As an appreciation for the impact of social determinants of health moves from academia to practical applications, many healthcare providers, payers, and policymakers are exploring the potential of “food as medicine.”
From healthcare systems delivering medically tailored meals (MTMs) for patients with complex medical conditions to Medicaid programs subsidizing the purchase of fruits and vegetables through “produce prescriptions,” mainstream healthcare is recognizing the relationship between diet and health and addressing the socioeconomic barriers to nutrition access.
While grounded in science and good intentions, the food as medicine movement is not without its critics. The imprecise definition of the concept has left it open to misrepresentation and appropriation, sometimes with harmful consequences.
Background
The appreciation for the association between diet and health is longstanding. The Ebers Papyrus lists a variety of foods employed as medical remedies in ancient Egypt and food has been a part of ayurvedic medicine in India since the second millennium B.C. While Hippocrates may never have said, “Let food be your medicine, medicine your food” as has been attributed to him, he did acknowledge the link between food and health.
In many cases, the understanding of the relationship between food and disease amounted to so much folklore. Spicy foods do not cause ulcers, nor have they been proven to promote weight loss. Nevertheless, chile peppers have been ascribed both pernicious and curative powers across time.
It has only been in the last century that carefully designed research has confirmed links between diet and several medical conditions. Among these are cardiovascular disease, diabetes, and certain cancers—some of the leading causes of death in America and worldwide.
Practical implementation
The Centers for Medicare & Medicaid Services (CMS) has begun to incorporate food as medicine initiatives in the last two decades, beginning with Medicare coverage of The Ornish Program for Reversing Heart Disease as a cardiac rehabilitation program option in 2010.
Since 2018, Medicare Advantage (MA) programs have been allowed to offer beneficiaries food and meals under Special Supplemental Benefits for the Chronically Ill (SSBCI). As an example, enrollees in Humana’s MA program receive a Healthy Options Allowance which can be applied towards the purchase of approved produce, beverages, dairy, meat and seafood, deli items, frozen and prepared foods, and bakery items.
In 2022, CMS approved a test program under which Arkansas’ Medicaid program will spend up to $85 million on medically necessary housing and nutrition support services. The Agency has signed off on similar initiatives in Massachusetts and Oregon.
Under the White House Challenge to End Hunger and Build Healthy Communities, the Biden Administration is encouraging private health insurance programs to explore produce prescription programs. Echoing the administration’s priorities, CMS Administrator Chiquita Brooks-LaSure has declared that “Health care can – and should – mean care for the whole person.”
The food as medicine movement has resulted in a variety of public-private partnerships, expected and unexpected. In Kentucky, Medicaid members with high blood pressure participating in the Good Measures’ Good Food Prescription program can have groceries delivered directly through Instacart’s Care Carts. The Rockefeller Foundation and the American Heart Association have partnered with Kroger for a Food as Medicine research initiative.
In Pennsylvania, Geisenger Health has reported significant improvements in blood sugars, HBA1c, cholesterol and blood pressure control among patients participating in its Fresh Food Farmacy program.
Politics
An economic evaluation of the potential of medically tailored meals for patients with diet-sensitive conditions concluded that their use could be “be associated with approximately 1.6 million averted hospitalizations and net cost savings of $13.6 billion annually.”
Given that the benefits of dietary adaptations are largely preventative, these savings would not be realized immediately. This leaves the question of covering upfront costs open to political debate. Some have suggested that food as medicine programs should be funded with a tax on sugared beverages, citing the authority granted to Congress in the Commerce Clause of the Constitution. But some conservatives and most libertarians contend that government involvement in food choices smacks of paternalism and “put(s) government resources to improper purpose.”
However there is a growing center ground and new bipartisan support for exploring the potential of food as medicine to improve health outcomes, while reducing healthcare spending.
Last month, the Bipartisan Policy Center announced the launch of a new working group focusing on food as medicine. Its co-chairs include former Senate Majority Leader Bill Frist, a Republican, and former Health and Human Services Secretary Donna Shalala, a Democrat.
In a recent blog post Douglas Holtz-Eakin, former director of the Congressional Budget Office and president of the center-right American Action Forum acknowledged that food as medicine initiatives allow Medicare Advantage and Medicaid programs to identify the resources which they believe will enable them to achieve targeted outcomes. Reflecting a growing willingness on the part of some Republicans to address the social determinants of health, he went on to say that “states deciding they want to pay for medically tailored meals in one experiment worth taking a look at.”
Confusion and controversy
Surprisingly, the food as medicine movement has been denounced by those who might be expected to embrace it, including some dieticians and physicians. Their concern is not that diet cannot be effectively used in the prevention and management of disease, but that directly equating food with medicine opens the door to misunderstandings and misdirection.
Abby Langer, a Canadian dietician, is among those who believe that the phrase, as understood by the public and employed on social media, serves to shame those with chronic health conditions, implying that they are responsible for their conditions. Langer states that, “Telling cancer patients that they can ‘cure’ their cancer with food, also implies that they caused their cancer with diet.”
While responsible food as medicine programs are careful to not make claims about the curative potential of food, even a cursory review of social media supports Langer’s concerns. There is no shortage of influencers—with medical credentials and without—promoting specific foods as “proven” cures. Celery juice, we are told, can cure Lyme disease. Artichokes can “eliminate” thyroid disease. And there are any number of foods promoted as the definitive answer to the seemingly ubiquitous problem of “brain fog.”
Dr. Joshua Wolrich, a British physician and author of the unequivocally titled, Food Isn’t Medicine, warns that characterizing food as medicine may lead patients to mistakenly equate diet choices with pharmaceuticals in considering treatment options. Wolrich laments that when patients conflate the therapeutic potentials of food and drugs, they can make the “heartbreaking decision” to forego or delay conventional treatments.
The Academy of Nutrition and Dietetics Foundation acknowledges that while that while diet can be important in the management of diabetes, heart disease, and digestive disorders, “medication is often necessary for the management of these diseases.”
Price and Privilege
Celebrities and social media influencers promoting food as medicine often fail to recognize that their resources outstrip those of most. When even the average household is challenged by inflation and over 23 million Americans live in food deserts, access to healthy food is a struggle for many.
The U.S. Department of Agriculture reports that over 10 percent of U.S. households experience food insecurity annually. Yet, sometimes proponents of better nutrition for better health overlook this fact.
On Freakonomics podcast in 2020, John Mackey, the co-founder and former CEO of Whole Foods who was an active opponent of the Affordable Care Act, declared, “The best solution is not to need health care. The best solution is to change the way people eat, the way they live, the lifestyle and diet. There’s no reason why people shouldn’t be healthy and have a longer health span.” He went on to reference using his smart watch to track his own health metrics, ignoring the fact that over five million American households have difficulty accessing sufficient food, let alone technology.
The situation may soon worsen. With emergency allotments under the Supplemental Nutritional Assistance Program (SNAP) ending with the expiration of the COVID-19 public health emergency, households in the 32 states and three territories still offering expanded assistance will experience a sudden drop in benefits.
And it isn’t just a matter of money. Many factors can impact food security, including mental health, disability status, and geography. Ironically, Americans living in rural counties often have less access to fruits and vegetables than their urban counterparts.
Noting that burden of diet-related disease disproportionately impacts low-income and majority Black, Latinx, and Indigenous communities, the Aspen Institute and the Harvard Law School Center for Health Law & Policy Innovation argue that any food as medicine research much include an equity focus.
The future
A commitment to identifying and addressing food insecurity is one of the key ideas distinguishing the food as medicine policy movement from the food as medicine noise on social media.
The Academy of Nutrition and Dietetics Foundation lists improving access to nutrition in its definition of food as medicine. And screening patients for food insecurity is among the pillars of the Biden Administration’s Challenge to End Hunger and Build Healthy Communities.
It’s likely that we will see the food as medicine conversation continue along divergent paths in coming years, with celebrities touting the near magical powers of the latest fad food, while policymakers pursue decisions based in science.
This article was updated on October 9, 2023. An earlier version of this story attributed a quote from a Deloitte study to The Academy of Nutrition and Dietetics. While the Academy never said that food as medicine should not “detract from the importance of pharmaceuticals prescribed by a physician,” it does acknowledge that medication is “often necessary” for disease management.