In a Q&A, ACLM member Dr. Marianna Wetherill shares the learned challenges and best practices in developing a targeted food as medicine intervention for low-income populations during her experience leading NOURISH-OK, an NIH-funded study that explored the relationship between food insecurity and metabolic health.
As Food as/is Medicine (FAM/FIM) programs expand nationwide, clinicians are seeking practical guidance on how to design interventions that meet the needs of people with limited resources. For nearly two decades, Marianna Wetherill, PhD, MPH, RD, DipACLM, associate professor at the University of Oklahoma Health Sciences Center, has been doing exactly that.
In her most recent five-year NIH-funded study, NOURISH-OK, Dr. Wetherill partnered with Tulsa CARES, a nonprofit HIV service organization, to explore the relationship between food insecurity and metabolic health—and test a targeted FIM intervention. In an interview with ACLM, she shared lessons learned for clinics, nonprofits, and health systems looking to launch or strengthen their FIM efforts.
Can you give a high-level overview of NOURISH-OK?
The study began about five years ago with funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Our first goal was to understand how food insecurity affects insulin resistance and chronic inflammation among people living with HIV. Based on those findings, we designed a 12-week, home-delivered FIM grocery intervention delivered in partnership with Tulsa CARES.
Many people don’t realize that some of the earliest FIM models actually emerged from HIV organizations nationwide as a community-based response to the HIV epidemic in the 1980s. They’ve been providing nutrition support for decades, so they brought invaluable on-the-ground experience into what it takes to deliver evidence-based, high-quality food assistance to people with complex biopsychosocial needs.
While final analyses are still underway, we’ve already learned a tremendous amount from participants’ experiences, baseline data, and program implementation.
What was one of your biggest early insights from the population served?
We talk about “healthy eating” like it’s one behavior, but it’s really a series of separate behaviors. We saw wide variation in participants’ readiness to try different types of foods. Some were eager to experiment; others were hesitant or unfamiliar with certain ingredients.
That reinforced a core lifestyle medicine principle: start where people are most ready. Even when we provided the same foods to everyone, participants gravitated toward certain items and avoided others. Choice matters—it empowers people and increases engagement.
How can FIM programs build in that sense of choice?
Flexibility is key. Curated food boxes need optionality. In NOURISH-OK, participants received three different boxes that all aligned with an anti-inflammatory eating pattern. Each included similar food groups but different varieties, such as multiple types of beans or intact whole grains.
But we also learned that too much variety in new food options can overwhelm people. Several participants told us they opened the box, saw so many unfamiliar foods, and just shut it again. The lesson is to provide choices but also prepare people for what they’ll encounter and offer support early.
We eventually implemented a one-week “booster” text, asking whether they had opened their box and whether they wanted a phone call to answer questions. Many did. That simple check-in made a difference.
What logistical lessons did you learn while delivering food boxes?
People often underestimate the manpower required for these programs. It’s easy to budget for the food, but harder to estimate the true staffing needed for assembly, delivery coordination, troubleshooting and even replacing boxes stolen off the porches of participants, which happened.
Clinics should think creatively and sustainably about staffing. Community health workers are fantastic for this work. Dietetic interns can also play a role and gain skills not covered in traditional training. But this work cannot simply be added to an already overloaded staff member.
In our project, Tulsa CARES had its own budget as a full sub-awardee, which gave them the capacity they needed. I can’t say that all federal grants are structured that way though.
You mentioned participants sometimes felt overwhelmed. How else did you support them?
One small but meaningful component was providing simple kitchen tools like immersion blenders. Many participants were missing teeth or had other oral health issues, making certain foods difficult to eat. That $20–$30 tool changed the experience for them. It signaled “We want you to succeed. We want these foods to be accessible to you.”
We also learned to frame the foods as opportunities to explore—not tests to pass or fail. That helped reduce anxiety, which can be a very real barrier.
Were there foods that surprised you in terms of how participants reacted to them?
Beans were the most polarizing food. People either loved them or wouldn’t touch them. And some said they only eat beans in winter, which drove home how culturally and emotionally connected food is.
Surprisingly, a big winner was dehydrated vegetables like the kind backpackers use. You just pour them into pasta sauce or soups with no chopping or waste, and people loved the convenience.
You’ve emphasized the emotional component of eating. Why is that important in FIM?
Food access and nutrition education are critical, but many people’s eating patterns reflect early life experiences or coping strategies for toxic stress. If a program doesn’t acknowledge that, it risks missing what people truly need.
Through our pre-testing, participants specifically asked us for more content on mind-body connections with food. As a result, we created a 12-week workbook, My Food Journey, that contains relatively little traditional nutrition content. Much of it focuses on relationships with self, with others, with community, and reconnecting food to personal values.
I’m extremely proud of that curriculum because it came directly from the community. We’re now in the process of testing the curriculum in a small group format with other populations. We’ve received very positive feedback among women participating in substance recovery programs and are looking for more partners who might like to pilot the curriculum in their FIM projects.
Absolutely. Often people write a grant and then look for a community partner. We did the opposite and we sat down with the partner to decide whether to apply in the first place. They were equal partners from day one.
While developing the My Food Journey workbook, we conducted interviews and focus groups to better understand community wants and needs. These interviews heavily shaped the content of the workbook, and we’ve woven their direct quotes throughout the book to help illustrate concepts in people’s own words. We hope this also helps to foster a better sense of community connectedness among people and show the community how their participation in this project led to something that will help others.
We also formed a participant advisory committee of clients who were eligible for the study. They reviewed our surveys and immediately asked, “Why aren’t you measuring chronic pain?” We didn’t have a good answer, so we added it. Their feedback also helped us refine the study.
In a recent ACLM webinar, Dr. Wetherill discussed her work implementing Food Is Medicine programming in Oklahoma.
Any final takeaway you think every FIM program should consider?
Remember that food is almost always eaten at the household–not the individual level. When we spoke to participants, we heard about family members who lost weight, ate vegetables for the first time in years, or joined in mindfulness practices at night.
If we only measure individual outcomes, we may mistakenly conclude an intervention failed at the participant level, when it might have initiated diverse changes within a whole household. I believe the future of FIM includes expanding both our lens and our evaluation methods to reflect that reality.
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