Student Research Blog: Julian Xie, MPP, MS4
Monday, May 3, 2021
The roots of medicine are intertwined with food: the Rx on a medication prescription is short for the Latin word "recipere" or "you take"— the same word that gives rise to “recipe.” Today, medicine is increasingly getting back to those roots. Produce Prescription Programs are one in a growing menu of interventions where health systems are getting involved in assisting with food security and improving food systems at large.
Working with Duke Department of Family Medicine and Community Health on research around the Bull City Bucks Produce Prescription Program has done so much to satisfy my appetite for food systems policy. During my clinical rotations in hospitals and clinics as a medical student at Duke University School of Medicine, I noticed a common story when I saw patients. One patient summed it up best: “When it comes to SNAP, you can eat healthy or you can eat more than once.”
She was talking about the Supplemental Nutrition Assistance Program (SNAP), our federal food assistance safety net. It’s a great program that has been shown to lift people out of poverty, particularly by protecting them from having to choose between food, housing, and medications. However, it’s also extraordinarily difficult to live in poverty while trying to eat healthy with the limited budget afforded by SNAP and the extra constraints of time and access to food that low-income people face. My clinical year was marked by patients sharing stories like this.
Here in Durham, we as health care providers can luckily offer something to help. Bull City Bucks was a pilot Produce Prescription Program that gives patients experiencing food insecurity $40 each month to spend on fruits and vegetables at Durham’s Food Lion grocery stores (a program that has since grown and spread all over North Carolina). After meeting Neal Curran from Reinvestment Partners, the Durham nonprofit administering Bull City Bucks, I helped implement recruitment for the program at Duke Outpatient Clinic, where I was doing my second-year clinical rotations and where I also was doing my Primary Care Leadership Track Longitudinal Integrated Clerkship. In 2017, I also founded the Root Causes Fresh Produce Program, a Duke student social drivers of health organization, to distribute fruits and vegetables to food-insecure patients.
For my medical school third-year research project, I worked with Ashley Price, Ph.D., MPH, and Truls Østbye, Ph.D., in the Duke Department of Family Medicine and Community Health on an impact evaluation of Bull City Bucks. We acquired electronic health record data for the patients enrolled in the program and accessed their grocery store transaction data to get a detailed look at every purchase patients had made.
There are a few common denominators that catalyzed my ability to participate in Bull City Bucks research, the School of Medicine’s Primary Care Leadership Track, the Margolis Scholarship in Health Policy and Management, and founding the student organization Root Causes:
Showing up and listening.
Showing up at community coalition meetings and listening to what organizations, community members, and patients have to say has guided everything I do. A public health data expert from Durham County Department of Public Health gave a talk at my MD Program orientation about the Partnership for a Healthy Durham. During my first year of medical school, I attended monthly Partnership for a Healthy Durham Obesity, Diabetes, and Food Access (ODAFA) committee meetings, where I met community leaders like Neal Curran, and Betsy Crites from End Hunger Durham. It was through these connections that I learned about Bull City Bucks. If you’re just entering this world of community health and food policy, I highly recommend the ODAFA committee and also the Durham County Food Security Task Force, which was formed at the beginning of COVID-19 to address the negative effects of the pandemic on food security.
Learning about processes from start to finish.
Through my involvement with Bull City Bucks, I learned about multiple steps from start to finish to get healthy food in the hands of food-insecure patients. This increased the quality of my research because my clinical and community experiences made it easier to understand what was going on in the data. During those Partnership for a Health Durham meetings, I learned from Mr. Curran about the process of getting funding from the U.S. Department of Agriculture. I was also a part of program implementation. Mr. Curran and I worked with Duke Outpatient Clinic social workers and dietitians to get Bull City Bucks in the clinical workflow, including making it easy to give instructional handouts to newly enrolled patients. I learned about data cleaning and analysis from Dr. Price, and then she and Dr. Østbye guided me in the writing and publication process. Our manuscript is now published in Public Health Nutrition, where we have shared our findings on Bull City Bucks’ impact on our patients’ food purchasing and health outcomes. Moreover, these experiences made me a better community health leader and refined my ability to design and evaluate population health programs.
Forming multidisciplinary teams.
During my medical school third year, I pursued a Master of Public Policy degree at the Duke Sanford School of Public Policy. Dr. Price has a Ph.D. in Public Affairs and brings to the table a wealth of experience in food policy and social policy analysis. Our collective policy training enabled me to clean millions of lines of grocery store transaction data and health data. Dr. Østbye understands clinical trials in and out, especially for weight loss. That meant we could contextualize an evaluation of a fairly novel intervention against established research. Our collaborator Dr. Shu Wen Ng at the UNC Gillings School of Public Health lent us her team’s expertise in processing grocery store transaction data, particularly the categorization of individual food items, in which we truly had to compare an apple to an orange juice. Moreover, everyone on the team was extremely accessible and welcoming, allowing me to lead this research whilst providing helpful guidance.
Thanks to the Duke Department of Family Medicine and Community Health, I have participated in a unique community health implementation and research experience. The department helped me develop in community engagement, program implementation, and big data analysis. I am drawing upon these skills as I graduate and build upon my work with Global Alliance for Improved Nutrition on healthy food procurement research in low- and middle-income countries. I am grateful for these experiences, and for my mentors, teammates, and friends I’ve gained along the way who will continue this important mission of building a better food system.
Julian Xie's lead author manuscript, entitled "The Impact of a Produce Prescription Programme on Healthy Food Purchasing and Diabetes-Related Health Outcomes" is available to read now on Public Health Nutrition. Xie graduated from Duke University in 2015 with a major in economics and a minor in music, and his main interest is creating a healthier and more sustainable food system. He is in the Primary Care Leadership Track and completed a Master of Public Policy in spring 2020. During his MPP, he was a Margolis Scholar in Health Policy & Management, and also received the Michael R. Nathan Award to support the Root Causes Fresh Produce Program. His third-year research included a quantitative evaluation of the Bull City Bucks Produce Prescription Program, and a qualitative project for Global Alliance Improved Nutrition on healthy food procurement in low- and middle-income countries. He also co-founded Root Causes, a Duke health care student organization dedicated to social drivers of health, including the Fresh Produce Program that home-delivers food, masks, and household essentials to over 300 households a month during the covid-19 pandemic. After graduating, he will pursue a full-time career in food system policy.