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. That’s exactly what associate professor Marianna Wetherill, PhD, MPH, RD, DipACLM, at the University of Oklahoma Health Sciences Center, has been doing for nearly two decades. Dr. In her most recent, NOURISH-OK, five-year NIH-funded study, 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 provide a concise summary 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 objective was to learn how HIV-positive individuals’ insulin resistance and chronic inflammation are affected by food insecurity. We developed a 12-week home-delivered FIM grocery intervention in collaboration with Tulsa CARES based on those findings. Many people are unaware that HIV organizations across the country developed some of the earliest FIM models in the 1980s as a community-based response to the HIV epidemic. They have been supporting nutrition for decades, so they have a wealth of practical knowledge of how to provide high-quality, evidence-based 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 fundamental principle of lifestyle medicine: start where people are most prepared. Participants preferred some foods over others, even when we served the same foods to everyone. 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. Participants in NOURISH-OK received three distinct boxes that were all in line with an anti-inflammatory eating plan. Each contained distinct varieties of food groups that were similar to one another, such as multiple varieties of beans or intact whole grains. However, we also learned that people can become overwhelmed by too much new food variety. A number of participants told us that after opening the box and seeing so many unfamiliar foods, they just closed 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.
What else did you do to help 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 sparked the most debate. 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.
It appears that community partnerships played a crucial role in shaping the intervention?
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.
Do you have any final thoughts that each FIM program ought to take into account?
Keep in mind that food is almost always consumed collectively, not individually. We talked to participants about family members who lost weight, ate vegetables for the first time in a long time, or participated in nighttime mindfulness practices. If we only measure individual outcomes, we run the risk of erroneously concluding that an intervention was ineffective at the participant level when it could have brought about a variety of changes throughout the entire household. To reflect that reality, I believe that the future of FIM will require us to broaden both our perspective and our methods of evaluation.