Bridging the Health & Nutrition Gap: An Interview with Benjamin Perkins of Wholesome Wave

Below is the edited transcript of the video above:

Ocean Robbins: Welcome to this Food Revolution Conversation. I’m Ocean Robbins. And I am so thrilled to be here with you right now to talk about one of the most important topics of our times, which is how we can bridge the health gap and the nutrition gap to support healthy, ethical, and sustainable food for all. 

And we’re going to pay special attention to the communities that need support and are struggling the most right now. The communities that are suffering the most egregious consequences from a toxic food culture. 

And we’re going to look today at what’s possible, at hope, at visions, at how we can truly up-level the health and the well-being of all communities everywhere — and at practical examples of what works. 

And we’re here today with the perfect person to be in this conversation with, Benjamin Perkins. He is a social justice practitioner, an intellectual, and a creative thinker, and he is the CEO of Wholesome Wave.

Wholesome Wave is probably one of my favorite nonprofit organizations on the planet. They are creating partnership-based programs that enable underserved consumers to make healthier choices by increasing affordable access to healthy and locally and regionally grown foods. 

Ben has worked in the public health field for two decades. And since 2014, his focus has been on ending health disparities and inequities. He’s worked for the American Heart Association as Vice President for Multicultural Health Initiative and Health Equity and as Vice President of Health Strategies. And at Wholesome Wave, he is championing positive, practical, community-based solutions that can bring health and wellness where they’re needed. 

So Ben, thank you so much for being here today, and thanks for your amazing work.

Benjamin Perkins: Thank you for having me. Thanks for that great introduction. I sound interesting.

Food & Nutrition Insecurity

Ocean Robbins: Well, you are interesting. And we’re thrilled to be with you. 

You’ve talked about how food insecurity and addressing food insecurity is about providing enough food to those in need. But nutrition insecurity and addressing it is about providing the right food to prevent or alleviate diet-related diseases. 

So, tell us a little bit about what nutrition insecurity means to you, and why you think it’s so important in the world right now.

Benjamin Perkins: That’s a great question. I think in terms of thinking about food insecurity and nutrition insecurity, I was talking to someone last night. And I was saying that one of the ways to think about food insecurity, or nutrition insecurity, is to think about it as a subset. If you had a little Venn diagram, nutrition insecurity would be inside of food insecurity. In that, food insecurity is addressing the lack of food that folks might have. So issues of hunger. But nutrition insecurity… And this goes back to co-founder of Wholesome Wave, [Chef] Michel Nischan’s sort of assertion, that it’s not just about getting people food. It’s about getting people the right food and healthy food. 

And I think embedded in that is this concept of human dignity. That it is not just feeding people anything, but it’s about getting at healthy foods where people can thrive — particularly folks who are on the margins, which is a large part of the population that we pay especially close attention to.

Obese but Nutrient-Starved

Ocean Robbins: In the world right now, we have, perhaps for the first time in human history, more people who are obese than people who are starving. Right now, there are almost a billion people on the planet who are in danger of literal starvation — who have fundamental core food insecurity on a daily basis. But there are also over a billion people on the planet who are obese. In the United States, it’s now 40% of our population. Mexico is right up there with us. 

And there’s an interesting and really painful corollary here that people who are in poverty are more likely to starve. But they’re also more likely to be obese because they’re fundamentally fueling from maybe enough calories, maybe too many calories, but they are nutrient-starved.

Benjamin Perkins: Yes. That difference between energy dense and nutrition dense. And it really sort of drives home exactly the point you’re making. This idea that foods that are energy-dense often aren’t nutrient-dense. And there’s that sort of chasm between those things potentially.

Food 3.0

Ocean Robbins: Yeah. The way I look at it, food 1.0 is about survival. If you can get enough calories to fill your belly, then that’s success. Food 2.0 is governed by commerce. It’s the buying, selling, and marketing of goods. And it’s a step up for a lot of people to be able to have choice and authorship and some mobility around food. But unfortunately, it’s morally bankrupt. And it’s brought us nutritional and health disasters for many of the world’s people. 

And that’s why at Food Revolution Network, we’re calling for what we call food 3.0, which is a food system based around health. Health for our bodies and health for our planet. 

And it seems like what you’re doing is addressing how we can kind of leapfrog, for people who are on the margins, straight from Food 1.0 to Food 3.0. How we can move from, get enough calories; yes, of course. I mean, if all you can eat is a bag of potato chips, and that’s all you got, for goodness sake, eat the potato chips. But at the same time, what would happen if we focus on nutrient quality and nutrient density and how we create those opportunities for people? 

Addressing the Cost of Healthy Food

Ocean Robbins: But a lot of folks struggle with the cost of healthy food. I mean, Whole Foods has the unfortunate nickname, “Whole Paycheck.” And we see a lot of people who just feel like they have to pay an arm and a leg just to do the right thing. It’s almost like you’re being fined for wearing your seatbelt. You want to feed yourself and your family right, you have to pay extra. How are you guys trying to address that?

Benjamin Perkins: Another great question. How we’re trying to address it is… And you had mentioned SNAP, for instance, and that concept of doubling up SNAP bucks, which is one of our claims to fame. One of our co-founders, the late, great Gus Schumacher, who was the undersecretary of agriculture during the Clinton administration. He was a big proponent of the idea of incentivizing SNAP so that you could get more for your dollar by buying healthy produce, healthy fruits and vegetables. 

Now, the idea there is still giving people choice, but incentivizing healthier choices so that folks might be more drawn to those healthier choices. Because exactly what you said, if the perception is that healthy foods cost more, and I only have a limited pool of resources — namely dollars — I’m going to gravitate towards the cheaper food, the more energy-dense food, and less nutritionally-dense food. And so, that’s one of the ways we think about it. 

The Double Up Food Bucks Program

Ocean Robbins: So the Double Up Food Bucks program basically says for somebody who is on food stamps, who has food stamps, and there’s about what, about 42 million Americans who are a part of that?

Benjamin Perkins: Fourteen percent of the population.

Ocean Robbins: Fourteen percent of the population, and a lot of them kids, are dependent on this program to eat right now. And we could debate until the cows come home, what’s the right role of government. And I don’t think any of us want to see a world in which people depend on SNAP dollars to feed their families. Everyone wants to be self-reliant and have the resources they need to provide for themselves, but that’s not the world we live in right now. 

But at this point in time, we have a lot of people who are marginalized, who are on the edge, and who depend on SNAP in order to eat and live. 

Unfortunately, most SNAP dollars are not buying healthy foods. A lot of them are going to foods that are making people fat and sick and increasing their likelihood of getting diabetes and heart disease and cancer and Alzheimer’s, and fueling ADHD in kids who then have a harder time in school because they don’t have the nutrients they need to thrive. 

So you guys created this program where for every dollar SNAP recipients spend on fruits or vegetables, they’re getting double bucks, right? That means they go twice as far. So instead of paying a dollar for X amount of broccoli, you now only pay 50 cents, which means you can get twice as much broccoli. So it creates this financial incentive to buy more fruits and vegetables, specifically. 

Health Outcomes & Nutrition Incentives

Ocean Robbins: So when that happens, do people buy more fruits and vegetables? And maybe, more importantly, do they eat more fruits and vegetables? How many people are in the program? And what kind of results have we seen in terms of any possible health impact so far?

Benjamin Perkins: Yeah, so the research suggests that people, when presented with the opportunity, and I think this is something that’s really important to highlight, regardless of which program we’re talking about. When people have the opportunity to do healthier, to engage in healthier behaviors, namely eating healthier fruits and vegetables and foods in general, that they do. That’s the bottom line. 

The other thing to know about SNAP, specifically, is… So you’ve got 42 million people on SNAP. The research on SNAP beneficiaries tells us that they are twice as likely to die of cardiovascular disease and three times more likely to die of diabetes complications.

So you see, there is a huge need in terms of that population to do whatever we can to incentivize consumption of healthier fruits and vegetables. So things like looking at the drop in A1C, looking at drops in systolic and diastolic blood pressure, those sorts of things. All of those health outcomes tend to improve with nutrition incentive programs. And the thing is, right now, this is all proof of concept. 

Now, certainly, I would argue, and I think most people would argue that it seems pretty intuitive that people would get healthier. But what we have to do is we have to make the case. So all that we’re doing now is creating a gigantic proof of concept, marshaling all the data from all of the studies that we are a part of, all the work, and then using that data in the service of making the case so that, ultimately, these kinds of things can be embedded in federal and state policy in a long-term, sustainable way.

Expanding the Program

Ocean Robbins: Yes, absolutely. And there are about 882,000 people who are participating in the Double Up Food Bucks Program, in more than 20 states. And is that all funded by private donors so far? Or has the government pitched in?

Benjamin Perkins: There’s a mix. So Gus Schumacher, who I mentioned before, part of his legacy was that there was a farm bill in 2014; there was $100 million earmarked for these kinds of programs. And then he died in 2017. So in 2018, when that farm bill got reauthorized, it was renamed the Gus Schumacher Nutrition Incentive Program, or what we affectionately called GusNIP. 

So that came in at $250 million over five years. That’s not a lot of money for an entire nation. So part of the program really looks to public-private partnerships. So the government put some money in. But also, we’re looking for matching dollars. So whether it’s corporations or foundations that are also interested in the health of communities and populations, they bring dollars in from private donors. And these partners match the federal dollars.

Community-Based Nutrition Education

Ocean Robbins: Got it. Thank you. So I guess the cynic might say, “Well, if people get double the value for fruits and vegetables, they might buy more fruits and vegetables because it’s sort of like it’s on sale, so to speak, but will they actually eat them? Or will they just rot in the fridge? Will people know what to do with them?” And so, do you have any thoughts about that? Have you brought in any sort of culturally appropriate recipes, or cooking techniques, or lifestyle habit education?

Benjamin Perkins: Yeah, that’s a great point. And yes. 

So part of it is that we also want to embed nutrition education programs. And so, at Wholesome Wave, our program directors work closely with community partners in health systems to, first of all, assess what kinds of resources they have. And then, we provide resources, which might include a nutrition education component. Because to your point, it’s great that people have access to healthy fruits and vegetables, but if they don’t know what to do with them, then, of course, we’re talking about the potential for food waste. 

It’s great that people have access to healthy fruits and vegetables, but if they don’t know what to do with them, then, of course, we’re talking about the potential for food waste.

Benjamin Perkins

The other piece of it that you alluded to that’s critically important, and this is a part of the dignity component, is it’s not just about getting people healthy food. It’s about understanding the particular culture because if you can get healthy produce that’s culturally specific, then the chances are greater that folks will know what to do with it in the first place.

The Produce Prescription Program

Ocean Robbins: Yeah, absolutely. Fabulous. Okay. Well, let’s look at another program your team has been running called the Produce Prescription (Rx) Program. A lot of Ps there.

Benjamin Perkins: Yeah.

Ocean Robbins: So the Produce Prescription Program, as I understand it, you’re piloting this. And the concept is that, at least for Medicare and Medicaid recipients, and perhaps, ultimately, all insurers could get in on this, that doctors can prescribe produce. Like go to the Farmacy with an F, not the pharmacy with the P-H, and essentially get your produce.

Diet Responsive Conditions

Ocean Robbins: It’s interesting because, for somebody who has heart disease or type 2 diabetes, which are extremely diet-responsive conditions, they can get results fast. I mean, arguably as quickly as with going on statin drugs, for example. They can bring down their LDL cholesterol levels. They can bring down their blood pressure rapidly with diet and lifestyle choices. This is proven in study after study. 

And unlike with drugs, the side effects are all positive. They’re also bringing down their risk of dementia and cancer, and they’re probably going to feel better and maybe even have a better sex life too. 

So my thought is that if their doctor tells them they need to change their diet, sure, some people will struggle. But if they really know what’s at stake, for those people who are in these conditions where it’s life or death, a lot of people are willing to make choices, even if it’s a little less fun, even if it requires some work or some new habits because they get what’s at stake. 

So obviously, we need doctors who are informed about nutrition and motivated and who give it appropriate gravitas. But then, we also need the resources so that they can not just say, “Hey, you need to eat better. Good luck with that.” And send somebody off on their own into the wild world of a toxic food culture. But rather somebody who can specifically prescribe specific things. Like saying, “I want you eating broccoli every day.”

So is this specific to produce, or do you include any other foods? How widely has it been used so far? And what’s the strategy here?

Better Health & Nutrition Access

Benjamin Perkins: I’ll start with the first question. The strategy is really, as you detailed, the idea that someone who has a specific and chronic health condition, namely cardiovascular disease and diabetes, would be prescribed produce. So fruits and vegetables, primarily. Although, there’s now talk about the role of legumes, but that is it right now. Now, that may evolve at some point, but for now, our focus is really on the healthy fruits and vegetables. 

So if you have a chronic health condition, or you are trending — and this is important — trending towards one… So you’re prediabetic, or you have a history of hypertension or those sorts of things, and the doctor really identifies that you are at risk, the idea is that they would then give you the produce prescription in the form of a credit card that you could use at a specific outlet grocery market. It could be a gift card that can be used at a certain venue. Or it could be our work with certain fulfillment vendors who will get you the produce. It can even be delivered directly to your home.

The idea is they’re enrolled; they’re able to get their healthy fruits and vegetables and are monitored over six months to a year. We actually like it to be as long as possible, but six months to a year is best, although some of the programs have been shorter.

The idea is to give them the fruits and vegetables, and then to look at the health outcomes. So things like their blood glucose or A1C, their systolic and diastolic blood pressure, their BMI, and see what the trends are over the duration of the prescription program. And that data is the data that we use to make the case for why this is impactful. And we look at things like the reduction of cost burden to the system. Improved health outcomes mean that the burden in terms of healthcare costs gets decreased. 

We’re also looking at improving patient quality of life, and that’s all part of this notion of the triple aims of value-based care now, which is a huge part of a paradigm shift in healthcare overall.

Improving Health Markers

Ocean Robbins: So what does the data say so far? Do you have any results back yet?

Benjamin Perkins: The data is compelling. One of our programs in Ohio, this is a Produce Rx program, saw a 0.5 point drop, a half a point drop in A1C, which if you know how A1C works, a half a point drop is quite significant. So a 22.3 point drop in systolic blood pressure, 14.2 point drop in diastolic blood pressure, and 4.9 point drop in body mass index or BMI.

Ocean Robbins: Wow. And that’s after what? Six months? A year of produce?

Benjamin Perkins: We usually look at, on the short end, about a four-month program. On average though, six. And the gold standard is getting it as close to a year as possible. Because what we know is the longer you have someone in these, the longer amount of time they have to build those habits and get that reinforcement that’s essential to sustain long-term health changes.

Ocean Robbins: Yeah. So Double Up Food Bucks and Produce Rx Programs are two brilliant strategies. 

Incentives for Scaling Up Programs

Ocean Robbins: Let’s talk about implementation and scaling and what could happen. So what would it take for the USDA to expand the Farm Bill to make Double Up Food Bucks normal throughout SNAP in the United States for the 42 million or so people who use SNAP to feed their families?

Benjamin Perkins: That’s a great question. And the question cuts right to the heart of the necessity for there to be both a public, so the role of the government, certainly, easily billions and billions. And we’re talking about every year. But also, in addition to the government, the private sector could play a really critical role. 

And one of the things you alluded to is about insurers. So the idea that insurers could play a key role in this. Because, guess what? If people are healthier, they’re less likely to need to avail themselves of medical visits that the insurer has to pay for.

Ocean Robbins: Sure. There’s a lot of incentives here. Employers have incentives, too, by the way. A healthier workforce is going to save them insurance premiums in the long run, especially for those that are self-insured, but it’s also going to give them better productivity. Their teams will have clearer minds on the job, and get more done. They’ll have fewer sick days. They’ll feel better. And all of that is good for company success as well. 

So employers have a stake in it. Public health initiatives have a stake. All of the insurers have a stake. The government social safety nets have a stake because a healthier population is going to be wealthier. It’s going to be more productive. It’s going to be more capable and able to respond to challenges in life effectively. 

And, of course, humanitarians and philanthropists have a stake here too. For anybody who’s got a little extra, these are places that you can invest in that could have an incredible bang for the buck in terms of net impact on human quality of life.

Utilizing Medicare & Medicaid

Ocean Robbins: I want to talk about the Produce Rx Program for a moment and a study that Tufts University did in 2019 on this. They looked at what could happen if this was scaled, on a large scale, through the Medicare and Medicaid program, which combine for 27% of federal spending. And if we implemented Produce Rx Programs throughout the Medicare and Medicaid system, for those people who are dealing with lifestyle responsive health ailments, what would happen?

Well, the first co-author of the study ended up commenting: “We found that encouraging people to eat healthy foods in Medicare and Medicaid, healthy food prescriptions, could be as or more cost-effective as other common interventions, such as preventative drug treatments for hypertension or high cholesterol.” 

Giving out the big numbers, they concluded that if they were to implement a program where people were not just prescribed fruits and vegetables, but also legumes and nuts and seeds, and they also added in there seafood and plant-based oils — because these are all things that have been found in studies to be beneficial for health. And if they provided a 30% coverage for those things, essentially through the Produce Rx Program, that the total cost would come in at a couple hundred billion dollars over the course of a long period of time. We’re also talking about savings of a hundred billion dollars in immediate health care utilization within just a five-year period.

Long-Term Healthcare Savings

Ocean Robbins: But we’re also talking about long-term savings that go far beyond that. The conventional cutoff point for a medical intervention to be considered cost-effective is if it’s less than $150,000 per quality of life year gained. If costs are less than $50,000 per quality of life year gained, those are considered highly cost-effective and medical best buys. 

Well, here we wound up with looking at around $13,000 in net intervention cost per quality of life year gained. And half of that comes back through reduced medical savings within a five-year period. And obviously, there are so many other benefits to it from the humanitarian perspective, public health, economic productivity, etc., not to mention just caring about people’s lives and wanting them to be happy and well.

They found that the Produce Rx Program could, in a five-year period, prevent 120,000 cases of diabetes. It could prevent 3.28 million cases of cardiovascular disease. And again, it will be as or more cost-effective than a lot of currently covered medical treatments. 

Ben, when you hear about these numbers, what goes through your mind?

Health Promotion Over Disease Management 

Benjamin Perkins: Let’s do it. I mean, you marshaled all of this data. And as I was saying, a lot of our work is around marshaling more data through these programs. But there is tremendously compelling evidence already. 

And one of the things I think you alluded to, which a lot of us are aware of, is in the United States, our health system is really disease management and not health promotion. And so, when you ask yourself, where are the incentives to doing stuff like produce prescription if there’s more money in medication and those sorts of things? It really sort of leads you to some uncomfortable kinds of conclusions about how our system is configured in the US.

In the United States, our health system is really disease management and not health promotion.

Benjamin Perkins

Ocean Robbins: Well, I mean, the bottom line is nobody’s getting rich from prescribing broccoli right now. I have often thought if reimbursements were the same for prescribing broccoli as prescribing chemo drugs, we’d see more broccoli prescribed, and we’d probably see fewer chemo drugs prescribed. The reality is that food is medicine, and it prevents the need for other medicines. But unfortunately, we have a healthcare system that sometimes acts as if food didn’t matter. 

Navigating a Toxic Food Culture

Ocean Robbins: And, of course, we have a food system that acts as if health didn’t matter. And at the end of the day, in this context, it’s up to each of us to take as much personal responsibility as we can, to not be a victim of the status quo, which is a fast track to disease and premature death.

But a lot of folks in this system do not have the means, the resources, the time, or the money to be able to exercise that kind of self-authorship. Because when you’re working two jobs, and you’re barely able to pay rent, and you’re super stressed out, it’s really hard to learn a whole new way of cooking and feeding your family. And it can be hard to afford it.

So what you all are doing is hitting the nail on the head on how to address that issue. I know of no other organization in the world that is addressing, so directly, this core problem we face right now, so pragmatically and so effectively, with solutions that really could change the entire game.

So Ben, what’s your vision, what’s next? How do we make this happen? And how can folks help you?

The FED Principle

Benjamin Perkins: So the vision for me, as someone who stepped into this role of leading this organization, is really to help us live out our core values. And so, one of the things that I have sort of coined is this concept called The FED Principle, which coincidentally, as an organization that does work in nutrition security, is kind of fun to play with. But FED stands for Fidelity to communities, Equity, removing barriers and improving access, and Dignity — the acknowledgment that human beings have inherent worth and, therefore, are entitled to healthy food. Nutritious food is a human right.

So that FED Principle is our north star. And so, everything that we do in terms of how we think about our work needs to measure up to that. That is the measure by which I am gauging our success. 

And ultimately, the vision is that we can get things like produce prescriptions embedded in federal and state policy. Because what we know is that that policy lever plays such a vital role in the health and well-being of not just communities, but entire populations. Because we know that, ultimately, there’s a deeply structural element to this. And one of the ways you get at structural issues is through policy levers. So that is key to how I see us in the future moving forward.

The Link Between Illness & Poverty

Ocean Robbins: Yeah. I’m just reflecting on how illness, chronic illness, is a leading cause of bankruptcy in the United States. There’s a direct connection between illness and generational, and even intergenerational, poverty. When someone dies penniless, they leave nothing to their children. And so, cycles of poverty continue across generations. 

And I think it’s not too bold an assertion to suggest that if programs like what you’re talking about were implemented, let’s say we even just, let’s just talk about Double Up Food Bucks for a second. If that was implemented on a broad scale, I think that within a generation, we would have fewer people dependent on SNAP because we’d have less grinding poverty because we’d have a healthier population. 

And by focusing on those communities that are the most impacted by chronic disease, and that are struggling the most, and giving them a leg up on their health outcomes, we can change the whole game. We can build a fairer, more equitable society that empowers people and families to save instead of depleting their resources on medical expenses they can’t afford. And maybe we can turn things around. That gives me a lot of hope. I’m so grateful to you. 

Supporting Wholesome Wave’s Mission

Ocean Robbins: And, of course, it goes without saying, but this is a nonprofit organization, Wholesome Wave. And it should be said, anybody who can, please contribute. Spread the word. Share this video. Share their website. 

And if you can, donate money. 

People can support Double Up Food Bucks programs or Produce Rx Programs, and they can also support the organization that’s seeking to leverage tens of billions of dollars in public funds to make these things happen. 

We’re probably never going to get all the way there, just with private donations. We can pilot stuff with private donations, but the goal here is much, much bigger. So, investing in this organization really is leveraged in a huge way.

And if we can establish the data that shows that this stuff works, and I think it’s inevitable that that data is going to come out more and more, then it’s just a question of getting folks in power to act on that data. And I think we can get something done here.

So Ben, thank you. Bless you.

Benjamin Perkins: Thank you.

Ocean Robbins: It’s been wonderful to have this time with you. And we look forward to doing a lot more together in the future. And by the way: Food Revolution Network is a major supporter of Wholesome Wave. My dad and I, and our whole team, are on board. And we invite all of our members to join us. Ben, thanks so much.

Benjamin Perkins: Thank you.

Note: Find out more and support the work of Wholesome Wave, here.

Tell us in the comments:

• Do you struggle with the cost of healthy food?
• Were you aware of Wholesome Wave or their Double Up Food Bucks program?
• Are you aware of any other programs or incentives to encourage healthy eating among low-income individuals?

Feature image: iStock.com/PeopleImages

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