EXPLORING THE CSA MODEL AS A HEALTH INTERVENTION
A RESEARCH PROJECT FUNDED BY THE UNITED STATES DEPARTMENT OF AGRICULTURE AND THE BLUE CROSS BLUE SHIELD FOUNDATION OF MASSACHUSETTS.
PARTNERS
Dr. Seth Berkowitz: Dr. Berkowitz is an Associate Professor of Medicine at the University of North Carolina at Chapel Hill School of Medicine. He is a general internist and primary care doctor. He studies interventional approaches for addressing health-related social needs in clinical care, with a particular focus on the health effects of food insecurity.
Just Roots and the Community Health Center of Franklin County with lab support from Baystate Franklin Medical Center.
OBJECTIVE
Socioeconomically vulnerable individuals often face poor access to nutritious food and bear a disproportionate burden of diet-related chronic illness. Therefore, two key objectives drove this research:
- To test whether a subsidized community supported agriculture (CSA) intervention could improve diet quality.
- estimate the population-level effectiveness and cost-effectiveness of a subsidized community supported agriculture (CSA) intervention.
METHODS
From May 2017 to December 2018, we conducted a randomized clinical trial (clinicaltrials.gov registration number NCT03231592) to explore the health outcome impacts of CSA participation. Adults with a BMI > 25 kg/m2, primarily but not exclusively patients of a community health center in western Massachusetts, were eligible to participate. Health-related eligibility requirements beyond BMI were limited, aiming to study the impact of the CSA model on a broad demographic of health rather than on people experiencing specific health challenges. Individuals were randomized to one of two study groups: One group received a subsidized CSA membership for two years, which provided weekly farm produce pickups each year from June to November. The other group received healthy eating information produced by the United States Department of Agriculture, www.choosemyplate.gov, and functioned as the control group. Each group received $300/year for participation. The CSA intervention participants were then required to purchase a CSA share from Just Roots, the money from the study stipend serving as a subsidy or rebate for their CSA purchase. The control group was provided the same level of funding, but in the form of unrestricted funds. The primary outcome was the Healthy Eating Index 2010 (HEI) Total score (range: 0-100, higher indicates better diet quality, minimum clinically meaningful difference: 3). HEI, participant-reported metrics on health and well-being, participant-reported metrics on food security and finance-related medication underuse, anthropometrics and biomarkers were assessed. Following the study, we developed a microsimulation model from nationally-representative demographic, biomedical, and dietary data (National Health and Nutrition Examination Survey, 2013-2016), and the data resulting from the previously mentioned study. We modeled 2 interventions: unconditional cash transfer ($300/year) and subsidized CSA ($300/year subsidy).
RESULTS
Demographics of the study:
- 122 participants
- Mean age of 50.3
- 82% women
- 88% non-Hispanic white
- Control and intervention groups shared similar distribution of baseline characteristics.
Baseline data:
- HEI Total score
- Control group = 53.9
- Intervention group = 55.1
Change in HEI:
- Intervention group increased 4.3 points relative to the control group
Change in food Insecurity:
- Intervention group proved a reduction in food insecurity.
Microsimulation:
- Quality-Adjusted Life Years (QALY)
- Total discounted QALY lost over life-course reduction:
- Cardiovascular disease and diabetes complications
- Baseline: 24,797 per 10,000 people
- Reduced to:
- 23,463 per 10,000 people under cash intervention
- 22,304 per 10,000 people under CSA intervention
- Cardiovascular disease and diabetes complications
- Societal Perspective over life-course horizon
- Cost savings to society (expressed as negative incremental cost-effectiveness ratios)
- -$191,000/QALY gained for cash intervention
- -$93,182/QALY for CSA intervention
- Cost savings to society (expressed as negative incremental cost-effectiveness ratios)
- Total discounted QALY lost over life-course reduction:
CONCLUSIONS
A subsidized community supported agriculture intervention resulted in clinically meaningful improvements in diet quality. Further, the study pointed to subsidized community supported agriculture as well as a cash intervention as both potential important public health/socioeconomic interventions for low-income, vulnerable individuals. As no one health intervention can treat a whole population and the benefits of the interventions lead to both public health and societal benefit, a cross-sectoral approach that bundles private resources with those from multiple programs (food programs designed in part to boost agriculture, low-income programs designed to address inequities in food access, health programs designed to improve nutrition, and housing programs intended to improve the quality of life and stability of low-income families) may generate broad health and social benefit while reducing the burden to a single stakeholder/payer.
PUBLISHED FINDINGS:
Findings were published in two leading peer-reviewed research journals in the fall of 2019:
The American Journal of Public Health
The American Journal of Preventative Medicine
Final Report to Blue Cross Blue Shield Foundation of Massachusetts
CONTEXT: Why the research was conducted
SUMMARY
The CSA (Community Supported Agriculture) farm share approach is a widely utilized model to get farm fresh food direct from farm to customer. In Massachusetts alone, there are over 400 CSAs according to the USDA census data. CSAs however, have been relatively inaccessible to low-income populations due in large part to the economic model it is premised on: pay the full CSA fee (avg $600 – $800) months in advance of the harvest season and collect a weekly allotment of produce during the harvest season. However, Just Roots believed that the “membership structure” and repetitive nature of a CSA offered a powerful opportunity to build healthy eating habits for those who participated, distinct from a decision to visit a grocer, market or farm stand. Just Roots aimed to challenge the status quo of the CSA and reinvent it as a health intervention model, accessible to all people regardless of economic circumstance. Following four years of success with its accessible CSA farm share program which regularly demonstrated member data indicating improved health measures, Just Roots aimed to model its accessible CSA farm share program as a health intervention broadly. To that end, Just Roots partnered with Dr. Seth Berkowitz and the Community Health Center of Franklin County to run a research study to understand the potential of the CSA to improve health and save healthcare dollars. For two CSA seasons, the study researched CSA participants and non-participants in Franklin County, MA. If the findings proved the CSA effective, they would be used to attract stakeholder investment to expand access to low-income populations to a model widely used across the country, improve health for participants and save healthcare dollars.
BACKGROUND
Since its inception Just Roots has worked to increase access to healthy, local food by connecting people, land, resources and know-how (the mission of Just Roots). In 2011, Just Roots gained access to a piece of municipally owned agricultural land through a long term lease, which they helped place into Agricultural Preservation Restriction (APR). Just Roots grows roughly sixty types of vegetables, small fruits and herbs on approximately 5-7 acres of land, using organic practices. Just Roots made the decision to adopt the CSA model as their primary method to distribute their produce from farm to table. However, the organization dedicated itself to reinventing the CSA model as an accessible health intervention by addressing key barriers inherent in the model which disproportionately limited access for those with lesser socioeconomic means from participating. Just Roots understood the important role repetition and support services played in the formation of habits of health, and the CSA offered this unique opportunity to connect with the customer regularly over the course of a 20-24 week harvest season, offering local produce and wrap around support services to promote health (physical, mental and social). Just Roots began distributing CSAs in 2013 and within four years became the largest provider of farm-based “low-income” CSAs in the Commonwealth of Massachusetts.
Committed to understanding the health impacts of the CSA program, Just Roots surveys its CSA participants bi-annually and the results have been both obvious and astounding. Note that while 2018 results include members of the (Im) Proving the CSA Study, these surveys were produced independent of the methodology used in the study and are conducted on a bi-annual basis by Just Roots to its entire CSA membership (inclusive of low-, moderate- and high-income individuals.
Survey Snapshot:
CSA program impact on member health/habits in 2018:
- 93% of Just Roots CSA members reported increasing their vegetable consumption by at least half a cup/day, and for the members receiving the subsidized share, the impact was even more significant reaching 100%,
- 54% reported improvement in household attitude toward vegetables,
- 72% reported an increase in their general willingness to try new veggies/dishes.
The Just Roots CSA is set up like a farmers market stand, with a wide variety of vegetables to choose from. Participants have full autonomy to choose what vegetables they take home. Even so:
- 83% reported trying a new vegetable this year
- 70% also reported expanding their cooking repertoire by utilizing recipes offered by the CSA program, with 31% reporting cooking together with family/friends at home more frequently.
Social and physical outcomes related to participation
- 55% reported creating at least one new meaningful connection in the community as a result.
- 35% of members reported increased energy levels;
- 19% reported an improvement in weight (loss for those overweight and gain for those underweight);
- 47% reported an improvement in general well-being,
- 35% reported an improvement in mental well-being.
Results such as those listed above reinforced Just Roots’ conviction that the CSA model might prove a powerful health intervention that could improve the health and wellbeing of those who participated. Just Roots began to explore opportunities to model its program regionally, even nationally. Two initial key components would be needed to move from a program offered by a single organization to a program broadly adopted/implemented: research and stakeholder investment.
Historically, research has proven to drive public policy and stakeholder investment. Building the case for stakeholder investment in CSAs is a critical next step in beginning to convert a recognized and dominant model of healthy food distribution from an exclusive model to an accessible one.
However, research was and continues to be lacking specific to the health intervention power of a CSA. While we understand and can point to research associated with incorporating more fruits and vegetables into the diet, the CSA specifically had not been well researched, especially not within a clinical trial environment. Just Roots approached Dr. Seth Berkowitz, with extensive experience in research on nutrition’s impact on health outcomes, about his interest in conducting a study to research health outcomes associated with CSA participation targeting low income individuals. He agreed to design and complete the analysis of the research. Just Roots then sought out the Community Health Center of Franklin County (a federally qualified community health center, FQHCH) due to its potential to serve as a model for the more than 1400 Health Center Organizations and 11,000 locations in urban, suburban and rural communities across the United States. Together, this team secured funding from the USDA, followed by Blue Cross Blue Shield Foundation of Massachusetts to fund a three-year research project, including two years of data collection. The project began in the fall of 2016 and wrapped up analysis in the fall of 2019.
IN THE LOCAL NEWS:
- Study to look at health impact of taking part in a CSA: Just Roots, health clinic project to involve 100, published in the Greenfield Recorder on 11/30/2016
- Local Researchers Seek to Measure Health Benefits of Access to Farmshares, published in the Montague Reporter on 12/12/2016