Written by Erin Yeh
At the Food as Medicine Summit this month, there were many conversations about engaging payers in expanding food as medicine in health care and how to expand programs to include patients from different backgrounds. There is one question that still needs to be answered: How can we integrate food as medicine into our current models of care?
A panel consisting of Ajay JosephMD, FACC, DipABLM, Medical Director of Lifestyle Medicine at Saint Francis Health System; Susan SprattM.D., senior medical director of Duke’s Population Health Administration at Duke Health; and John van der VeerDO, founder and CEO of Hy-Vee Health Exemplar Care, to discuss how to integrate food as medicine into existing care pathways. Managed by Sunny SharmaMD, FACP, DipACLM, CMD, RMO, MD, MDVIP, and regional medical officer for Ascension Medical Group in Illinois, the group shared stories from their own practices and their thoughts on what needs to be done to normalize and sustain nutrition and healthy eating.
Integrating food as medicine into existing care
There is a need to normalize food as medicine, according to Joseph. Food as medicine is often viewed as something different or even going against the grain, but he noted that every guideline — the medical community, high blood pressure, diabetes, etc. — has diet and lifestyle listed as the first recommended change.
“We’ve just skipped this most important guideline over the last 40 years, and we’re asking ourselves why we’re doing so poorly,” Joseph said. Whether it is for doctors, medical associations or providers, food as medicine should already be treated as part of the protocol. “You’re just doing the basic steps.”
Persistence is key to normalization so that people’s views on food can change. However, there are some obstacles to this. Doctors with decades of practice are often very deep in their habits and may be more focused on turning patients around, Sharma explained. Fortunately, Sharma expressed that as the medical space shifts toward value-based care, it offers the opportunity to continue pushing for change.
Another obstacle is lack of funding. Being from North Carolina, Spratt spoke about how the General Assembly cuts Medicaid funds for food and housing funds, reducing people’s access to healthy foods. Fortunately, the association agreed to fund Meals on Wheels, a community program that provides nutritious meals to seniors and individuals with disabilities living in their homes. But obtaining this information is difficult.
“We were able to send out 900 referrals, but … we missed 2,100 people who were eligible because I couldn’t be at every patient’s bedside and say, ‘You’re eligible,’” she said.
Spratt hopes that once eligible programs are funded, case managers and social workers will be notified of who is eligible, and each patient will receive a text message notifying them of their eligibility. “But I am waiting for funding.”
Spratt also mentioned the Health Opportunity Pilot (HOP) Project in North Carolina that saved thousands of dollars per member per year compared to unenrolled patients. This reduction in cost is due to the positive effect of healthy food on cardiovascular disease. HOP didn’t just address food insecurity; It also addressed housing insecurity and care management. The program is no longer funded.
Long-term patient commitment and engagement
“Nutrition is very personal,” Spratt commented. “Being able to customize that on an individual basis is essential.”
An important factor to keep in mind about food as medicine is that there is no one-size-fits-all approach. Each patient has unique circumstances. Joseph recounted his experience with a diabetic patient whose mother had advanced pancreatic cancer. “For me to ask her to come home and eat a Mediterranean diet is not going to happen, and it is borderline insensitive.”
Instead, he focused on other problems his patient was experiencing, such as trouble sleeping. Joseph focused on her sleep problems and gave her small goals to work on and adjust what she could achieve that week. The principle is the same when it comes to diet. By focusing on small, realistic goals and establishing specific measures, the chances of changing someone’s diet are more likely. Joseph also encouraged the family to participate, because it creates a support system—and thus a community—for the patient.
Community was emphasized during the discussion. Sharma shared his experience using social media to connect with younger demographics. While social media allows anyone to post anything, Sharma emphasized using evidence to support what he includes in his posts.
While online platforms can provide valuable sources of information and community, van der Veer urged connection and community through personal, face-to-face conversations. “It has been proven time and time again that (online platforms) are not a suitable community (compared to) real human contact and communication.”
For some people, they suffer from a fear of self-consciousness, which makes them reluctant to step out of their comfort zone, according to Sharma. But he encouraged the audience, saying: “You are not fighting this battle alone, and there are other people with you.”
Personalized, scalable, and It can be proven Programs
Before starting any program, Joseph recommended starting with young pilots because of the logistics that occur when a program expands and becomes formal. Starting small also allows for easier collaboration between different disciplines, specialties and dietitians. In terms of community, it takes a “village” to create something sustainable and effective.
There must also be evidence that these programs work. Van der Veer used himself as an example. Having lost 40 pounds the previous year, he provides patients with tangible proof of the effectiveness of the programs he prescribes or reports to them. They have a realistic example they can follow and stay motivated. “When we start designing health plans, you have to practice what you preach.”
By the way, patient empowerment can determine the effectiveness of programs. Van der Veer discussed the use of a color-coded scoring system that could motivate patients to purchase healthier options. For example, a bag of candy might get a low score of four, while a healthy option might get a score of 68. For a “higher score,” patients might choose healthier options instead. While the costs of their goods are higher, it is not a significant amount, and the consumer is healthier.
“You are a customer and patient,” Van der Veer said. “You have the power and the power, and you can make these decisions for yourself. Here’s a tool that will put you in the right direction.”
However, there remain unanswered questions about how best to design food-based interventions. According to Spratt, there are mixed results for different health conditions. There is a low rate of readmission and heart failure, but diabetes shows a mixed case. In addition, some studies have shown no effect on A1C.
Spratt also expressed concern about studies that only look at a particular type of intervention and apply it to a group of patients who require several types of interventions, leading to negative results and dismissing the potential of that specific intervention.
Double standards
While more payers are showing increasing interest in FDA programs, evidence is needed. Van der Veer said there is still a need for “double-blind, randomized, controlled trials of seven million patients” that prove they can save costs per patient, which may be difficult.
Joseph pointed to an experience in which a patient with poorly controlled diabetes underwent a stent procedure every six months. He joined Team Joseph’s experimental cooking program in 2022, after which his A1C levels declined. Most importantly, the patient no longer needs stent procedures, which cost about $25,000 each. The patient saved about $150,000 out of pocket, and the cooking pilot program only cost $500.
“The bar has been set very high for us. You have to prove that in a multicenter, million-dollar, randomized controlled trial to prove that this works. I would say that’s a double standard,” Joseph said. He said the way research is conducted and how studies are approached needs to change because scientific consensus and extensive research show that a nutritious diet generally pays off in better health and longer lives.
