
-Experience collaborating with
multiple FQHCs
Community Health Center
network
County-wide network
of Federally
Qualified Health
Centers
Share electronic health record data with
R4H-affiliated researchers in alignment
with formal data-sharing agreements
-Centralized access to EHR and
other data across FQHCs
-Built centralized dashboard for all
participating FQHCs
LifeLong Medical Care Federally Qualified
Health Center
Refer patients to R4H, and staff IGMV
program with primary care clinicians
-Represents northern Alameda
County
-History of established group
medical visit programs at multiple
sites
Bay Area Community Health Federally Qualified
Health Center
Refer patients to R4H, and staff IGMV
program with primary care clinicians
-Represents southern Alameda
County
-Serves diverse population including
many recently arrived refugees
Tiburcio Vasquez Health Center Federally Qualified
Health Center
Refer patients to R4H, and staff IGMV
program with primary care clinicians
-Represents mid county area
-Primarily serves Hispanic/Latine
communities
Native American HealthCenter Federally Qualified
Health Cnter
Refer patients to R4H, and staff IGMV
program with primary care clinicians
-Represents mid county area
-Centers Native American
communities
Alameda Alliance for Health Non-profit Medicaid
managed care plan
Seed funding to support early
implementation of R4H
Collaboration to ensure operational
readiness in preparation for 2022
Medicaid 1115, 1915b, ILOS
waivers
Stanford University, Food for
Halth Equity Lab
Academic medical
center
Research and evaluation -Financial support for research from
university sources
-Experienced researchers
University of California San
Francisco, Osher Center for
Integrative Health &
Department of Pediatrics
Academic medical
center
Research and evaluation -Experienced researchers from
multiple departments
10 Global Advances in Integrative Medicine and Health
A broader implementation challenge was the need for
access to more land to provide adequate food for the
growing program. Though Dig Deep Farms steadily
increased the amount of land available, farmers noted
that growing large supplies of fruit was a multi-year
process. Despite these challenges, patients reported
that R4H supported consistent access to fresh produce
during their participation. However, patient per-
spectives depended on their unique situations, in-
cluding how many people they lived with, access to
other food resources, and enthusiasm about trying new
foods. Over time, Dig Deep Farms worked to respond to
patients’requests for more information about what
produce to expect and how to prepare new foods, and
provided bilingual recipes for the produce provided each
week. The Food Farmacy team was in ongoing dis-
cussion about how to provide foods that would be fa-
miliar to an extremely diverse group of participants,
while growing them locally and year-round. Recipe4-
Health implementation was constrained in many ways
by the pandemic conditions in which it took place, but
partners went to great efforts to make the program ac-
cessible to as many people as possible.
Maintenance
As of fall 2024, all FQHCs that have implemented Rec-
ipe4Health continued to participate in the program. Clinics
faced varying challenges relating to program sustainability
including staff turnover and associated difficulties sustaining
referrals, as well as other COVID-related difficulties de-
scribed above. However, all clinics continue to offer R4H
services; two have expanded to additional sites, and when one
FQHC closed its R4H site, services were shifted to an al-
ternate site. Since 2022, several have begun offering in-
person IGMVs as well as new IGMVs in Spanish that al-
low them to serve a broader range of patients. R4H im-
plementation informed statewide Medicaid policy changes
that were implemented in September 2022, making medically
supportive foods a covered service across the state for 5 years
through CalAIM, California’s version of the combined
Medicaid Waiver 1115, 1915b, and In Lieu of Services.
Discussion
As part of a mixed-methods evaluation of the Recipe4Health
produce prescription and Integrative Group Medical Visits
program,
31
we report on the implementation of Recipe4-
Health from 2020-2022. During this time, the program served
a total of 1997 patients (61% of those referred by primary care
teams) with 1681 participating in the Food Farmacy and
316 in the Food Farmacy with Integrative Group Medical
Visits. The program was adopted by four FQHCs in Alameda
County, all of which continue to provide R4H services.
Successful implementation of R4H was supported by county
government and federal funding for produce prescriptions
through a multi-sector partnership with a centralized team
responsible for coordination and implementation. Given its
initial implementation during the COVID pandemic, it was
essential that the program took a flexible, pragmatic ap-
proach. Challenges to R4H implementation included clinics’
frequently shifting priorities due to the ongoing pandemic;
communication challenges, intensified by largely remote
communication; and initial limitations in land access for the
farmers growing produce.
Our findings point to the benefits and challenges of par-
ticular ways of structuring produce prescription programs.
Broad eligibility criteria (in this case based on a range of
diagnoses and food insecurity status) and substantial staff
training made it more feasible for FQHC staff to implement
the program. Though this was not a study of the COVID
pandemic, it became one. The ongoing COVID context in-
terwove with existing challenges in safety-net health care,
which affect organizations, staff, and patients. At the patient
level, clinic staff spoke to the broad accessibility of the
program while acknowledging limitations where multiple
social needs intersect. For example, unhoused people and
Single Room Occupancy hotel residents were unable to use
produce prescriptions due to lack of stable housing and kitchen
access, while people who did not speak English or Spanish
were unable to participate in IGMVs because they were offered
in a limited number of languages. However, the unanticipated
shift from offering food in clinic waiting rooms to providing
home delivery meant that produce prescriptions were accessible
for people without reliable transportation. At the staff level,
primary care staff turnover and burnout continue to be high and
clinic teams faced tremendous personal and professional
challenges related to the pandemic. At the organizational and
structural levels, clinics grappled with how to implement R4H--
a program they supported--while juggling competing priorities,
including COVID care and vaccine provision, clinician and
staff shortages, and the challenge of providing patient-centered
care in 10-15 minute primary care visits. Recipe4Health re-
quired ongoing commitment to daily patient referral and or-
ganizational partnership while providing IGMVs to
acknowledge and support the context of health behavior
change, address social isolation worsened by COVID, and
address food insecurity through home delivery of produce.
Strengths of this study include its mixed-methods, lon-
gitudinal approach with a research team embedded in an
ongoing program. The nature of this partnership will allow
for continued longitudinal research on Recipe4Health im-
plementation, including its current stage funded in part
through the CalAIM Medicaid 1115 waiver.
39
Limitations
include the fact that qualitative data were collected over
2 years in a rapidly changing context due to the COVID
pandemic, and inability to thoroughly examine site-level
differences in implementation. Like many programs to ad-
dress food insecurity, Recipe4Health serves a dispropor-
tionate number of women (approximately two-thirds of those
Thompson-Lastad et al. 11
referred and enrolled); future research should explore the
roles of clinic staff referral patterns and patient preferences in
this gender imbalance.
40
Additionally, due to COVID-related
research challenges, our qualitative participants were a
convenience sample that was almost entirely female and did
not include patients who received produce prescriptions only.
Amidst large expansion of Food as Medicine initiatives
with and without accompanying education, clinical and social
support programs such as IGMVs, many questions remain.
Future research might compare implementation experiences
of programs with varied “doses”including program length,
virtual vs in-person education and support programs, group
medical visits vs non-clinical programs, and distinct kinds of
organizations serving as the primary program convener.
Qualitative studies can use purposive sampling to includes
participants with a wide range of identities (eg, gender,
housing status, age) and levels of participation.
41
As has been
acknowledged elsewhere, Food as Medicine programs must
be flexible and creative in adapting to the needs of people and
communities who they aim to support.
16,17
Recipe4Health is
part of a growing shift in what counts as health care and who
can prescribe care for concurrent medical and social needs. In
tackling nutrition-sensitive chronic conditions (both physical
and mental health-related), as well as food insecurity and
social isolation, Recipe4Health brings together two estab-
lished approaches: produce prescriptions and integrative
group medical visits. Each of these has a body of encouraging
health outcomes research,
2,42-44
and a growing body of
research on implementation and sustainability in safety-net
settings.
16,17,21,45-47
Our findings demonstrate that Rec-
ipe4Health uses many of the best practices for produce
prescription programs that have been identified in prior
literature,
17,48
including (1) integration into health care or-
ganizations (screening for food insecurity, electronic health
record integration, and staff training in food as medicine); (2)
expanding access via home delivery; (3) multi-sector col-
laboration, including with small farms and health care payors.
Additionally, R4H has broad eligibility criteria for patient
participation (including chronic conditions as well as food
insecurity), allows people in many clinical roles to ‘prescribe’
participation in telehealth or in-person visits, and offers
IGMVs in two languages. While cooking classes and nu-
trition education are a fairly common accompaniment to
produce prescription programs, IGMVs also provide ongoing
support with health-related behavior change (eating, move-
ment, stress management), clinical care (eg, reducing med-
ication doses when chronic conditions improve), and peer
support. Other programs could tailor these practices to their
specific populations, offering IGMVs in different languages
or collaborating with other kinds of local food purveyors.
The national conversation about Food as Medicine
continues to develop rapidly as part of broader conversa-
tions about health equity, social and structural determinants
of health, and the important role of nutrition in preventing,
treating and reversing chronic conditions.
48
Funders
including the American Heart Association and the Rock-
efeller Foundation have committed to funding large-scale
research on Food as Medicine programs. At the federal
level, Alameda County’s longtime Congressmember, Bar-
bara Lee,
49
introduced a bill in 2024 to increase funding for
Food as Medicine programs, largely modeled after R4H (eg,
with a focus on sourcing food from local and regional farms
run by farmers from historically marginalized groups, using
regenerative and organic practices). Meanwhile, the gov-
ernor of California vetoed a 2024 bill by Alameda County
representative Mia Bonta that would have enshrined Food as
Medicine programs as a permanent covered benefitinthe
state’s Medicaid program. Given the vital role of food and
nutrition in integrative health care, it is essential that in-
tegrative health equity practitioners and researchers work in
partnership with Food as Medicine programs supporting
marginalized communities. They can be involved in policy
advocacy to make Food as Medicine programs nationally
covered benefits in Medicaid and Medicare, as well as ef-
forts to strength the role of the USDA in supporting local
and regional agriculture.
Centralized implementation, training, and administration of
Food as Medicine programs can support Federally Qualified
Health Centers’capacities to concurrently address medical and
social needs through an integrative health equity approach.
Findings from Recipe4Health suggest that it is more feasible for
clinics to do this work when eligibility criteria are broad, focused
on preventing as well as treating chronic conditions. As FQHCs
have known from the beginning, food is the medicine for food
insecurity—not only for chronic conditions.
3
Primary care
clinics cannot do this work alone, and partnership is labor-
intensive but essential for providing equitable care and ensuring
broad reach and adoption of Food as Medicine. Investments by
government, philanthropic organizations, payors and health care
organizations must include support for multi-sector partnership
development, maintenance, and communication to sustain Food
as Medicine programs.
Acknowledgements
The authors are grateful to the Recipe4Health patient participants
and staff at Bay Area Community Health, Dig Deep Farms, Life-
Long Medical Care, Native American Health Center, Open Source
Wellness, and Tiburcio Vasquez Health Center, with special thanks
to those who participated in interviews. Recipe4Health was possible
thanks to the late Alameda County Supervisor Wilma Chan and her
team, the Alameda County ALL IN team (Larissa Estes, Karen Ben-
Moshe), Scott Coffin of Alameda Alliance for Health, the Com-
munity Health Center Network, and Recipe4Health team members
including Corey Brown, Anna Clayton, Lyla Connolly, Joey Gallo,
and William Sugijoto. We also acknowledge Milton Chinchilla and
Sana Alsamman for contributing to qualitative analysis; June Tester,
Ben Emmert-Aronson, Julie Alvarez, and Erica Martinez for their
work on the Recipe4Health evaluation team; and Shelley Adler,
Maria Chao, Laura Gottlieb, and Hilary Seligman, for mentorship.
12 Global Advances in Integrative Medicine and Health
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: Rec-
ipe4Health research was supported in part by the intramural research
program of the U.S. Department of Agriculture, National Institute of
Food and Agriculture, Gus Schumacher Nutrition Incentive Program
(#1021597, 1027419, 1029334). Recipe4Health research is also
supported by the Stanford Impact Labs. Authors received additional
support for conducting research reported in this publication through
UCSF-Kaiser Department of Research Building Interdisciplinary
Research Careers in Women’s Health (ATL, #K12HD0521630) and
the National Institute of Minority Health and Health Disparities
(ATL, #K01MD015766), and the National Center for Comple-
mentary and Integrative Health (DTC, #T32AT003997). Consul-
tation and training support for this research was provided through
National Center for Advancing Translational Sciences of the Na-
tional Institutes of Health (#UL1TR003142). R4H receives pro-
grammatic funding through Alameda Alliance for Health and the
Stupski Foundation. The findings and conclusions in this publication
have not been formally disseminated by the U. S. Department of
Agriculture or any other funder and should not be construed to
represent any agency determination or policy.
Ethical Statement
Ethical Considerations
This research was approved by Institutional Review Boards at UCSF
(#19-28766, #21-34511) and Stanford University (IRB-57239).
Informed Consent
Interviewees provided informed verbal consent according to IRB
guidelines, and a waiver of consent was obtained for EHR data. All
authors have approved the manuscript for submission.
ORCID iDs
Ariana Thompson-Lastad https://orcid.org/0000-0002-4880-
1371
Dorothy T. Chiu https://orcid.org/0000-0002-4826-6217
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