National Pork Board Responds to NIH’s RFI: Food is Medicine Research Opportunities

The other week, I was able to review slides and notes from the Advancing Food is Medicine Approaches summit put on by Food Tank , in partnership with the The Friedman School of Nutrition Science and Policy at Tufts University .

Hearing the dialogue from this summit and knowing the Biden-Harris Administration has food is medicine (FIM) as a priority item in its National Strategy on Hunger, Nutrition, and Health, I was motivated to submit to the Request for Information (RFI) from the National Institutes of Health (NIH) on food is medicine research opportunities that closed on 6/30/23 - on behalf of the National Pork Board (NPB).*

While there were well over 30 questions as part of this RFI, I picked seven of them to respond to on behalf of the tens of thousands of American pig producers and farmers, and the health and wellness team of the NPB. #research #healthprofessionalseducation #researchgaps #dietitian #nutritionresearch #inclusivediets #animalprotein

*The National Pork Board is a Checkoff program and thus are prohibited from influencing government policy or action. As the Director of Nutrition Research, the comments are addressed to provide research-based comments and not to influence policy or action.

Below are my responses, let me know what you think!

RESEARCH

·????????What are considered high priority research gaps and opportunities for Food is Medicine?

Food is Medicine (FIM) has the potential to offer every American the opportunity to look at developing a positive relationship with food, with the core focusing on how every food can fit into their dietary pattern (omitting foods only due to dietary allergy, preference, religious or cultural reasons).

High priority items include:

1.??????Using various research design methods (quantitative and qualitative), explore healthcare professionals' education and training on nutrition and the role of the registered dietitian as part of the healthcare team to help facilitate FIM interventions.

2.??????Defining ‘food is medicine’ and how it is different from ‘culinary medicine’ or ‘food as medicine’ or ‘food for health’.

3.??????Conducting randomized controlled clinical trials and intervention studies that are inclusive to all foods. Not favoring or omitting a particular food group, but highlighting that cultural preference, affordability and variety are cornerstones to how ‘food is medicine’ is discussed with patients. For example, on the global scale, it is known that animal proteins offer a unique nutritional value (https://www.fao.org/documents/card/en/c/cc3912en). And when animal proteins like pork are omitted from the diet, there are unintended nutrient consequences when pork is removed from the diet or when pork is not on the plate – and this spans the lifecycle. Researchers suggest that pork intake was estimated with over 2.5 million more children and adolescents (7%) and over 5.7 million more adults (4%) meeting the adequate daily intake levels for potassium. This is important as potassium is a nutrient of public health importance that most people are not eating enough of and can be core considerations in any FIM intervention. (https://www.mdpi.com/2072-6643/15/10/2293)

Opportunities

1.??????Advocate for the role of the registered dietitian as part of the healthcare team to facilitate FIM interventions.

2.??????Highlight that nutrition should be cornerstone to every patient care interaction.

3.??????For the first time, demonstrate how all foods can be incorporated into a dietary pattern and not have a good/bad categorization of food items in the context of FIM. It is important to meet the patient where they are in terms of care, including as it relates to supporting the role all types of foods play in enhancing positive health outcomes when delivered as part of FIM.

PROVISION OF SERVICES AND ACTIVITIES

·????????How may Food is Medicine services be combined with other food assistance, nutrition and health education, and health care services (e.g., social services, meals on wheels, Community Health Workers, care transitions case management, etc.) to improve engagement and affect health outcomes?

FIM can be used widely across healthcare facilities, to optimize value-based care which is the current recommendation for Centers for Medicare and Medicaid Services. Patients when seeing healthcare professionals can be given ‘prescriptions’ for medically tailored meals, food assistance, food prescriptions and nutrition education. Leveraging FIM constructs, consultations with registered dietitian nutritionists could be covered by all insurance providers, regardless of medical comorbidities. Currently, CMS only covers minimal nutrition education (e.g., type 2 diabetes, chronic kidney disease). (https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=53)

FIM can be aligned with what is being discussed in the patient's office visit versus what is being offered in food assistance. If a healthcare professional prescribes food assistance or nutrition assistance, that healthcare professional would then be responsible to ensure that those assistance programs can provide foods mentioned. There is data to show that many food pantries are largely unable to support healthful diets (https://www.sciencedirect.com/science/article/abs/pii/S2212267216310371), so how will FIM play a role in bridging the gap? It was noted in that article in the Journal if the Academy of Nutrition and Dietetics review that supply of animal protein was low, of which animal protein, such as fresh lean pork, is a rich source of micronutrients (e.g., thiamin, riboflavin, niacin, Vitamin B6, Vitamin B12) [NDB #10229]. It is important for healthcare professionals to recognize nutrient shortfalls in dietary patterns and provide patients with resources to obtain familiar, well-tolerated foods that will meet all their nutrient needs in a culturally appropriate way.

FIM can be a link between healthcare professionals' offices and community programming. Yet, this is a big undertaking to encourage and inform healthcare professionals on how/why/when to refer patients to these health care services outside of their practice.

·????????In what ways can Food is Medicine services be used to address nutrition disparities and unequal access to nutritional foods?

FIM services can use the social determinants of health (SDOH) as a framework to supporting nutrition education and intervention. In the past decade, there has been little focus on nutrition and health disparities research so FIM research programming can add significantly to the literature (https://www.ajpmonline.org/article/S0749-3797(22)00126-X/fulltext).

Within the SDOH, food affordability and food insecurity are major priorities. Our version of the TFP 2021 showed that the optimization model preferentially selected pork to arrive at the lowest-cost healthy diets that met all nutrient requirements, followed dietary guidance, and respected existing eating habits. (https://www.mdpi.com/2072-6643/15/8/1897). Insights from research such as this can be integrated into FIM curricula for trainee healthcare professionals, foodservice departments within hospital settings, community FIM outreach programs, and even patient education to support food affordability. In addition, when designing research studies to assess the effectiveness of FIM produce prescriptions, it could be appropriate to learn how benefits can be used for fruits and vegetables, but also animal protein goods (e.g., fresh lean pork) that can support local farmers and producers, while contributing nutrients to the diet. It is well established that animal products can contribute to total nutrient requirements including vitamin B12, vitamin B6, riboflavin, niacin, zinc and protein. (https://www.ncbi.nlm.nih.gov/books/NBK218176/)

COMMUNITY OUTREACH AND ENGAGEMENT

·????????What are key strategies for community engagement and outreach, or obtaining local community input from those with lived experience or organizations that provide direct Food is Medicine or related services to persons with hunger and food insecurity, populations who experience health disparities, or other health-related social needs?

Building foundational relationships is going to be critical to be able to implement FIM approach to healthcare. In the past, nutrition has been an afterthought in patient care, so it will take time to build trust with this new approach. Researchers and healthcare professionals will need to work with community leaders in vulnerable communities to show this is not just a ‘trendy’ approach to care, but a complete overhaul in how they are focusing healthcare.

In addition, FIM can offer resources, such as access to healthcare professionals, to persons with hunger and food insecurity by being physically present at areas they go to (e.g., food pantries, food banks, community centers, homeless shelters). NPB members in the pork industry give back to their local communities through donations of hundreds of thousands of pounds of pork to continue fighting hunger (https://www.porkcares.org/pork-indsutry-gives-back/).

·????????How might Food is Medicine programs integrate a culture is medicine approach that incorporates cultural foods and food practices (e.g., Indigenous gathering, hunting, and agricultural food practices)?

Health disparities, especially obesity, cardiovascular disease, and type II diabetes, are prevalent in the United States and occur, in large part, as a result of racial and cultural differences in food choice and food insecurity. (https://www.ers.usda.gov/webdocs/publications/84467/err-235.pdf?v=0; https://www.ahajournals.org/doi/epub/10.1161/JAHA.119.014433)?Thus, developing dietary patterns that incorporate personal preferences, financial availability, and cultural traditions while improving overall diet quality is a critical strategy to promote health and well-being across race, ethnicities, and life stages.

FIM can support cultural diets by being inclusive in their recommendations. Many commonly recommended dietary patterns within the FIM umbrella seem to omit entire food groups, which may not align with cultural dietary patterns or personal food preference. Globally, pork is one of the highest meats consumed per capita, which could show to how pork can be included in dietary FIM across cultural groups (https://www.oecd-ilibrary.org/sites/ab129327-en/index.html?itemId=/content/component/ab129327-en). Additionally, pork has a lower environmental impact among animal-based proteins, of which it has been shown by the World Resources Institute that making small dietary shifts in animal protein sources such as switching from beef to pork, or poultry to beans, can support sustainable behaviors (https://www.wri.org/data/protein-scorecard). FIM has the opportunity to support and promote foods that are culturally relevant and sustainable, and pork is one such food that is already beginning to be utilized in FIM approaches as a source of nutrient-dense, high-quality protein that can support the cultural foodways of patients and bring with it other under consumed nutrients and food groups when it’s on the plate (e.g., potassium, whole grains, vegetables, etc.) (https://culinarymedicine.org/community-class-recipes/dinner-recipes/).

To achieve a health-promoting, dietary pattern, most intervention-based human clinical trials include the addition of foods and beverages within the Dietary Guidelines for Americans’, while replacing foods that are typically higher in saturated fat, sodium, and/or added sugar.?Given that the latter components provide the taste and flavor profile liked by many Americans, food additives, like non-calorie herbs and spices (culturally tailored to the study population), are needed to establish diet acceptability for long-term satisfaction and adherence. As an example, garlic or onion powder can be added to meat-based meals to enhance overall flavors without adding sodium or fat. [Work to be presented on at American Society of Nutrition annual conference 2023; https://nutrition2023.eventscribe.net/index.asp?sessionTarget=1261303) Culturally appropriate dietary and education interventions are critical. (https://www.frontiersin.org/articles/10.3389/fnut.2023.1114919/full ; https://www.mdpi.com/2072-6643/14/24/5239)

When developing culturally appropriate, dietary interventions for human clinical trials or intervention studies in the context of FIM, participant characteristics; geographic location; accompanying foods (i.e., side dishes); and portion sizes could be considered.

To improve the clarity, reproducibility, and translation of the FIM science for practical use, researchers need to move beyond only publishing the ‘caloric and nutrient’ characteristics of the dietary interventions of funded FIM studies to include specific food characteristics (i.e. brand, meat cuts/quality, quantity); preparation methods; and study recipes, including herbs and spices. The added depth and description of the dietary pattern would align with the inclusion/exclusion criteria of the Dietary Patterns and Risk of Cardiovascular Disease: A Systematic Review protocol, among others for 2025-2030 NESR protocols. (https://nesr.usda.gov/sites/default/files/2023-05/2025-DGAC-Protocol-Dietary-patterns-Cardiovascular-disease.pdf)

EDUCATION AND TRAINING

·????????What training is needed for health care providers (e.g., physicians, nurse practitioners, nurses, physician assistants, dentists, pharmacists, registered dietitian nutritionists, doulas, etc.) to successfully use and disseminate Food is Medicine services and information services?

It is well documented that healthcare professionals, besides a registered dietitian, have little to no training in nutrition (https://journals.lww.com/EDHE/Fulltext/2022/35030/Nutrition_Education_for_Providers_is_Limited__It.7.aspx; https://pubmed.ncbi.nlm.nih.gov/24717343/; https://pubmed.ncbi.nlm.nih.gov/31728505/).

FIM education and training could be integrated into secondary education, post-graduate education and continuing education across healthcare professionals. A three-prong approach can help to center nutrition as a cornerstone of healthcare practices. With that said, not every healthcare provider may be interested and/or practice FIM, so having targeted education and/or certificate training programs may be an alternative to get healthcare professionals up to speed with the constructs of what/how they can talk to patients. If certificate programs are being utilized, they must be comprehensive in nature and not simple in nature (e.g., a one-hour CEU).

Partnerships with a variety of agricultural commodity boards may be ideal in training healthcare professionals. Each commodity board conducts extensive research on their product and can help to educate healthcare professionals on why and how these foods can be incorporated into a dietary pattern or FIM intervention. Commodity boards often have independent scientific advisory boards and ethical research guidelines to help to guide funded research (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5287432/). At the NPB, you can review the research integrity guidelines that demonstrate how the organization promotes scientific research and rigor remain with scientific investigators (https://porkcheckoff.org/research-integrity-guidelines/). NPB also has plans to explore FIM components in future research projects and will gladly share information collected with NIH as pertinent.

It is important to emphasize that in FIM education and training of healthcare professionals, it could be inclusive in its dietary recommendations, by not omitting or favoring any food groups (https://hgic.clemson.edu/stigmatizing-food-good-and-bad-vs-healthy-and-unhealthy/). All foods can be included and that helps to support cultural sensitivity, food preference and personal choice. The closer FIM interventions remain to this perspective can help to provide valuable insight into food language and inclusivity in nutrition.

·????????What training is needed for Cooperative Extension professionals to successfully advance the Food is Medicine initiatives?

Cooperative extension specialists can be boots-on-the-ground in nutrition education to communities and childcare facilities. As above with healthcare professionals, it is imperative to train these specialists on inclusive dietary recommendations and positive food language. Training programs may include a certificate program delivered by registered dietitians, doctoral-trained nutrition researchers and/or healthcare professionals who have been extensively trained on FIM education. Cooperative extension specialists would also benefit from being provided lower-level literacy nutrition education handouts to be provided to communities about how to apply FIM concepts into their daily lives.

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