Treating Food as Medicine to Achieve Population Health

Population health improvement for accountable populations requires identifying the risks and health-related social needs (HRSNs) of the population and every individual under care and designing equitable interventions to address those needs and care gaps. Dr. H. Jack Geiger , a key founder of the community health center movement, provides a great example. He often told the story of his interaction with an Office of Economic Opportunity official who confronted him in Mississippi for giving food to health center patients and charging it to the pharmacy.

I said, “What’s wrong with that?” He said, “The pharmacy is for drugs and the treatment of disease.” And I said, “The last time I looked in my medical textbook, the most effective therapy for malnutrition is food.” And he went away.

That was in the 1960s…and we’re still discussing the value of nutrition as necessary for health and avoiding some highly prevalent conditions. The need is clear, and the first step in treating food as medicine is ensuring people have adequate access to healthy foods tailored, if necessary, to their unique needs. However, the U.S. Department of Agriculture Economic Research Service provides some alarming statistics about food insecurity among U.S. households in 2022:

• 12.8% (17.0 million) households were food insecure at some time during 2022 – up from 10.2% in 2021.
• 17.3% of households with children (6.4 million) were affected by food insecurity in 2022.
• About half of all American adults (117 million) have one or more preventable chronic diseases, many of which are related to poor quality eating patterns and physical inactivity (e.g., cardiovascular disease, hypertension, diabetes).

The Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health (September 2022) cites additional concerning statistics:

• Nineteen states and two territories have an obesity prevalence at or above 35%.
• One in 10 Americans have diabetes.
• More than 4 in 10 Americans have hypertension.
• Hunger and diet-related diseases disproportionally affect communities of color, people living in rural areas and territories, people with disabilities, older adults, LGBTQI+ individuals, military families, and Veterans.

In response, the Administration’s strategy outlines five pillars to drive change (copied from the document):

Pillar 1—Improve Food Access and Affordability: End hunger by making it easier for everyone—including individuals in urban, suburban, rural, and Tribal communities, and territories—to access and afford food.

Pillar 2—Integrate Nutrition and Health: Prioritize the role of nutrition and food security in overall health—including disease prevention and management—and ensure that our health care system addresses the nutrition needs of all people.

Pillar 3—Empower All Consumers to Make and Have Access to Healthy Choices: Foster environments that enable all people to easily make informed, healthy choices, increase access to healthy food, encourage healthy workplace and school policies, and invest in public education campaigns that are culturally appropriate and resonate with specific communities.?

Pillar 4—Support Physical Activity for All: Make it easier for people to be more physically active—in part by ensuring that everyone has access to safe places to be active—increase awareness of the benefits of physical activity, and conduct research on and measure physical activity.

Pillar 5—Enhance Nutrition and Food Security Research: Improve nutrition metrics, data collection, and research to inform nutrition and food security policy, particularly on issues of equity, access, and disparities.? ?

Many Population Health Alliance member organizations were asked to provide input to the White House on the strategy and remain committed to moving the agenda forward.

More recently, in January 2024, the Department of Health & Human Services (HHS) held a summit during which five Food is Medicine (FIM) principles and three public-private partnerships were announced to build on previous initiatives . The five principles are: ?

• Recognizing that nourishment is essential for good health, wellbeing, and resilience.?
• Facilitating easy access to healthy food across the health continuum in the community.
• Cultivating understanding of the relationship between nutrition and health.?
• Uniting partners with diverse assets to build sustained and integrated solutions.
• Investing in the capacity of under-resourced communities.

(More detailed descriptions of these principles can be found here , and recordings of the HHS summit are here ).

There are many challenges associated with the FIM movement. However, one significant barrier is the lack of health plan coverage for food as a necessary component of therapeutic interventions. A recent Health Affairs post (April 2024), “Food Is Medicine: The Road to Universal Coverage, ” outlines a pathway toward this goal. The authors describe Food is Medicine (FIM) interventions as coming in three forms: “medically tailored meals, medically tailored groceries or food packages, and produce prescriptions.” While CMS has offered flexibility under Medicaid to provide enrollees with a service or setting ?“in lieu of a service or setting” (ILOS) to address HRSNs, including food insecurity (see CMS letter to State Medicaid Directors, January 2023 ), and Medicare Advantage Organizations (MAOs) have similar flexibility through supplemental benefits for chronically ill enrollees (referred to as Special Supplemental Benefits for the Chronically Ill or SSBCI), traditional fee-for-service Medicare does not, leaving the 35 million beneficiaries without access to FIM coverage. Commercial insurers typically do not offer FIM benefits other than on a limited basis post-discharge to help avoid readmissions. The authors provide some suggestions to help expand FIM to more people, including the following (copied from the article):

• Expanding coverage under Medicare & Medicaid.
• Allowing MAOs broader discretion to offer FIM as a general supplemental benefit instead of just the SSBCI population.
• Classifying FIM benefits, including screening and counseling, as a preventive service under a provision in the Affordable Care Act.
• Allowing FIM as an eligible expense to be covered by Flexible Spending and Health Spending Accounts.

In a 2022 report, Addressing Nutrition and Food Access in Medicaid , the Population Health Alliance offered several additional ideas and examples that states and managed care plans have used to support nutrition education, screening and referral services, and food infrastructure/community investment:

1. Provide optional benefits via the individual State Plan (Medicaid), including medical nutrition therapy, nutrition education via disease management programs, and referrals to community and social support services via case management/care coordination programs.
2. Seek funding through public and private grants/pilots.

Last year, a Health Affairs post (May 2023) highlighted five problems that may limit any effort to scale FIM and achieve the desired goals (copied from the article):

1. Food recommendations contradict food subsidies.
2. Food acculturation and assimilation (adaptation of migrants’ dietary habits to American food habits) can lead to poorer health.
3. Culinary education is effective but time-consuming.
4. Medically tailored meals are a temporary fix.
5. Food funding is not sustainable.

The opportunity is clear, and great progress has been made in understanding the issues and developing strategies and tactics to advance FIM. PHA is committed to achieving better health and wellness through accountable care models. However, challenges remain.

Do you have any recommendations to help accelerate the FIM movement? ?What is your organization doing to address food insecurity?

The Population Health Alliance (PHA) is committed to Quality and Continuity of Care.?Our key priorities are advancing value-based care, improving consumer engagement, and addressing social determinants and health equity. If these issues or the topic of this week's article interests you, join us. Contribute your voice, ideas, and energy. Find out more on our membership page .

Michael S. Barr, MD, MBA, MACP, FRCP

Sr. Director, Population Health Improvement