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“Food is Medicine” in Navajo Nation

by Molly Marsh, Partners In Health

Store manager Cheryl Blair ushers a small group of employees and health workers into her second-floor office, which overlooks the shelves of Totsoh Trading Post near Tsaile, Arizona, in the Navajo Nation.

They settle themselves into chairs, ready to hammer out the mechanics of a program that aims to improve Navajos’ health by increasing their access to fruits and vegetables. Called the Fruit and Vegetable Prescription Program (FVRx®), the effort links retailers, community health workers, and clinics to create a better supply of and demand for fresh produce.

“Notice our food — it’s all junk food,” says Blair, gesturing toward aisles of chips and beef jerky, soda, and sugary confections. Not many kids are introduced to fresh foods at a young age, she continues. “It’s hard — if you can’t eat it as a kid, you’re not eating it now.”

There are only about 100 stores like this in Navajo Nation, an expanse of 27,425 square miles stretched across parts of Arizona, Utah, and New Mexico, and most carry little fresh produce. In fact, the U.S. Department of Agriculture has classified the entire territory as a food desert. The grocery stores and convenience stores are hard to reach — or out of reach — for Navajo who lack regular access to transportation, and high poverty rates mean most people can’t afford to buy healthier foods even if they were available: 44 percent of households live below the poverty line. With dollars to stretch, families opt instead for dense, calorierich food that fills them up.

The corresponding effect on health is alarming. Navajos experience high rates of obesity and malnutrition, as well as diet-related illnesses such as diabetes and hypertension. Heart disease and diabetes are the leading causes of death on the reservation; about 26,000 people — nearly 22 percent of the adult population—have diabetes. Half of all children are overweight or obese.

Community Outreach & Patient Empowerment (COPE), a Gallup, New Mexico-based project of global health nonprofit Partners In Health, helps tackle these health disparities by providing training and support to nearly 100 community health representatives (CHRs) employed by Indian Health Services.

These CHRs play a critical role in communities. They visit people in their homes — many of whom they’ve known for years — to provide health care, and connect them to clinics and hospitals when they need more specialized treatment. They also counsel clients on healthy living habits, including eating more nutritious foods. Without reliable access to those foods and extra money to buy them, however, clients struggle to change their diets.

In response, COPE has become a catalyst and partner in a movement under way across the reservation to create stronger links between food and health. Scores of local and tribal health facilities, community organizations, and food security activists are pushing to create more awareness among Navajo about the importance of eating nutritious foods. These groups are also working to revitalize Navajo food traditions, promote food sovereignty, and spur economic development.

FVRx® is one part of this effort. Developed by food access organization Wholesome Wave, the program in Navajo Nation targets new and expecting mothers with gestational diabetes, and overweight or obese children from 3 to 6 years old. CHRs work with local health providers to identify families with these health risks and enroll them in the program. Clinicians also encourage their patients who meet these criteria to participate.

When an expectant mother visits her doctor at Tsaile Health Center, for example, she is referred to a CHR who talks with her about nutrition and is given a “prescription” worth $1/day/per family member that she can redeem for fruits and vegetables at Totsoh Trading Post. The voucher is good for one month.

This mother will receive a check-up from her doctor once a month for six months, at which her weight and blood pressure are measured, as well as other vitals. If she has a young child who is overweight or obese, that child will also receive regular monitoring. Over their period of enrollment, COPE staff will collect data on their Body Mass Index measurements and fruit and vegetable consumption to check their progress.

“We’re working on the basic concept that food is medicine,” says Memarie Tsosie, COPE’s food access manager. “Back in the old days, most of our grandparents ate food to nourish their bodies. Now it seems like food is for convenience. We want to bring back the notion that families can use healthy food to create healthy lifestyles.”

So far, about 100 families from the territory’s southeast region are participating in FVRx®, as are 10 health centers, two grocery stores, four trading posts, six convenience stores, and one farmers market. More of each will join the mix in subsequent months. COPE’s goal over three years is to expand into every region of Navajo Nation, reaching 75 percent of its population — about 135,000 people.

To ensure fruits and vegetables are available for them, COPE’s FVRx® team has identified all retailers on the reservation, recruited stores to participate in the program — Totsoh is one of the first — and helped owners better promote the purchase of fruits and vegetables in their stores. The team also works with farmers markets and local growers to try and get their produce on to store shelves. The idea is to encourage stores to increase the number of healthy offerings while guaranteeing a certain level of demand for owners and growers.

FVRx® teams also coach retailers through the voucher redemption process, which is the reason for the gathering in Blair’s office. The women work through possible snags — how to make sure IDs are accurate, what to do if shoppers forget their vouchers or if they buy more than they have credit for. The dietician among them also helps plan a menu for a cooking demonstration the store would like to hold. They settle on spinach smoothies, and chicken salad with pecans and cranberries.

While FVRx® enrolls specific families, the program’s underlying goal is to create an environment where entire communities have access to affordable fruits and vegetables. And it’s working — Blair and other store managers say they’ve seen an increase in the amount of produce purchased by families who aren’t participating in FVRx®. They initially worried they wouldn’t be able to sell everything; now they’re selling out.

Molly Marsh is Managing Editor of Partners In Health, a global nonprofit that provides health care to poor communities in 10 countries. Read more at www.pih.org.