Diet-related chronic diseases
The global epidemic of diet-related chronic diseases, coupled with the increasing awareness that many people face major obstacles in acquiring healthy foods, prompted increased attention to food is medicine (FIM). This term refers to the provision of healthy foods to prevent, manage, or treat diet-related chronic diseases in conjunction with health professionals.
A team of medical researchers asserted that persons’ interactions with the medical care system provides an opportunity to “offer evidence based food and nutrition interventions.” Yet these same authors acknowledge that food is medicine is hampered by “low levels of clinician nutrition knowledge and awareness of interventions, and narrow access to appropriate services and interventions.” Even for obviously diet-related conditions, such as type 2 diabetes or obesity, physicians don’t often refer patients to dieticians for advice. The authors also distinguish between “food is medicine interventions and community programmes that respond to general food insecurity by being designed or administered with the express purpose of tackling health concerns.” The authors also claim, in seeming contraction to the above, that “Healthcare systems are a logical delivery or connection point for food is medicine interventions …” The authors conclude that integrating food and nutrition interventions into healthcare systems offers significant promise for meeting nutritional needs.
Medically tailored meals
Obesity exacts enormous economic and social costs on America. Recent studies provide tantalizing evidence that medically tailored meals could provide a cost-effective way to improve the diets of underserved populations and reduce medical care expenses. One study estimated a potential cost savings of $9,000 per patient per year for medically tailored meals. Increasing expenditures for medically tailored meals upstream may reduce treatment expenditures downstream.
Healthy food prescriptions
The idea of health care professionals writing prescriptions for healthy food has grown considerably over the past 5 years. In 2021, researchers published a systematic review and meta-analysis of relevant studies. The 13 studies included mostly pre- and post-evaluations without control groups. The included studies provided monetary subsidies or direct provision of fruits and vegetables. Pooled estimates of data from 1,039 participants showed a significant 22 percent increase in fruit and vegetable consumption, equating to an average daily increase of 0.8 servings. In addition, body-mass index declined significantly by 0.6 kg/m2, while HbA1c declined by 0.8 percentage points. Alas, the included studies often suffered from methodological shortcomings, such as lack of control groups, small numbers of participants, and short duration. Nonetheless, according to the authors, the apparent initial success of healthy food prescriptions warrants large, well-designed, rigorously controlled trials to better understand the potential of healthy food prescriptions to improve diets and cardiometabolic health of low-income people.
Food is medicine programs
FIM typically refers to nutrition programs tied to health care with a focus on nutrition-related chronic diseases. Specific examples include medically tailored meals, healthy (but not medically tailored) meals, prescriptions for produce, and cash or cash-equivalent (coupons, vouchers, debit cards) to purchase healthy foods. Demonstration FIM programs are allowable under Medicaid and were established in five states as of 2023. Reports of programs in Massachusetts have appeared in the medical literature. Also on the federal level, the Gus Schumacher Nutrition Incentive Program includes produce prescription programs for eligible, at-risk patients. Non-governmental organizations and corporations have developed partnerships to provide healthy foods to low-income or food-insecure people, often with nutrition-related chronic illnesses.
A comprehensive FIM program disappoints
Researchers in Boston conducted a randomized clinical trial of a FIM program at one big-city urban site and one small city-site for participants with poorly controlled type 2 diabetes (HbA1c of 8 percent or more). Of the 1,064 participants, about half were randomized to the FIM program and the other half put on a wait list initially with usual care. After 6 months, wait-listed participants entered the FIM program. It provided healthy groceries for 2 meals per day for each household for about one year, as well as consultations with dieticians, nurses, health coaching, and diabetes counseling. The study ran during the COVID pandemic, which affected both the program participants and the wait-list participants.
From baseline to 6 months, participants in both the FIM program and the wait-list group reduced average HbA1c levels by 1.52 and 1.38 percent, respectively, a non-significant difference. From baseline to 12 months, HbA1c declined similarly in both groups by 1.56 and 1.69 percent, respectively. Thus, the FIM program and usual care were similarly effective at reducing blood glucose. Participants in the FIM program improved self-reported diet, diabetes knowledge, and engagement with medical professionals compared to the wait-list group. On the other hand, both groups showed similar changes in indices for healthy attitudes, diabetes self-efficacy, exercise, and smoking at either 6 or 12 months. Contrary to expectations, this intensive FIM program did not lead to significant declines in HbA1c or other improvements in ancillary health measures compared to usual care. The researchers speculated that perhaps the usual care in the two sites was exceptionally effective for patients with type 2 diabetes, thereby mirroring the effects of the FIM program.
American Heart Association Presidential Advisory
A team of experts wrote a presidential advisory on behalf of the American Heart Association relating to food is medicine. The authors lamented that 90 percent of Americans eat less than the recommended amounts of fruits and vegetables, not to mention skimping on other healthy foods such as whole grains, beans, other legumes, and low-fat dairy. Then there’s the fact that most Americans load up on unhealthy amounts of sugar and refined grains. The experts identified several impediments to healthy diet: 1) food and nutrition insecurity, 2) the promotion of junk food by the food industry, 3) limited or no access to healthy and affordable foods, and 4) the power of immediate versus delayed gratification. About 90 percent of the $4.3 trillion the US spends on medical care flows to chronic diseases. Thus, modest improvements in Americans’ diets could meaningfully reduce the prevalence of food- and nutrition-related chronic diseases, such as type 2 diabetes. The experts proposed ramped-up research focusing on FIM to find evidence-based ways improve American diets and reduce chronic disease, as if food-related health hasn't been happening for decades.
A contrary point of view
The food is medicine concept has grown dramatically over the past 5 years. Two researchers offered a counterpoint to the prevailing enthusiasm for food is medicine. For starters, food is medicine is not a new concept. It’s been around for decades in the form of community organizations that provide medically tailored food to patients with diet-sensitive conditions such as type 2 diabetes and obesity. Tying provision of healthy food to the medical community suffers from important defects: 1) The medical care system is difficult for many people to access; 2) The medical care system is overburdened; 3) Many physicians do not routinely refer patients to nutrition counseling programs in spite of the need; 4) Patient adherence of prescribed medications is low, even when the benefits occur relatively quickly; and 5) Healthy eating requires a series of steps that many people find difficult to achieve.
Other avenues to improving the US diet already exist. These include providing better quality food in school cafeterias, levying taxes on sugary drinks and other forms of junk food, institutional reformulation of ingredients to include less sugar, refined grains, and salt, and front-of-package labeling to help people make more informed food purchases. Food is medicine directs attention away from these topics.
The authors ask why not use existing programs to help people eat better, especially folks of lower socioeconomic status? Programs include the National School Lunch Program, School Breakfast Program, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), among others. A two-tiered approach to improving Americans’ diet would include 1) changing food industry behavior to create more healthful foods, and 2) rerouting funds directed to food is medicine to increasing funding for existing federal and state programs that already provide free of discounted healthy foods to people in need.
What to do
Doctors are not usually trained to be experts in nutrition. Plus, abundant evidence in the medical literature shows that doctors often feel overworked and burned out. Maybe I’m cynical but food is medicine sounds to me like a marketing strategy to increase funding for food-related medical research. While the broad outlines of a healthy diet are reasonably well known, a relatively small proportion of Americans consumes a healthy diet. It’s hard for me to believe that the medical care system in American would be able, at a reasonable cost, to serve as ground zero for achieving better health through better eating. Broccoli please.
