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Let Food be Thy Medicine

Teen volunteers in Ceres kitchen preparing meals

Teen volunteers in Ceres kitchen preparing meals

A revolution is taking place in community health centers, hospitals and community benefit organizations across the country. It has the potential to create an integrated, equitable and regenerative food and health care system – but only if we pay attention, raise our voices, and make it so. The goal is the full integration of healthy, sustainably raised food into our approach to preventing and treating illness, and into our health care system. The motivation comes from the abysmal state of American’s health and the epidemic of diet-related chronic disease.

At Ceres Community Project we’re working to create a food as medicine solution that layers positive impact throughout the community and our food system. We provide medically tailored meals for primarily very low-income people who are struggling because of an acute or chronic health condition. Our meals are made with 100% organic ingredients, sourced as much as we can from local farmers and food producers. We integrate a Youth Development program where hundreds of young people each year volunteer as gardeners and chefs, learning how to grow, prepare and eat healthy and organic food. We work to educate all our stakeholders about the link between healthy whole foods, a healthy food system, and our own health and well-being. And we work to change policy so that all people have access to affordable, healthy, sustainably raised and culturally relevant foods to support a thriving life.

This article provides an overview of why food as medicine is so critical for health, the basic food as medicine strategies or interventions that are gaining acceptance, and key policy approaches for scaling food as medicine to reach as many people as possible. We start with an overview of the state of America’s diet.

The State of America’s Diet

Impact of Providing Food on HealthPoor diet quality is now a leading risk factor associated with death and disability in the United States, contributing to approximately 678,000 deaths each year from illnesses such as heart disease, cancer, and type 2 diabetes. In the last 30 years, obesity rates have doubled in adults, tripled in children, and quadrupled in adolescents.From 100 years ago when food was primarily whole and always raised without pesticides, the typical American diet today suffers from cheap and readily available processed foods. As a result, it’s too high in calories, saturated fat, sodium, and added sugars, and lacks enough fruits, vegetables, whole grains, calcium, and fiber. The CDC reported in their 2018 State Indicator Report on Fruits and Vegetables that only 12.2% of adults were eating the recommended 1.5 to 2.0 cups per day of fruits, and just 9.3% of adults were eating the recommended 2.0 to 3.0 cups per day of vegetables. This eating pattern increases the risk of numerous diseases, including heart disease, diabetes, obesity, high blood pressure, stroke, osteoporosis; and many types of cancers, including cervical, colon, gallbladder, kidney, liver, ovarian, uterine, and postmenopausal breast cancers; leukemia; and esophageal cancer (after researchers took smoking into account).Millions of Americans are now living with one or more of these nutrition-related chronic diseases, and it’s costing hundreds of billions of dollars a year in health care spending:

Rethinking the Role of the Doctor’s Office

Illness table copyAlong with rising rates of nutrition-related chronic disease and the associated health care costs, there is another factor driving change in the health care sector – the realization that most of what impacts our health happens outside of the health care system. Some researchers believe that only 20% of our health outcomes are related to what happens in the doctor’s office. Thirty percent are related to health behaviors – choices that we make – such as diet and exercise, smoking, alcohol use, and sexual activity. We could probably add good sleep and stress management to the list. But what’s really important is the other 50% of the equation. These are the things out of our control – our physical environment and what are called the “social determinants of health”. The saying “your zip code is more important than your genetic code,” refers to this. The circumstances into which you are born provide either supports or barriers that have a significant impact on your health. This includes poverty, access to a quality education, the safety of our neighborhoods, and our likelihood of graduating from high school or college and therefore our ability to get and keep a good job. All of that is impacted by systemic racism.

As health care providers and, more importantly, insurers, began to study this information, they realized that they have to look outside the health care system if they want to improve health outcomes and manage health care costs. It’s not going to make any difference for a doctor to provide a prescription if the patient can’t afford it. A doctor can lecture all they want about getting exercise, but patients won’t comply if it’s not safe to walk in their neighborhood. It’s hard to prevent obesity and diabetes when patients can’t afford a healthy diet or there’s no grocery store within miles of their home.

The understanding of the role that social determinants of health play in patients’ health and well-being – and thus their health care costs – is driving health care providers and insurers to think in new ways about how to support patients’ health. Many health care providers are now implementing social determinants of health screening tools to assess patients’ social needs. New roles, including patient navigators and community health workers, are being added to help connect patients to community resources. Community referral websites are being developed that include the ability for health care providers to send referrals directly to community-based organizations. And health care organizations and insurers are experimenting with providing services that have traditionally been excluded from health care coverage. Even Medicare and Medicaid, the public health insurance programs, have recently allowed some flexibility to cover certain food and nutrition interventions. Because food insecurity is common, and addressing it is relatively cost effective compared to challenges such as housing or the physical environment, efforts by health care providers and insurers to improve food and nutrition security have soared.

Food as Medicine Starts with Food and Nutrition Security

In the broadest sense, food as medicine refers to the vital role that access to healthy food plays in overall health and well-being. This includes basic food and nutrition security as well as how we can use food to both prevent and treat chronic disease. The United Nations definition of food security makes this connection between food and “an active and healthy life” and in its definition assumes that by food security we mean nutrition security – not just enough food, but enough of the right kinds of food. The UN defines food security as: “all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their food preferences and dietary needs for an active and healthy life.”

Prior to the pandemic, 11.1% of US households experienced food insecurity with research indicating that this was responsible for $52.9 billion annually in direct health care costs. Food insecurity is not limited to low-income households. There is consistent data linking food insecurity and poorer health outcomes even after controlling for factors like income, race, and education. Those at similar income levels with increased consistent access to healthy foods (whether because of access to food supports like SNAP, food pantries, or the ease and availability of nearby grocery stores) have better health outcomes than those who have less consistent access to healthy foods. And there is also a dose-dependent relationship with food insecurity and health: those who are more severely food insecure are more likely to have a chronic disease.

In children, food insecurity is associated with behavioral issues, poorer academic performance, worse health and higher rates of hospitalization. Among adults, the impacts include higher rates of obesity, diabetes, hypertension, depression and hospitalization. Improved food security, on the other hand, is associated with decreased A1c, blood pressure, BMI, pre-term birth and depression, and increased medication adherence and heart failure symptom control.

Research on the SNAP program shows important benefits for both children and older adults. Children with access to SNAP are more likely to graduate from high school – which carries its own benefit for lifetime well-being, and are less likely to suffer from obesity, heart disease and stunted growth. Among seniors, receiving SNAP benefits increases the likelihood of adhering to medication – including taking it every day, taking the prescribed dose, and not delaying filling the prescription.

Food as medicine starts with meeting basic nutrition security needs and includes important federally supported programs like SNAP (Supplemental Nutrition Assistance Program), WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), school lunch and meals provided to seniors. These are interventions that can help prevent chronic disease by increasing nutrition security.

While all the clients we serve at Ceres Community Project are dealing with a health challenge that requires medically tailored meals, we also screen every client for food insecurity. For clients who screen positive, we provide either a double portion of prepared meals (14 per week) or 7 prepared meals plus a grocery bag of simple-to-prepare medically tailored items equal to about 8 meals.

Food as Medicine as a Medical Intervention

Food as medicine also describes specific kinds of nutrition interventions that can be offered by a health provider or insurer to address or treat specific chronic illnesses. Healthy food prescriptions, medically tailored groceries and medically tailored meals are all examples of food as medicine interventions that are being offered within a traditional health care context. In these situations, health care providers or insurers identify specific nutrition needs based on a patient’s diagnosis, acuity, income or other factors; refer the patient to receive the service; and in some cases also pay for the service. Below we’ll review broader policy efforts underway. Here are a few specific examples of how various food as medicine interventions are being researched or applied:

Medically Tailored Meals

Medically tailored meals (MTM) are delivered to individuals living with serious illness through a referral from a medical professional or healthcare plan. Meal plans are tailored to the medical needs of the recipient by a Registered Dietitian Nutritionist (RDN), and are designed to improve health outcomes, lower cost of care and increase patient satisfaction. MTM have the most robust research base of any food as medicine intervention (see chart below) with studies consistently demonstrating a net savings of at least 16% in health care costs and a wide range of additional benefits.

– California’s Nutrition Intervention Pilot for Medicaid members with Congestive Heart Failure: In 2017, the California legislature approved $6 million for the first statewide pilot of a MTM intervention. Ceres Community Project is one of the six non-profit nutrition service providers involved in this pilot. Together we cover 7 counties and 48% of the state’s Medicaid population. Eligible patients receive 12 weeks of full nutrition (21 meals/week) and up to 3 visits with a registered dietitian nutritionist. Meals are fully tailored to meet evidence-based guidelines for patients with congestive heart failure. A full evaluation is being done by a national health evaluator and will include an assessment of health care utilization and costs among patients receiving the intervention compared to similar patients who do not. Early self-reported data is showing dramatically lower 30-day hospital readmission rates for patients in the intervention compared to the state’s average, indicating that this program will likely provide cost savings to the state consistent with the research on medically tailored meal interventions. Full results will be available in 2022.

– A wide range of health care organizations are currently providing MTM to specific eligible patients/members through contracts with MTM providers or conducting pilots to evaluate the benefit of the intervention. Ceres Community Project is currently working with Kaiser Permanente on a large-scale randomized control trial providing 10 weeks of meals for patients being discharged with congestive heart failure, diabetes and/or chronic kidney disease. Other examples include Medicaid patients with any condition at discharge from the hospital; patients with uncontrolled diabetes either alone or in combination with diabetes self-management programs; women with high risk pregnancies including gestational diabetes; end stage cancer; food insecure patients at discharge from the hospital, and more.

Healthy Food Prescriptions/Medically Tailored Groceries

In these programs, physicians identify at-risk patients—either by a diagnosed diet-related health condition (such as diabetes, obesity, or heart disease), a screening for food insecurity or a qualifying income level, or both—and write prescriptions for the consumption of subsidized nutrient-rich foods, most often fruits and vegetables.

– Gus Schumacher Nutrition Incentive Program (GusNIP): Supported by approximately $50 million in grant funding annually through US Department of Agriculture, GusNIP provides grants of up to $500,000 over three years to pilot produce prescription programs where community health centers or other health providers partner with community-based organizations. Eligible participants must be low-income patients who are eligible for SNAP or Medicaid, and be suffering from or at risk of developing diet-related health conditions. At least 50% of the funds must go directly to the patients being served and a wide range of program models are allowed. Eligible patients receive a “prescription” for the produce from the health provider, and you must track and evaluate the impact of the intervention on dietary health, food security, health care use and costs.

Feeding America’s Diabetes Wellness Boxes

Food as MedicineSeveral years ago, Feeding America conducted a multi-year pilot with several food banks around the country to test the value of an appropriately tailored food box for food bank clients with diabetes. Patients were referred by their health provider and received a monthly box with perishable and non-perishable foods tailored to meet nutritional requirements for diabetes. While funding for the pilot ended, some food banks have maintained the program through grant funding and Feeding America provides a Resource Guide on their website.

In 2018, Ceres piloted a program that combined access to healthy food, medically tailored prepared meals and nutrition education. The goal was to improve healthy eating behaviors and health status among low-income patients who were at risk of developing heart disease. Patients and their families attended a Saturday morning nutrition education class at a local elementary school. Extended family members were welcome, child-care was included, and the classes were taught in Spanish with simultaneous translation. Each week, the families went home with several already prepared meals that met diabetic and heart healthy standards, recipes and the groceries needed to prepare them. Patients reported significant reductions in food insecurity, and improvements in healthy eating behaviors, attitudes about healthy eating, and confidence in healthy eating. All health metrics that we tracked remained stable or improved.

While not connected directly to health care referrals, California’s Market Match Program is another example of efforts to increase fruit and vegetable consumption among low-income community members while also supporting local farmers. Funded initially by $3.7 million in federal grants through the Food Insecurity Nutrition Incentive (FINI) Program matched with state funds, Market Match doubles the spending of food stamp recipients when spent at more than 300 farmer’s markets across the state. Research by the University of Southern California found that 75% of Market Match shoppers reported eating more fresh fruits and vegetables and 71% said their family’s health had improved.

Food Pharmacies

What we know - how medically tailored meals can helpOn their own or sometimes in coordination with produce prescription programs, community health centers, hospitals and others are developing Food Pharmacies. Most often, patients receive a prescription from their health provider to visit the Food Pharmacy either weekly or monthly. Sometimes patients participate as part of a cohort and also receive nutrition education and/or cooking demonstrations at each visit. The Pharmacies are small food pantries that contain only food choices that are healthy for the patient population being referred. Boston Medical Center launched their Preventive Food Pantry in 2001. Today, they distribute 50,000 pounds of healthy food a month to about 1,800 families with 40% of recipients being children. Participants receive a referral from their primary care physician and can visit the pantry twice each month. Their food options are pre-selected based on their family’s dietary restrictions and each visit is recorded in the patient’s medical record so their physician knows whether or not they are accessing the benefit.Boston Medical Center’s program also includes a Teaching Kitchen that was built at the same time as the Food Pantry to educate patients about how to cook nutritional meals at home. A Registered Dietician and nurse provides tips on how to cook healthy recipes and runs classes for people with diabetic, cardiac, and hypertension issues, as well as pregnant women and those fighting obesity.

The Opportunity of Food as Medicine

Faced with the epidemic of nutrition-related chronic disease outlined above, and the increased health care costs that are associated, health care providers and insurers, including CMS (Centers for Medicare and Medicaid Services), are innovating to connect patients to a wide-range of food as medicine interventions. While there is still a long way to go to fully integrate healthy food as a covered medical benefit, most national insurers have at least a toe in the water and progress is being made in federal and state-level health care programs. Here is an overview of the most promising efforts to scale food as medicine.

– Ryan White, the federal program for AIDS/HIV support approved in 1990, was the first time home delivered meals were funded for a population with a specific illness. The program, which provides a wide range of services for people living with AIDS/HIV, has been extremely successful. Ryan White Program patients have achieved retention in care rates (80%) and viral suppression rates (81%) that far exceed national averages. Ryan White was the first federal program to recognize and fund vital structural interventions like housing support, transportation, and most critically, food and nutrition services. Dozens of community-based organizations around the country continue to receive annual funding from Ryan White to provide MTM and medically tailored groceries to people living with AIDS/HIV,

– As of 2020, Medicare Advantage, the Medicare program used by about 33% of Medicare members, can include coverage of food and nutrition interventions for Medicare members who meet certain criteria. Medicare Advantage plans must choose to offer the benefit and receive approval from CMS to do so. While uptake of the benefit was slow in the first year, many plans are expected to begin some food and nutrition interventions like medically tailored or home delivered meals in 2021.

– To address the equity issues with nutrition benefits being available to only 1/3 of Medicare members, Congressman Roger Marshall (R-KS), Congressman Jim McGovern (D-MA), Congresswoman Jackie Walorski (R-IN) and Congresswoman Chellie Pingree (D-ME) have introduced H.R. 6774. The Medically Tailored Home-Delivered Meals Demonstration Pilot Act of 2020 would establish a Medicare MTM pilot program in at least 10 states to address the critical link between diet, chronic illness, and senior health. The goal is to evaluate the impact of a MTM benefit on health outcomes and costs. If the pilot is successful, the meal benefit could be expanded to every Medicare beneficiary who qualifies based on health status.

– While the traditional Medicaid program does not cover food as a benefit, several states have requested permission (through program waivers) to cover or pilot food as medicine interventions in their Medicaid programs. For example, both Massachusetts and North Carolina have received permission to provide a range of food and nutrition interventions, such as meals or transportation to a grocery store, to Medicaid beneficiaries who meet certain criteria. A number of state Medicaid programs also pay for home-delivered meals in order to keep people in their homes as opposed to nursing homes. Moreover, in light of the research that shows a reduction in health care utilization and therefore cost with participation in certain food as medicine programs, private insurers that participate in the Medicaid program are also offering meals with non-benefit funding.

– Private Funding – hundreds of private health care organizations and insurers, along with philanthropic funders, are conducting research studies, piloting interventions for different populations, or simply acting on the basis of the existing research and paying for food as medicine interventions for their patients and members.

Food as Medicine Challenges

While we’re seeing tremendous momentum in the food as medicine space, significant challenges exist to fully integrate food as a covered medical benefit. Our health care system is simply not designed to partner with non-clinical food providers, or to prescribe or refer to non-clinical food services. Here are just a few of the issues that must be addressed at a systems level if we’re going to recognize the full benefits of the food as medicine revolution.

Health care providers have not historically been set up to identify patients who might need a food as medicine referral. Often such referrals are based on a combination of a diagnosis and clinical data along with information about food insecurity, mobility issues, or other factors. Someone has to gather this data, make it available in the patient’s electronic medical record (EMR), and then someone at the health care provider needs to reach out to the identified patients, talk with them about the referral, and then follow through by making the referral. A wide range of strategies are being implemented to address these issues.

Health care organizations are implementing various social determinants of health screening tools to assess patients’ need for food, housing assistance, transportation, and other services. On-line Community Resource Guides are being set up that allow individual patients or patient navigators to find resources that best match a patient’s needs or that are available near a patient’s home. Many of these include the ability for “closed-loop” referrals – a health provider can refer a patient to a community-based organization and receive confirmation back that the patient has been enrolled in the service. And health care organizations and communities are investing in community health workers to serve as patient navigators, helping patients connect with community-based services like food programs that can help them better manage their health conditions.

Linking to Sustainable Food Systems

Planting beets in the Ceres garden, Sebastopol

Planting beets in the Ceres garden, Sebastopol

While food as medicine is gaining momentum, these efforts are not necessarily aligned with the movement to build a healthy, sustainable and just food system. In our own work across a range of coalitions, we are often asked why we choose to spend money on organic food. For those working to address hunger as an immediate condition, it seems an almost frivolous cost. Colleagues providing medically tailored meals lean on the nutritional tailoring of their meals without looking more deeply at food quality. Even for those who are beginning to acknowledge the superior nutritional quality of organically and regeneratively grown foods, cost continues to be a barrier.

Our challenge is to help our peers working across the food space – all of whom are doing critically important work – to understand the connection between what they do and two important issues: the health of the people they serve, and the health of the planet. And to understand that the two are inextricably linked.

To reap the full benefit of the food is medicine revolution, we need to articulate and adopt food guidelines that go beyond the nutritional components needed by an individual patient. We also need to establish guidelines for how that food was produced and processed. Thinking only about how food will impact an individual misses the broader impact that our food system has on the health of food and farm workers, communities and the environment. If the food we provide to a patient as part of a food as medicine intervention is produced in a way that increases cancer rates among farm workers or pollutes local drinking water, we’ve negated the value of our investment. By merging these two movements – the movement for a better food system with the movement for nutrition security and health equity – we can leverage the value of our food is medicine investments and create win-wins for our communities.

Health Care without Harm’s Environmental Nutrition Framework is a valuable starting point for this work:

Client enjoying Ceres meal

Client enjoying Ceres meal

“Healthy food cannot be defined by nutritional quality alone. It is the end result of a food system that conserves and renews natural resources, advances social justice and animal welfare, builds community wealth, and fulfills the food and nutrition needs of all eaters now and into the future. [We must expand] the definition of healthy food beyond measurable food components such as calories, vitamins, and fats, to include the public health impacts of social, economic, and environmental factors related to the entire food system.”Ceres Community Project published a white paper in 2016 called The Power of our Food Choices that summarizes research on organic and conventional food systems, pasture-raised vs factory farmed meats, and several other parts of our food system. Finally, in 2019 California Certified Organic Farmers (CCOF) produced the Roadmap to an Organic California Benefits Reports summarizing more than 330 studies on the value of organic agriculture, many of which tie directly to health and health equity.

Using the information in these three documents we can educate those providing and paying for food as medicine interventions; we can urge them to establish and meet food sustainability guidelines, to give preference to providers who include organic and sustainably raised products, and to be willing to pay more for food that meets higher standards. In 2019, we used these documents to help create a food quality pledge for organizations providing emergency food in Marin County.

The reality is that our health depends on a healthy and sustainable food system, a healthy environment, healthy community connections, equitable access to health care, and wide range of other issues. Connecting the dots between our food system and our health care system is a first step in building a more holistic approach to health. If we’re thoughtful and intentional, we can use the food as medicine movement to make that connection. By doing so, we’ll improve health for individuals and improve chronic disease while also fostering a healthier and more just food system for all.

Where do We Go from Here?

All of us can play a role in moving the food as medicine movement forward. While major work needs to – and is – moving forward to integrate food as a covered benefit as part of federal health care programs and among major insurers, there are many opportunities to advance this work at a local level. Here are a few suggestions:

– Share what you’ve learned with key decision makers – local legislators, leaders of health care organizations, farmers market managers and others

– Advocate for increased access to healthy food:

  • Have local farmers markets offer Market Match or double up bucks for SNAP recipients using local philanthropic dollars or funding from your local health department
  • Work with a nutritionist to offer free cooking demos and nutrition information at the farmers market
  • Work with community health centers to offer a weekly on-site farmer’s market – offer produce at a lower rate or get a local funder to subsidize the produce

– Create a Food as Medicine Coalition that brings together representatives of key health providers and key food providers (food banks, senior meal providers, farmers market managers) to create joint strategies for improving access to healthy food while also strengthening your local food system

– Work with a local meal provider like a Meals on Wheels program to have them improve the quality of the food they source. Connect them to local farmers and help them raise local philanthropic dollars to purchase local food.

Reframing our mindset that investments in food and nutrition security are investments in the health and wellbeing of our society as a whole, rather than investments only in those who receive the benefits directly, helps to build the connection between food and health. Continuing to integrate healthy food as a credible intervention paid for by health care dollars will dramatically increase funding for food at critical times for those who need it most.

NOTE: The author wishes to thank Dr. Rita Nguyen, Chronic Disease Physician Specialist at San Francisco Department of Public Health and Assistant Clinical Professor, UCSF, for the use of several slides that were part of our join presentation at the Eco Farm Conference in January 2020.

Author Bio
Cathryn Couch is the founder and CEO for Ceres Community Project, a non-profit working to foster health by connecting people to one another and to a healthier food system. Ceres provides 120,000 organic medically tailored meals annually to primarily low-income people struggling because of a health challenge. Youth volunteers grow food and prepare the meals as part of a youth development and culinary and food system education program. Ceres has trained a dozen communities across the United States and in Denmark to replicate their model and the organization supports 8 Affiliate Programs. Couch is the 2020 chair for the California Food is Medicine Coalition, a six agency collaboration conducting the first statewide medically tailored meal pilot for Medicaid members. Ceres is also one of four agencies currently conducting large-scale randomized control trials for medically tailored meals at Kaiser Permanente. Couch is as advisor to the Aspen Institute’s Food & Society initiative; sits on the leadership team for Hearts of Sonoma County – a collaborative working to reduce heart attacks and strokes; and participates in Marin Food Policy Council, California Food & Farming Network, and the Food Lab at Google. Couch was finalist for The Robert Wood Johnson Foundation’s Community Health Leaders Award, a finalist for the James Irvine Leadership Award, a Red Cross Adult Humanitarian Hero for Northern California and a CNN Hero. She holds an MBA from the University of Michigan.

We have omitted notes and some text from this article for space reasons. Anyone wishing the original version of this article can get one by Emailing the editor for a copy. I will send it to you as a .docx attachment.
– Jack (TNF@nofa.org)