美國(guó)農(nóng)產(chǎn)品處方政策研究及對(duì)我國(guó)的啟示

韓世范，馮耀清，朱瑞芳，曹妍，寇麗紅

·食療研究·

美國(guó)農(nóng)產(chǎn)品處方政策研究及對(duì)我國(guó)的啟示

韓世范1，2，馮耀清1，3，朱瑞芳1，2，曹妍4，寇麗紅2*

1.山西醫(yī)科大學(xué)護(hù)理學(xué)院，山西 030001；2.山西醫(yī)科大學(xué)第一醫(yī)院；3.內(nèi)蒙古醫(yī)科大學(xué)護(hù)理學(xué)院；4.山西醫(yī)學(xué)期刊社有限責(zé)任公司

分析了美國(guó)近20年來(lái)的農(nóng)產(chǎn)品處方項(xiàng)目，對(duì)比了我國(guó)相關(guān)政策現(xiàn)狀，認(rèn)為美國(guó)的農(nóng)產(chǎn)品處方項(xiàng)目在模式、執(zhí)行和財(cái)政投入等方面對(duì)完善我國(guó)引導(dǎo)合理膳食防治慢性病方面具有重要借鑒價(jià)值。本研究主要對(duì)美國(guó)農(nóng)產(chǎn)品處方項(xiàng)目的背景及發(fā)展歷程進(jìn)行研究，梳理農(nóng)產(chǎn)品處方項(xiàng)目實(shí)施的歷史脈絡(luò)，結(jié)合我國(guó)國(guó)情對(duì)農(nóng)產(chǎn)品處方項(xiàng)目研究意義進(jìn)行探討，旨在認(rèn)清農(nóng)產(chǎn)品處方項(xiàng)目的定位與方向，并為進(jìn)一步制定政策作理論性鋪墊。

水果；蔬菜；農(nóng)產(chǎn)品處方；低收入；營(yíng)養(yǎng)相關(guān)性疾??；慢性病；政策

不良飲食是導(dǎo)致死亡和疾病的主要風(fēng)險(xiǎn)因素。自20世紀(jì)50年代以來(lái)，飲食營(yíng)養(yǎng)相關(guān)性疾病給美國(guó)造成了越來(lái)越重的健康和經(jīng)濟(jì)負(fù)擔(dān)。據(jù)統(tǒng)計(jì)，美國(guó)每年由飲食相關(guān)性慢性疾病造成的直接醫(yī)療成本達(dá)1萬(wàn)億美元[1?2]。全球近3%的死亡是由于水果和蔬菜攝入不足造成，給各國(guó)經(jīng)濟(jì)造成巨大損失。縱觀我國(guó)近十幾年的經(jīng)濟(jì)與衛(wèi)生事業(yè)發(fā)展?fàn)顩r，人民生活水平日益提高，人均壽命不斷延長(zhǎng)，疾病譜發(fā)生重大改變。慢性病病死率增高，慢性病醫(yī)療費(fèi)用增多，慢性非傳染性疾病現(xiàn)已居于我國(guó)死亡構(gòu)成首位，成為疾病負(fù)擔(dān)的主要原因。其中，不良飲食結(jié)構(gòu)與習(xí)慣是我國(guó)人群慢性病發(fā)病率、死亡率及醫(yī)療費(fèi)用升高的主要原因[3]。農(nóng)產(chǎn)品處方是預(yù)防與飲食有關(guān)的慢性病的一種創(chuàng)新方法，是美國(guó)政府聯(lián)合農(nóng)業(yè)部和衛(wèi)生部開(kāi)展的為應(yīng)對(duì)飲食營(yíng)養(yǎng)相關(guān)慢性病快速增長(zhǎng)而發(fā)起的食藥同源（food is medicine，F(xiàn)IM）項(xiàng)目之一，其最初的設(shè)計(jì)理念來(lái)源于中醫(yī)傳統(tǒng)食療思想[4]。農(nóng)產(chǎn)品處方項(xiàng)目從2002年實(shí)施至今已成為美國(guó)實(shí)用的公共衛(wèi)生干預(yù)措施，改善了慢性病相關(guān)健康指標(biāo)，并降低了醫(yī)療成本。此項(xiàng)措施對(duì)我國(guó)目前飲食相關(guān)慢性病防控政策的制定具有重要借鑒價(jià)值?，F(xiàn)根據(jù)已有研究證據(jù)分析、評(píng)價(jià)美國(guó)農(nóng)產(chǎn)品處方項(xiàng)目實(shí)施現(xiàn)狀及效果，梳理其實(shí)施的歷史脈絡(luò)和演變過(guò)程，以期為制定適宜我國(guó)國(guó)情的相關(guān)政策提供參考。

1 美國(guó)農(nóng)產(chǎn)品處方的來(lái)源及模式

1.1農(nóng)產(chǎn)品處方項(xiàng)目的研究背景美國(guó)膳食指南顯示，美國(guó)每年與飲食相關(guān)的心腦血管疾病及代謝疾病花費(fèi)達(dá)1.72萬(wàn)億美元，占美國(guó)生產(chǎn)總值的9.3%，給政府、社會(huì)和家庭帶來(lái)了巨大壓力[5]。尤其是低收入人群受影響最大，飲食和健康的不良影響可導(dǎo)致其生病、學(xué)習(xí)和工作表現(xiàn)欠佳、醫(yī)療成本增加、生產(chǎn)率和工資下降等一系列連鎖反應(yīng)。美國(guó)慢性病與營(yíng)養(yǎng)監(jiān)測(cè)研究結(jié)果顯示，不合理的飲食習(xí)慣尤其是水果和蔬菜低攝入是導(dǎo)致人群慢性病發(fā)病率、死亡率和醫(yī)療費(fèi)用增加的主要原因。絕大多數(shù)美國(guó)人日常果蔬攝入量未達(dá)美國(guó)膳食指南規(guī)定標(biāo)準(zhǔn)。對(duì)于一些群體，如低收入人群和有色人種，由于結(jié)構(gòu)性的不平等和系統(tǒng)性的種族主義，更難以滿足水果和蔬菜的供應(yīng)。此外，糧食不安全或無(wú)法持續(xù)獲得足夠的食物以維持積極、健康的生活，會(huì)加劇不良健康結(jié)果風(fēng)險(xiǎn)。已有研究顯示，受新型冠狀病毒肺炎（COVID?19）影響，經(jīng)濟(jì)衰退，飲食相關(guān)慢性病發(fā)病率急劇上升[6?10]。

1.2農(nóng)產(chǎn)品處方的來(lái)源及模式農(nóng)產(chǎn)品處方項(xiàng)目是食藥同源公共衛(wèi)生政策的組成部分，美國(guó)衛(wèi)生部門提出該政策旨在將一系列量身定制的食品和營(yíng)養(yǎng)服務(wù)整合到衛(wèi)生保健中，以解決慢性病發(fā)病率和衛(wèi)生保健成本不斷上升的問(wèn)題。農(nóng)產(chǎn)品處方項(xiàng)目是一項(xiàng)低成本的公共衛(wèi)生策略，可以改善人群健康狀況，并可能降低長(zhǎng)期醫(yī)療成本[1]。農(nóng)產(chǎn)品處方計(jì)劃最初被稱為水果蔬菜處方、素食處方等[11?14]，其定義隨著時(shí)間推移而變化。2019年，美國(guó)國(guó)家農(nóng)產(chǎn)品處方聯(lián)盟成立（由農(nóng)產(chǎn)品處方從業(yè)者、研究人員和倡導(dǎo)者組成），將農(nóng)產(chǎn)品處方項(xiàng)目定義為由醫(yī)療保健提供者或健康保險(xiǎn)計(jì)劃為具有飲食營(yíng)養(yǎng)相關(guān)健康風(fēng)險(xiǎn)或狀況、食品不安全或在獲得營(yíng)養(yǎng)食品方面存在問(wèn)題的病人提供的醫(yī)療或預(yù)防服務(wù)。該項(xiàng)目對(duì)食品的價(jià)格和成分有官方規(guī)定，并通過(guò)食品零售完成，使病人能夠以較低或免費(fèi)價(jià)格獲得沒(méi)有添加脂肪、糖或鹽的健康農(nóng)產(chǎn)品。

美國(guó)各州農(nóng)產(chǎn)品處方項(xiàng)目運(yùn)行模式不盡相同，但實(shí)施步驟和框架大致相同。醫(yī)療保健人員根據(jù)服務(wù)對(duì)象收入水平、診斷結(jié)果、是否具有飲食相關(guān)疾病風(fēng)險(xiǎn)或糧食不安全狀況確定哪些病人可以從增加農(nóng)產(chǎn)品消費(fèi)和獲取中受益[11?15]，并為其開(kāi)具水果蔬菜處方。處方通常是通過(guò)農(nóng)產(chǎn)品優(yōu)惠券或憑證的形式提供，可以憑借處方在指定農(nóng)產(chǎn)品零售點(diǎn)兌換。優(yōu)惠券金額因計(jì)劃不同而不同。除處方之外還包括對(duì)參與者提供營(yíng)養(yǎng)教育。

2 農(nóng)產(chǎn)品處方項(xiàng)目的歷史演變

2.1自由化階段（2014年以前）伴隨著美國(guó)民眾飲食相關(guān)慢性病的日益加重，農(nóng)產(chǎn)品處方雛形出現(xiàn)，最初由高校和民間學(xué)術(shù)組織自籌發(fā)起。20世紀(jì)60年代末，密西西比州土崗灣的1個(gè)社區(qū)健康中心為有營(yíng)養(yǎng)不良兒童的家庭提供食物處方。隨后20年里將低收入購(gòu)物者與當(dāng)?shù)剞r(nóng)民聯(lián)系起來(lái)的試點(diǎn)項(xiàng)目在全國(guó)各州實(shí)施[16]。20世紀(jì)90年代中期，該模式成功促成了1992年馬薩諸塞州婦幼營(yíng)養(yǎng)補(bǔ)助計(jì)劃(WIC)農(nóng)貿(mào)市場(chǎng)營(yíng)養(yǎng)計(jì)劃的建立[17]、2002年老年農(nóng)貿(mào)市場(chǎng)營(yíng)養(yǎng)計(jì)劃以及在地方、州甚至國(guó)家層面上實(shí)施的數(shù)十項(xiàng)由政府撥款支持的營(yíng)養(yǎng)激勵(lì)計(jì)劃[18]。

2002年美國(guó)農(nóng)業(yè)法案首次提出健康飲食激勵(lì)計(jì)劃。在此農(nóng)業(yè)法案中，農(nóng)產(chǎn)品激勵(lì)計(jì)劃最初是作為改善低收入美國(guó)人健康的一種機(jī)制被提出。在法案制定過(guò)程中，公共衛(wèi)生倡導(dǎo)者推動(dòng)了一項(xiàng)計(jì)劃，旨在為食品援助受益人購(gòu)買水果和蔬菜提供財(cái)政激勵(lì)。但該項(xiàng)目最終未被納入法案。對(duì)此，倡導(dǎo)者要求美國(guó)農(nóng)業(yè)部(USDA)構(gòu)建一個(gè)激勵(lì)模型，以收集關(guān)于農(nóng)產(chǎn)品處方項(xiàng)目有效性的數(shù)據(jù)。隨后民間組織支持下的農(nóng)產(chǎn)品處方項(xiàng)目研究發(fā)現(xiàn)，素食和富含植物的飲食與缺血性心臟病、2型糖尿病、癌癥以及其他與不良飲食、肥胖相關(guān)的疾病風(fēng)險(xiǎn)較低有關(guān)[17,19?20]。

2008年—2012年，在密歇根康涅狄格、緬因州、馬薩諸塞州、新墨西哥、紐約、羅德島和華盛頓特區(qū)等28個(gè)州，農(nóng)產(chǎn)品處方作為一種獨(dú)特的干預(yù)措施得到了撥款支持[21]。在這一背景下，馬薩諸塞州漢普登縣一個(gè)由7 500戶家庭組成的隨機(jī)小組利用高級(jí)營(yíng)養(yǎng)援助計(jì)劃(SNAP)資金，獲得了精選水果和蔬菜30%的折扣。通過(guò)與另外47 595戶領(lǐng)取傳統(tǒng)社會(huì)保險(xiǎn)津貼的家庭對(duì)照，結(jié)果顯示，參與者的水果和蔬菜支出增加了8.5%[12]，且水果和蔬菜消耗量比對(duì)照組高0.24杯[22]。

2.2制度化階段（2014年—2018年）在2014年農(nóng)業(yè)法案完成之前，美國(guó)國(guó)家糧食和農(nóng)業(yè)研究所收集了對(duì)農(nóng)產(chǎn)品處方擬議計(jì)劃的意見(jiàn)；“健康浪潮”（一個(gè)致力于增加健康食品獲取機(jī)會(huì)的全國(guó)性非營(yíng)利組織，也是此階段農(nóng)產(chǎn)品處方項(xiàng)目的主要資助者）收集了來(lái)自美國(guó)近40個(gè)項(xiàng)目合作伙伴的評(píng)估報(bào)告，根據(jù)報(bào)告反饋，建議將農(nóng)產(chǎn)品激勵(lì)資金用于農(nóng)產(chǎn)品處方計(jì)劃?；诖耍?014年農(nóng)業(yè)法案撥款1億美元支持農(nóng)產(chǎn)品激勵(lì)計(jì)劃[23]。

2016年—2018年，醫(yī)療保險(xiǎn)和醫(yī)療補(bǔ)助服務(wù)中心(CMS)批準(zhǔn)了來(lái)自馬薩諸塞州等州的申請(qǐng)[24]和北卡羅來(lái)納[25]實(shí)施醫(yī)療補(bǔ)助的申請(qǐng)，其中包括解決與健康有關(guān)的社會(huì)需求的項(xiàng)目，這些項(xiàng)目允許各州利用醫(yī)療補(bǔ)助基金為某些醫(yī)療補(bǔ)助參與者提供營(yíng)養(yǎng)干預(yù)，包括農(nóng)產(chǎn)品處方[26]。

2.3社會(huì)化階段（2018年至今）美國(guó)的農(nóng)產(chǎn)品正式走向社會(huì)化起源于2018年的立法推動(dòng)。美國(guó)政府于2018年12月20日簽署2018年農(nóng)業(yè)法案，農(nóng)產(chǎn)品處方項(xiàng)目獲得農(nóng)業(yè)法案資助，主要包括5年內(nèi)撥付2 500萬(wàn)美元專門用于農(nóng)產(chǎn)品處方項(xiàng)目[27?29]。符合條件的實(shí)體將申請(qǐng)補(bǔ)助資金以實(shí)施農(nóng)產(chǎn)品處方計(jì)劃。同時(shí)法案規(guī)定，農(nóng)產(chǎn)品處方資金必須用于研究和評(píng)估農(nóng)產(chǎn)品處方對(duì)以下3種結(jié)果的影響：①通過(guò)增加水果和蔬菜的消費(fèi)改善健康；②減少食物不安全；③減少醫(yī)療保健的使用，從而降低醫(yī)療保健成本[30?39]。

在制定2018年農(nóng)業(yè)法案的同時(shí)，眾議院核心小組成立了藥食同源工作組，“健康浪潮”被邀請(qǐng)參加工作組簡(jiǎn)報(bào)會(huì)，并介紹了各種農(nóng)產(chǎn)品處方模型和案例。藥食同源工作組的成立標(biāo)志著聯(lián)邦政府農(nóng)產(chǎn)品處方項(xiàng)目被正式認(rèn)可。同時(shí)在制定法案時(shí)期美國(guó)民眾表示，由于醫(yī)療提供者的參與，農(nóng)產(chǎn)品處方計(jì)劃與其他激勵(lì)措施相比是獨(dú)特的，他們希望政府在制定農(nóng)業(yè)法案時(shí)認(rèn)識(shí)到農(nóng)產(chǎn)品處方計(jì)劃的獨(dú)特之處。

3 農(nóng)產(chǎn)品處方項(xiàng)目的效果評(píng)價(jià)

研究表明，農(nóng)產(chǎn)品處方項(xiàng)目會(huì)對(duì)服務(wù)對(duì)象飲食、疾病管理以及潛在醫(yī)療成本產(chǎn)生積極影響，尤其是可以改善服務(wù)對(duì)象營(yíng)養(yǎng)相關(guān)行為，包括增加水果和蔬菜的攝入、增加營(yíng)養(yǎng)和烹飪知識(shí)[40]。同時(shí)，參與人員健康飲食指數(shù)及對(duì)健康膳食指南的依從性也均有所提高[30]，具體體現(xiàn)在生理指標(biāo)及社會(huì)性層面，其中，生理指標(biāo)的積極結(jié)局包括降低體質(zhì)指數(shù)(BMI)和/或體重[41]、降低糖化血紅蛋白水平[42]、改善血糖水平[43]等；社會(huì)層面包括降低家庭糧食不安全[22,44]、提升與醫(yī)療保健提供者討論飲食和預(yù)防的動(dòng)機(jī)[12,16,18,21?23,43,45]、提高對(duì)農(nóng)貿(mào)市場(chǎng)的認(rèn)識(shí)以及增加相關(guān)知識(shí)[18,45]。但也有少數(shù)研究發(fā)現(xiàn)，農(nóng)產(chǎn)品消費(fèi)、體質(zhì)指數(shù)未發(fā)生變化[18,43]。因此，可能需要進(jìn)行更多項(xiàng)目評(píng)估，以確定農(nóng)產(chǎn)品處方項(xiàng)目帶來(lái)的相關(guān)健康結(jié)果。此外，當(dāng)前對(duì)醫(yī)療保健的額外成本研究正在進(jìn)行，初步評(píng)價(jià)模型表明，農(nóng)產(chǎn)品處方項(xiàng)目具有較高成本效益潛力。據(jù)估計(jì)，如果在全國(guó)范圍內(nèi)向醫(yī)療補(bǔ)助和醫(yī)療保險(xiǎn)參保人員提供30%的水果和蔬菜購(gòu)買補(bǔ)貼，將節(jié)省397億美元的正規(guī)醫(yī)療保健成本[16]。

4 啟示與展望

4.1開(kāi)發(fā)農(nóng)產(chǎn)品健康處方中國(guó)路徑，助力健康中國(guó)建設(shè)美國(guó)農(nóng)產(chǎn)品處方實(shí)施至今已有20余年歷史，其在政策制定、社區(qū)參與及群體教育等方面的效果已被多方證實(shí)。我國(guó)是世界人口大國(guó)，隨著我國(guó)進(jìn)入老齡化社會(huì)，慢性非傳染性疾病成為影響我國(guó)全面現(xiàn)代化建設(shè)健康政策實(shí)施的重大障礙。農(nóng)產(chǎn)品處方項(xiàng)目是美國(guó)食品營(yíng)養(yǎng)援助中的重要措施，此項(xiàng)措施對(duì)我國(guó)目前營(yíng)養(yǎng)相關(guān)性慢性病防控政策的制定具有重要借鑒意義。不合理膳食的影響因素主要有兩方面，即健康飲食素養(yǎng)認(rèn)知、飲食成本。當(dāng)前我國(guó)營(yíng)養(yǎng)教育與政策較為到位，在提高我國(guó)居民健康飲食素養(yǎng)方面發(fā)揮了一定作用，但也應(yīng)認(rèn)識(shí)到，影響居民尤其是低收入居民健康飲食決定的因素不僅是營(yíng)養(yǎng)認(rèn)知，還有高成本的蔬菜、水果。

在我國(guó)傳統(tǒng)飲食習(xí)慣與健康膳食模式基礎(chǔ)上開(kāi)展類似農(nóng)產(chǎn)品處方的公共衛(wèi)生政策，不僅有利于改善居民飲食營(yíng)養(yǎng)健康，減輕營(yíng)養(yǎng)相關(guān)慢性病醫(yī)療負(fù)擔(dān)，還可以促進(jìn)農(nóng)產(chǎn)品持續(xù)發(fā)展和生態(tài)環(huán)境改善，實(shí)現(xiàn)三贏局面。此外，我國(guó)是世界農(nóng)業(yè)大國(guó)，農(nóng)產(chǎn)品功能導(dǎo)向?qū)θ嗣耧嬍硾Q策起著至關(guān)重要的作用，可以充分借助這一優(yōu)勢(shì)，開(kāi)展以農(nóng)養(yǎng)醫(yī)、以農(nóng)助農(nóng)的健康處方新路徑。

4.2弘揚(yáng)傳統(tǒng)中醫(yī)食療公共衛(wèi)生功能潛力美國(guó)很早就開(kāi)展了食藥同源項(xiàng)目[19]，這與我國(guó)中醫(yī)理念下的藥食同源理論不謀而合。我國(guó)自古以來(lái)中醫(yī)學(xué)就有食藥同源理論，認(rèn)為許多食物同時(shí)也是藥物，可用于防治疾病[46?47]。美國(guó)農(nóng)產(chǎn)品處方項(xiàng)目的創(chuàng)立和發(fā)展契合了藥食同源理念，不論是降低醫(yī)療成本還是提高全民健康水平，抑或預(yù)防飲食營(yíng)養(yǎng)相關(guān)性疾病，農(nóng)產(chǎn)品處方項(xiàng)目都是一種高性價(jià)比成本效益的公共衛(wèi)生策略[48]。本團(tuán)隊(duì)前期研究成果支撐了國(guó)家2022年兩會(huì)提案《關(guān)于實(shí)施中國(guó)特色的“農(nóng)產(chǎn)品處方”公共衛(wèi)生策略的提案[第04403號(hào)（醫(yī)療衛(wèi)生416號(hào)）]》，此提案已被全國(guó)政協(xié)采用。

5 小結(jié)

農(nóng)產(chǎn)品處方計(jì)劃在不斷發(fā)展和完善，具有較高成本效益潛力。我國(guó)對(duì)國(guó)民營(yíng)養(yǎng)問(wèn)題的重視程度持續(xù)提高，應(yīng)指導(dǎo)城鄉(xiāng)居民食品消費(fèi)結(jié)構(gòu)由“溫飽型”向“營(yíng)養(yǎng)型”轉(zhuǎn)變。新型冠狀病毒肺炎疊加在慢性病之上，進(jìn)一步凸顯了與飲食相關(guān)慢性病的問(wèn)題。而合理膳食是預(yù)防和治療慢性病的有效方式，將農(nóng)產(chǎn)品處方干預(yù)措施整合到醫(yī)療保健中有著巨大前景，同時(shí)，也契合我國(guó)傳統(tǒng)食藥同源思想，不但可以滿足當(dāng)前人們的健康飲食需求，而且有助于提高生活質(zhì)量。此外，農(nóng)產(chǎn)品處方可以作為一個(gè)有價(jià)值的橋梁，將農(nóng)業(yè)和食品整合到以醫(yī)療保健為導(dǎo)向的工作中，重點(diǎn)是改善健康和減少醫(yī)療保健支出。

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Research on American produced prescription policy and its enlightenment to China

HANShifan,FENGYaoqing,ZHURuifang,CAOYan,KOULihong

Nursing College of Shanxi Medical University,Shanxi 030001 China

This paper analyzes the American produced prescription project in recent 20 years，and compares the current situation of China's related policies.It was concluded that America's produced prescription project had important reference value in the pattern，implementation and financial input to perfect the prevention and treatment of chronic diseases in rational diet in China.This paper mainly studied the background and development history of the produced prescription program in the United States，combed the historical context of the implementation of the produced prescription program，and discusses the research significance of the produced prescription program in combination with China's national conditions.The aim of this paper was to clarify the orientation and direction of the produced prescription project，and to lay a theoretical foundation for further policy making.

fruits；vegetables；produced prescription；low income；nutrition?related diseases；chronic diseases；policy

KOU Lihong,E?mail:369992474@qq.com

10.12102/j.issn.1009-6493.2022.22.022

山西省科技戰(zhàn)略研究專項(xiàng)課題，編號(hào)：202104031402136

韓世范，主任醫(yī)師，博士生導(dǎo)師

寇麗紅，E?mail：369992474@qq.com

韓世范,馮耀清,朱瑞芳,等.美國(guó)農(nóng)產(chǎn)品處方政策研究及對(duì)我國(guó)的啟示[J].護(hù)理研究,2022,36(22):4069?4073.

（收稿日期：2022-10-26；修回日期：2022-10-29）

（本文編輯 陳瓊）