An official website of the United States government
Evaluation of the 2021–2024 Implementation of the Fresh Start Enhanced Food Is Medicine Intervention Among Rural, Underinsured People With Type 2 Diabetes
IMPLEMENTATION EVALUATION — Volume 23 — July 23, 2026
PEER REVIEWED
| Determinants of health | Fresh Start interventional model |
|---|---|
| 40% Socioeconomic status (education, employment, and income, with income being the greatest predictor of food security | Health food access: produce prescription provision of 5 to 7 pounds of fruits and vegetables at 9 community group classes through partnership with the Food Bank of Central and Eastern North Carolina and the Society of St Andrews. |
| 30% Health behaviors (diet, physical activity, smoking, alcohol consumption) | • Knowledge, skills, self-efficacy: community group education classes held at churches/community centers with lessons/activities grounded in Health Belief Model, physical activity demonstrations, cooking demonstrations and taste testing to build health and food literacy and self-efficacy • Behavior change: individualized health coaching was telephone-base, and used motivational interviewing to set personal goals for nutrition and physical activity |
| 20% Access to quality health care (cost, health care providers, treatments, education, medications) | Access: no cost (free program), mobile (rural community education sites), and telephone-based health coaching (vs Wi-Fi/data needed telehealth/Zoom) |
| 10% Physical environment (recreational space, greenspace, housing) | — |
Figure 1. Theoretical model for the Fresh Start produce prescription intervention, or FSPRx, rural eastern North Carolina, 2021–2024. The determinants of health were based on Hood et al (39).
| Timeline | ||
|---|---|---|
| Preintervention actions (4 months) • Participant recruitment and enrollment August–February on site at NCAFCC clinical partners • Recruitment and training of health coaches: 25–30 ECU students/year, formal ECU course or virtual/rapid training, proficiency exam • Development or/updates to program educational resources (eg, recipes, group class lesson plans, handouts, physical activity routines and support) |
Intervention implementation (5 months) Intervention services and resources: • 9 biweekly community group classes at various partner sites (churches, community centers) per region • 1-on-1 telephone-based health coaching to set individual goals • Produce prescription/Rx of 5–7 lb (provided at 9 group classes) via Food Bank of Central and Eastern North Carolina and Society of St. Andrew • Year 1: 1 region; Year 2: 3 regions; Year 3: 6 regions |
Postintervention actions (3 months) • Complete collection, review, and analysis of postintervention cycle program evaluation data • Program planning: modifications per program evaluation data • Community/clinical partner connections: updates with changes, expansion connections |
| Impact evaluation (preintervention) • Baseline survey: sociodemographic characteristics, dietary intake, physical activity behaviors and self-efficacy, food literacy, food security, stress, diabetes self-management efficacy • Clinical measures: HbA1cvia electronic health record review |
Process evaluation (feasibility and acceptability) • Produce distribution logs • Encounters with health coaches (record review) • Group class attendance and postclass surveys (satisfaction, experience, feedback for specific group class) • Postprogram experience survey and telephone interviews (experience, satisfaction, suggested changes for overall program) • Formative evaluation survey (only at the end of year 3) |
Impact evaluation (postintervention) • Postintervention survey: sociodemographic characteristics, dietary intake, physical activity behaviors and self-efficacy, food literacy, food security, stress, diabetes self-management efficacy • Clinical measures: HbA1cvia electronic health record review |
Figure 2. Annual activities for the Fresh Start produce prescription intervention, or FSPRx, rural eastern North Carolina, 2021–2024. Abbreviations: ECU, Eastern Carolina University; NCAFCC, North Carolina Association of Free and Charitable Clinics.
| Successes | Lessons learned | Implications for Food Is Medicine interventions |
|---|---|---|
| • Satisfaction with the intervention approach was high • Supportive, knowledgeable staff and volunteers were recognized and valued • Theory-driven education with DSME grounded in food literacy had an impact on behavior change and health • Culinary/cooking support tailored to overcome barriers (time, cost, complexity) lead to dietary behavior changes at home • Partnerships were essential for food, space, and recruitment |
• Attendance to in person group classes in rural areas faced access barriers (time/scheduling, transportation) • Relying on partners for clinical measures limited health outcome data (HbA1c) • Enrollment in person at clinics limited accessibility • Telephone-based health coaching was accessible and slightly more utilized, but less impactful • Motivation to participate centered more on health and nutrition and diabetes/health education than on food |
• Education and support beyond health food access is desired, valued, and substantially drives health behavior change and health outcomes. • Focus: Future interventions should consider expanding education to integrate DSME (as appropriate) and/or food literacy competencies grounded in theory to follow evidence-based best practice. • Partners: Partnerships with cooperative extension, health departments, community centers, and/or local registered dietitian nutritionists could be explored. • Accessible: Virtual and/or flexible remote education options warrant further exploration and evaluation, particularly for rural and/or difficult-to-reach populations that face barriers to in-person or online attendance (eg, communities of lower income). • Evaluation: Identifying the most efficient and effective mediators and models requires better process evaluation to increase knowledge and understanding of implementation processes and related impact. • Process: Evaluations should be expanded to examine use of resources (eg, food, education) to identify and understand mediators for food behavior changes in Food Is Medicine interventions to establish evidence-based best practices for implementation. |
Figure 3. Successes and lessons learned during the Fresh Start produce prescription intervention, or FSPRx, rural eastern North Carolina, 2021–2024, and implications for Food Is Medicine interventions.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.