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THE NATION DEBATE ON HEALTHCARE in the United States — which has been going on for decades — centers on who should be covered and who should pay the bill. It’s an argument that has no clear answers and cannot be easily resolved because of two fundamental realities: Health care is expensive, and Americans are sick.
Americans benefit from highly trained personnel, remarkable facilities and access to the newest drugs and technologies. Unless we eliminate some of these benefits, our health care will remain costly. We can trim around the edges — for example, with changes in drug pricing, lower administrative costs, reductions in payments to hospitals and providers, and fewer defensive and unnecessary procedures. These actions may slow the rise in health care spending, but costs will keep rising as the population ages and technology advances.
And Americans are sick — much sicker than many realize. More than 100 million adults — almost half the entire adult population — have pre-diabetes or diabetes. Cardiovascular disease afflicts about 122 million people and causes roughly 840,000 deaths each year, or about 2,300 deaths each day. Three in four adults are overweight or obese. More Americans are sick, in other words, than are healthy.
Instead of debating who should pay for all this, no one is asking the far more simple and imperative question: What is making us so sick, and how can we reverse this so we need less health care? The answer is staring us in the face, on average three times a day: our food.
Poor diet is the leading cause of mortality in the United States, causing more than half a million deaths per year. Just 10 dietary factors are estimated to cause nearly 1,000 deaths every day from heart disease, stroke and diabetes alone. These conditions are dizzyingly expensive. Cardiovascular disease costs $351 billion annually in health care spending and lost productivity, while diabetes costs $327 billion annually. The total economic cost of obesity is estimated at $1.72 trillion per year, or 9.3 percent of gross domestic product.
These human and economic costs are leading drivers of ever-rising health care spending, strangled government budgets, diminished competitiveness of American business and reduced military readiness.
Fortunately, advances in nutrition science and policy now provide a road map for addressing this national nutrition crisis. The “Food Is Medicine” solutions are win-win, promoting better well-being, lower health care costs, greater sustainability, reduced disparities among population groups, improved economic competitiveness and greater national security.
Some simple, measurable improvements can be made in several health and related areas. For example, Medicare, Medicaid, private insurers and hospitals should include nutrition in any electronic health record; update medical training, licensing and continuing education guidelines to put an emphasis on nutrition; offer patient prescription programs for healthy produce; and, for the sickest patients, cover home-delivered, medically tailored meals. Just the last action, for example, can save a net $9,000 in health care costs per patient per year.
Nutrition standards in schools, which have improved the quality of school meals by 41 percent, should be strengthened; the national Fresh Fruit and Vegetable Program should be extended beyond elementary schools to middle and high schools; and school garden programs should be expanded. And the Supplemental Nutrition Assistance Program, which supports grocery purchases for nearly one in eight Americans, should be leveraged to help improve diet quality and health.
Coordinated federal leadership and funding for research is also essential. This could include, for example, a new National Institute of Nutrition at the National Institutes of Health. Without such an effort, it could take many decades to understand and utilize exciting new areas, including related to food processing, the gut microbiome, allergies and autoimmune disorders, cancer, brain health, treatment of battlefield injuries and effects of nonnutritive sweeteners and personalized nutrition.
Finally, Government plays a crucial role. The significant impacts of the food system on well-being, health care spending, the economy and the environment — together with mounting public and industry awareness of these issues — have created an opportunity for government leaders to champion real solutions.
– This has been edited from an opinion piece that
originally appeared in the New York Times on Aug. 26, 2019
In a word: yes.
Food is the only thing that can heal us. Wendell Berry says that eating is an agricultural act—which means, of course, that eating is also an environmental act. You cannot separate the act of eating from the act of farming. Every time we eat, we have the power to choose foods that are vibrant, real, and alive—foods that have been grown by local, organic farmers who support the health of the land, which in turn nourishes us and supports our own health. Real health begins in the ground, with soil that has been replenished through regenerative agriculture. When we begin to eat food that’s been grown in this way, we begin to heal not only our own bodies but also the planet.
But when we say this sort of food can heal us, we are not simply talking about the ways in which certain foods can make us feel better when we’re sick. Nor is it simply about eating foods that are good for us. We are talking about health in a deeper, more profound way that relates to the pleasure of cooking and sitting down together at the table. This is also part of what heals us: a sense of belonging; of community and tradition; of season, time and place; of living in harmony with nature. When we gather at the table and share this food with family and friends, we are connecting with the roots of human civilization; we are connecting with our shared humanity.
It’s obvious. We must eat to live. We must get energy (calories) and the nutrients we cannot make ourselves from food in order to grow, reproduce, and live long and healthy lives. Beyond these individual needs, how we produce and consume food is related to the three most prevalent public health nutrition problems facing today’s world: hunger (which affects about a billion people), obesity and its consequences (about 2 billion), and climate change (which affects everybody). Fortunately, the same dietary pattern addresses all three issues. Diets that best promote the health of people and the planet are largely, but not necessarily exclusively, plant-based, not excessive in calories, and avoid ultra-processed (‘junk”) foods to the extent possible.
Food is one of life’s greatest pleasures and plenty of truly delicious foods, meals, and cuisines fit this pattern.
There is one place that nearly everything that matters in the world today converges: our food and our food system—the complex web of how we grow food, how we produce it, distribute and promote it; what we eat, what we waste and the policies that perpetuate unimaginable suffering and destruction across the globe that deplete our human, social, economic and natural capital.
Eleven million people die every year from eating ultra-processed food and not enough real food. More than 2 billion are overweight and sick because of our food system. Over the next 35 years, the costs of chronic disease in the US, mostly driven by our industrial diet, will be $95 trillion, more than the annual economy of the entire world. Health care costs are threatening businesses and governments globally.
The single biggest driver of chronic disease, which affects 1 in 2 Americans, is our industrial ultra-processed diet. Food is the biggest cause of disease, the cure for most chronic diseases, yet doctors learn nothing about food in medical school, and our health care system focuses managing symptoms and diseases without addressing the root causes. One in three Medicare dollars is spent on type 2 diabetes (and more if you include pre-diabetes). Data show that by simply annually providing $2400 of whole real foods and social support to food insecure poorly controlled type 2 diabetics and their families, health care costs could be cut 80% from $240,000 a year per patient to $48,000.
Perverse financial incentives encourage intensive use of insulin, medications, amputations, and dialysis rather than food as medicine. Shifting health care’s focus to prevention, health promotion and using food as medicine through produce prescriptions, medically tailored meals, reimbursement for food as medicine would improve the health our nation while dramatically reducing health care costs. Changes in payments for services and programs that create health must be combined with polices shifts that address our toxic food environment. This includes supporting agricultural production of whole foods and regenerative agriculture, ending supports for commodity crops turned into disease producing ultra-processed foods, regulating food marketing and reforming our food programs (like SNAP) to address not only hunger, but health. These and other food and agriculture policies must be implemented to alter our toxic food environment and to address the loss of human, economic, social and natural capital.
Physicians and Nutrition.
Today, US healthcare is estimated to be an $8.7 trillion dollar industry and healthcare costs rose rapidly from 4.6% of GDP in 1950 to 17.9% in 2019.
During the 20th century, the burgeoning industry myopically focused on the treatment of disease that was reinforced through innovative pipelines that researched and developed expansive pharmaceutical and medical device interventions.
These advances prolonged and saved lives, however their success reinforced a reductionistic approach to the management of population health. In parallel, third party payment systems were introduced in 1929 and by 1955 more than 70% of the population was enrolled in a health insurance plan.
Source: Health Catalyst
Reimbursement models focused on a modern view of healthcare that emphasized the treatment of the “chief complaint”. This cultivated a volume-based healthcare system and created a financially disadvantageous milieu for the delivery of time intensive preventative care like dietary and lifestyle counseling.
Medical education was also influenced by the 20th century evolution in healthcare delivery that emphasized first line interventions including pharmaceuticals, procedures, or other technologic solutions.
Nutrition and lifestyle training was limited and today only 27% of medical schools offer the recommended 25 hours of nutrition education.
Thus the majority of physicians and clinicians are inadequately trained to deliver effective preventative lifestyle and nutrition care to their patients and rarely reimbursed for their time.
Physicians currently receive minimal nutrition education and, once in practice, are generally ill-equipped to even begin to help their patients make dietary changes. The deficiency of nutrition education in medical training has sobering implications for both our health and economy. For example, the current epidemic of diabetes is responsible for skyrocketing costs, yet fully 90% of type 2 diabetes is preventable through low-cost dietary and lifestyle interventions. Moreover, the World Health Organization estimates that 80% of premature heart disease is preventable through nutrition and lifestyle changes. Dietary approaches have an added bonus: unlike pharmacologic and procedural therapies, the side-effects from nutrition-based interventions are entirely favorable.
Improvement of nutrition education and practice among physicians holds the promise of the ultimate win/win in medicine: better health at lower cost.
Doctors with training in diet and nutrition can have a monumental impact on individual patient health and the public health landscape. The general public trust their doctors, and consider doctors to be among the most credible sources for accurate, up-to-date guidance on diet and food.
Yet, on average, doctors receive less than 25 hours of nutrition training (less than 1% of total lecture hours) throughout medical school. Most physicians are not prepared to counsel patients on nutrition and diet, and only 14 percent of practicing physicians report feeling qualified to offer nutritional advice to their patients.
With rates of obesity, heart disease, type-2 diabetes, and diet-linked cancers all on the rise, we are missing a critical opportunity to leverage the medical profession in order to support better outcomes for these most common and costly diseases.
Opportunities to increase the amount and quality of nutrition education provided to doctors exist at every stage of medical education. To name a few: for medical schools, Federal or state governments could create grants to launch or expand curricula on diet and nutrition; for residency programs, the Federal government could tie all or a portion of Medicare residency funding to the inclusion of nutrition education; and for continuing medical education, states can require a certain number of CME credits be taken in diet and nutrition to retain licensure.
Non-governmental accrediting bodies such as the Liaison Committee on Medical Education (LCME) and the American Council of Graduate Medical Education (ACGME) can require competency in diet and nutrition as criteria for accreditation of medical schools (LCME) and residency programs (ACGME).
Even a modest investment in nutrition training for physicians can significantly improve patient outcomes and provide for better population health, reducing the larger and more costly long-term human and economic costs.
I stood in the middle of tens of thousands of acres of row-crop, monoculture agriculture in the heart of the U.S. Midwest shocked as I listened to my Missouri farmer host tell me how hard it was to find fresh food for miles around. While we were surrounded on all sides by his farm what was growing—genetically modified soy, mostly—wasn’t destined for his dinner plate, or any dinner plate. It was headed to the vast global commodity market, eventually finding its way, most likely, into the bellies of cattle. The result? This farmer and his community faced a crisis of food access.
As one of the United Nations central tenets of food security, food access is both the physical and economic accessibility to healthy food. Importantly, food access isn’t valued by proximity to calories, but to real food: food that is nourishing and culturally appropriate. All around the world there are local, state, and national governments innovating policies and programs to improve food access and there are social movements inspiring farmers, like the one I met in Missouri, to rethink the wisdom of growing crops for industrial use and reviving indigenous foods and biodiversity on farms to grow real food. Before I left that Missouri farmer’s land, he was proud to tell me that the year before his young daughter, having returned from college, inspired him to start their first kitchen garden. He wouldn’t let me leave without sending me off with me a freshly harvested watermelon—his first.
I believe Food Literacy is the collective understanding of our food system; including the growing, harvesting, packaging, selling, wasting and eating of our food. Understanding how our food system impacts our health, the health of farmers and farm workers, the health of the earth, the health of our climate, the health of the economy and the long-term health of generations to come – are all part of the knowledge base of Food Literacy.
At its most basic, Food Literacy is an understanding of the cycle of life, from soil to farm, to plate, to body and back to soil. This understanding helps us recognize the impact of our food choices on our lives, the lives of children and their children and on the planet in perpetuity.
The magnitude of Food Literacy’s import should lead us to make Food Literacy curriculum a mandatory component of PK-12 education – for there is nothing more meaningful than the health and wellbeing of the generations to come and the planet that we all call home.
The most common disease associated with food insecurity is deep and enduring poverty. Poverty is a disease because it negatively affects the structure or function of an organism despite the absence of an external injury. It undermines the development of the mind, cripples because of health care costs and missed work and educational opportunities, and creates enormous psychological and physical pain. Poverty is also chronic because it undermines the ability to escape it – creating a trap that can last for generations.
Food is medicine programs.
Medically tailored meals are one example of a food is medicine intervention. These are meals that are tailored to meet the unique nutritional needs of an individual based on their diagnos(e)s, as well as the additional complications that might come with that illness (i.e. treatment side effects, comorbidities, etc.). Research consistently shows that medically tailored meals improve health outcomes, lower the cost of care, and increase patient satisfaction.
Most often medically tailored meals are provided through a referral from a medical professional or healthcare plan. A medically tailored meal intervention includes three elements: a medical referral, a nutritional assessment by a registered dietitian nutritionist (RDN) who also oversees the meal plan design, and the preparation and home-delivery of these meals. Patients also benefit from the human connection provided by the home delivery of these meals, with research indicating that medically tailored meals reduce isolation and loneliness, which can negatively impact health outcomes.
Most providers of medically tailored meals are community based organizations who are members of the Food is Medicine Coalition. This group’s Clinical Committee has issued a sophisticated set of Medically Tailored Meal Nutrition Standards, based on research and more than 30 years of experience developing the science of medically tailoring meals. The Clinical Committee is made up of Registered Dietitian Nutritionists, who are experts in treating serious illness with nutrition.
A medically tailored meal intervention, as defined by the Food is Medicine Coalition, does not simply mean putting someone on a diet. FIMC clients’ medical lives are often complex – many are living with more than four serious illnesses at once – and they require an equally complex nutrition intervention. Medically tailored meals help the “sickest of the sick” in communities, often the 5% of patients that cost 50% of healthcare costs.
As well as having to manage a complex medical diet, many of the patients FIMC serves are too sick to shop or cook, and the majority are living at or below the federal poverty guideline meaning that their access to healthy food is severely limited.
People living in low income communities have food access issues that can lead to a number of chronic diseases that are devastating. Fresh produce has been proven to produce better health outcomes for those who effectively increase their produce consumption. Instead of waiting until they require treatment, doctors can prescribe healthy food instead of medicine with the resources that result in affordable access to fresh food, and the knowledge to use it.
Here’s how it works: A patient is diagnosed as at-risk, and then qualifies for a 20-week intervention that includes the diagnosis from a prescriber, counseling from a nutritionist, basic nutrition and cooking education, and the financial incentive to purchase the produce. The “patient” participates in the programming, purchases and consumes more produce, then visits the clinic to check-in, adjust their healthy weight goals, and get a refill.
We know healthy food plays an important role in overall health and treatment of diet responsive conditions but when patients begin to see just how profoundly they are impacted through the simple incorporation of fresh, healthy food, they began to fully appreciate just how much food influences their health.
A prescription-based “food is medicine” program that provides fresh, healthy, nutritious food, paired with education and clinical services, to a health plan’s most vulnerable population, and most importantly empowers participants to manage their medical conditions through food-related behavior and lifestyle changes.
By offering fresh food as part of a prescription-based program to their most at-risk patients, Geisinger improved patient outcomes while lowering per-patient costs Its Fresh Food Farmacy program has shown that participating patients have 75% less hospital admissions, 30% less Emergency Room visits, and are more likely to close their preventive care gaps by having more regular visits with their primary care physician. In addition, their participating patients with Type II Diabetes average a 2 point reduction in HbA1c, leading to a cost savings of $16,000-$20,000 per patient.
Making the case to payers.
Historically, our primary public insurance programs, Medicare and Medicaid, have not covered food. However, emerging evidence that medically-appropriate food improves health outcomes and decreases health care utilization and cost has increased interest among policy-makers in experimenting with including food in these programs. Active Medicaid demonstrations that (in limited circumstances) cover food in states such as California, Massachusetts, and North Carolina, represent a critical first step to more widespread integration of food into health care delivery and financing.
Pioneering insurance companies across the country that administer Medicare and/or Medicaid through managed care or value-based payment structures have also started using medically-tailored meals and other nutrition interventions to great effect, albeit on a very small scale. Establishing uniform coverage and widespread access to critical food and nutrition services in Medicare and Medicaid depends on a few factors:
(1) Robust evaluation of current demonstration programs and a commitment to expand and institutionalize innovations that are shown to improve health and curb costs.
(2) Strong guidance from the Centers for Medicare & Medicaid Services (CMS) on how to fully leverage flexibility within Medicare and Medicaid to cover these services coupled with incentives to do so.
(3) Bipartisan legislative support and action at the federal and state level for mandating new benefits.
To some extent, through legislative mandate or specific regulations, FIM is a required covered benefit for individuals meeting particular clinical criteria such as infants suffering from severe GI disorders or inborn errors of metabolism, e.g. phenylketonuria (PKU). Additionally, Medicaid recipients may be eligible for food delivery under the 1981 Social Security Act, and as of 2018 CMS expanded the supplemental benefits provisions for Medicare Advantage plans to better address issues related to SDoH, including food.
That said, in the broader sense FIM is something that payers (health insurance companies and self-funded employers) typically have been unwilling to pay for. Unfortunately, this continues even today despite increased awareness of the positive impact good nutrition has on health and wellbeing.
FIM has been shown to be least as effective, if not more so, for treating certain chronic non-communicable disease states, than prescription medications. An excellent example of the impact that FIM can have is the Fresh Food Farmacy program run by the Geisinger Health System that has demonstrated a 40% reduction in diabetes complications and a 70% reduction in hospitalizations for patients enrolled in the program. Another example is the CHIP pilot program for diabetes management at Vanderbilt University Medical Center that showed a positive ROI within 6-months primarily through the need for fewer medications.
To be sure, the reasons that FIM is often not funded by payers are diverse and complex. However, a foundational problem is that healthcare coverage (insurance) is not designed to address a patient’s health and social needs outside of the medical setting. In other words, health insurance benefits are structured to help cover the costs associated with services and procedures traditionally deemed as medical expenses e.g. doctor visits, hospitalizations, labs, X-rays, surgery, and prescription medications. Despite what Hippocrates said dating back to 400 BC —”Let food by thy medicine…”, the fact that FIM has not been “medicalized” into a prescribed standard of care is the reason it goes largely unpaid. Equally important is that few providers (only a quarter of medical schools offer even a single course in nutrition) appreciate the clinical power of FIM or how to effectively use it.
Therein lies the conundrum.
How does FIM become a standard of care and something that providers demand, in order for it to become a recognized benefit and receive broad reimbursement?
Over the next decade (2020-2030) our health care system shifted to a “Pay for performance” model, first demonstrated through governmental innovation grants from the Centers for Medicare and Medicaid and a handful of experiments by forward thinking organizations and researchers. Together, they proved that by preventing chronic disease (e.g. obesity and diabetes) through enhanced lifestyle, and by managing chronic diseases more effectively through a range of innovative Food Is Medicine interventions, money could be saved and profits generated by keeping people well, managing their diseases more effectively, keeping them out of hospitals, and reducing the frequency of hospital readmissions.
Experiment by experiment, evidence accumulated to show that teaching people to choose their foods more wisely; instructing them how to shop for and/or prepare healthier menu choices; encouraging them to move more; assisting them with access to more local, whole vegetables, fruits, nuts, whole grains, healthier animal proteins and fats; delivering medically tailored meals to all patients upon discharge (and performing a nutrition assessment- with documentation in the medical record- at all stages of health care ) resulted in lower rates of obesity, diabetes, heart disease and other lifestyle related chronic diseases; lower overall medical and health related costs; enhanced quality of life; improved employee satisfaction and efficiency; and a more sustainable food system (and global environment).
Hospitals, which had previously offered some of the least healthy and least tasty foods imaginable were transformed into showrooms of healthy, delicious, sustainable, affordable food options. Teaching kitchens were built as extensions of hospital cafeterias; trained chefs made hospital cafeterias destinations for local diners as opposed to grab and go convenience options for those visiting patients or working there full time; and on-demand room service went from inedible to superb and family members visiting loved ones looked forward to ordering off these same delicious and nourishing menus. These healthy destination hospital cafes created new profit centers for hospital CFO’s. Hospitals negotiated long-term contracts with local farmers, reducing their food costs, strengthening local economies, and protecting the global environment. Hospital employees were incentivized to eat better; learn to prepare their own healthy, delicious meals; and were provided “meal prep” kits on their way out of work, so that they could eat and cook the same healthier foods with their families, enabling them to “walk the walk” while enhancing employee satisfaction.
Medical schools and schools educating all health professionals began to require education in and competency testing with respect to nutrition and lifestyle guidance to all patients young and old, healthy and sick. Licensing and board examinations shifted accordingly, as did the training of health care professionals worldwide.
In 2020, when a few self-selected third party payers looked at the Food is Medicine Map, launched in 2019 by The Lexicon’s GREEN BROWN BLUE activator, they identified “hot spots” where numerous programs involving Medically Tailored Meals, Fresh Food Farmacies, Veggie RX programs and multi-disciplinary Teaching Kitchens co-existed in geographic areas, funds were invested in demonstration projects aimed at proving that Food Is Medicine programs: (1) could improve personal health-enhancing behaviors in a sustainable fashion; (2) that these approaches were replicable and scalable; (3) that these programs resulted in significant increases in patient satisfaction and quality of life; and (4) most importantly, that these food is medicine interventions saved money and could convincingly bend cost curves for multiple populations at risk of chronic disease (including health care professionals and hospital employees).
This evidence led to third party coverage for these interventions within a reshaped health care delivery system, which cost less and began the US’s forward journey towards a “Culture of Health” for all. It also inspired legions of new health professionals to become skilled in Food as Medicine and Lifestyle Medicine approaches. It sparked countless synergies with local and regional farmers and those developing urban agriculture and ways to refine and improved a regenerative food supply worldwide. These newly covered benefits led the way to scientific discoveries and practical advice with respect to how different foods impact different people’s microbiomes (and genes) differently. Large databases launched by real and virtual FIM research networks provided the data to better understand how changes in behaviors, including diet, impacted human and planetary health. As such, these initiatives also established FIM Learning Laboratories and nutrition-related translational research hubs of the 21st century.
Yes, the health care delivery system in 2019 was broken. However, between 2020 and 2030 we made good on the notion that “if you can break it, you can fix it”. And that’s what happened once US leading third party payers invested in this co-created, renovated health delivery system in which Food is Medicine interventions sparked a series of transformations that led to better health for both people and planet.