Is ‘food is medicine’ actually being integrated into medicine?

Can food be medicine? Will insurers cover it? And other big questions about a new health movement

After nearly forty years of obscurity, the “food is medicine” movement is having a moment.

Multiple federal agencies are working on food is medicine projects, major organizations have pledged hundreds of millions in research funding, and billions more are being invested in food-focused startups. Even the White House has publicly announced its support for the movement, which focuses on the use of healthy food as a medical intervention for certain chronic and diet-related diseases.

“We are at the inflection point,” said Dariush Mozaffarian, the dean for policy at the Tufts Friedman School of Nutrition Science and Policy. “Five or six years ago I would go to major health care organizations and talk about food [is] medicine and I’d get blank stares, crickets, and polite emails.”

But now comes the hard part: Integrating food into medical practice. Despite the newfound enthusiasm in Washington, hospitals and doctors aren’t using food to treat most patients, and insurers by and large are not covering these services. It’s a frustrating fact for supporters of the movement who insist there’s no debate that quality food improves health.

“For whatever reason, we think it’s appropriate to write out prescriptions that cost exorbitant amounts of money for people when they get sick, but we don’t think it’s appropriate to give them a prescription for fresh produce,” said Rep. Jim McGovern (D-Ma.), a prominent backer of the movement. “Why is it that we are so hesitant to move more aggressively in that direction?”

STAT asked that question to more than a dozen food policy experts, researchers, insurance executives, investors, and food advocacy organizations. Nearly all highlighted two major barriers that need to be overcome to treat patients with food: the lack of good research demonstrating what conditions best respond to food and regulatory requirements that keep certain insurers from offering these services to their members.

Whether those barriers can be overcome anytime soon remains to be seen. Several major organizations are standing up an effort to run more clinical trials testing these policies, but it’ll likely take years before those studies are completed. And in Congress, Republican lawmakers are trying to roll back, rather than scale up, federal nutrition programs — prompting a potential showdown over a must-pass agriculture bill later this year.

What exactly is food as medicine, and what evidence do we have that it works?

There’s no agreed-upon definition of what constitutes food as medicine, but broadly it’s anything that recognizes food as a way to address health. The term has been used to describe everything from the delivery of dietician-designed premade meals to cooking classes for doctors. Some argue that nutrition programs aimed at tackling food insecurity and hunger — like the federal programs WIC and SNAP — are food-is-medicine programs, too.

Most groups working in the field highlight three specific interventions as clear embodiments of the idea: the delivery of dietician-designed meals for certain conditions, known as medically-tailored meals, the provision of meal boxes meant for certain conditions, known as medically-tailored groceries, and offerings of vouchers for unprepared fruits and vegetables, known as produce prescriptions.

The strongest research at the moment, according to several experts, studies the benefits of so-called medically-tailored meals. A retrospective study found that roughly 100 patients dually enrolled in both Medicare and Medicaid who received the meals had 70% fewer emergency room visits and 52% fewer hospital inpatient admissions than the 1,002 patients who went without. Another retrospective study of around 1,000 adults found that the roughly 500 individuals receiving medically tailored meals had 49% fewer inpatient admissions and 72% fewer admissions to skilled nursing facilities than the 500 who did not receive meals.

Backers of medically-tailored meals were definitive that the growing body of data demonstrates the idea should be quickly expanded nationwide.

“I do think there is enough [evidence] at this point to take the next steps,” said Alissa Wassung, the executive director of the Food is Medicine Coalition, which advocates for providers of medically tailored meals.

But other experts argued that more research will still need to be done to determine the sort of specifics — like duration of treatment — that an insurer or doctor would need to “prescribe” such meals like they would a prescription.

“Is it 10 meals per week, is it 15 meals per week, how medically-tailored does it have to be, does it have to cover the whole family, or is it just for patients, and so on,” asked Mozaffarian, the Tufts dean. “There are a lot of very real, nuanced questions that need to be answered.”

There’s far less evidence for other food medicine interventions. Early studies have shown both medically tailored groceries and produce prescriptions can improve food security and may have some impact on chronic conditions like diabetes, but those studies were not designed with the type of rigor necessary to say definitively that they positively impacted health.

A recent literature review from experts at the Aspen Institute found that of the 12 studies looking at medically-tailored groceries, only three had a comparison group and only five had a sample size larger than 100. Of the 27 studies looking at produce prescriptions, just five had control groups.

What’s going on in Washington?

The food is medicine concept was catapulted into the mainstream here in Washington after a nutrition conference and corresponding national nutrition strategy released by the White House in September. There, the Biden administration announced its support for efforts to increase insurance coverage of food is medicine initiatives, including Medicare piloting the provision of medically-tailored meals to certain seniors. (Under current law, traditional Medicare is actually barred from covering food.)

As part of the summit, several major organizations, including the American Heart Association, the Rockefeller Foundation, and Kroger also announced they were pledging $250 million to create a Food Is Medicine Research Initiative. Nancy Brown, the CEO of the American Heart Association, told STAT that the initiative “will create the evidence so that this can become a standard of care in this country.” Devon Klatell, the vice president of food initiatives at the Rockefeller Foundation, said one of the primary goals of the initiative will be “setting up a research infrastructure that can generate definitive evidence about which food is medicine programs are most effective, what is optimal program design, and for which patients … to get to a point where there are no excuses.”

Prominent backers of “food is medicine” say the conference dramatically accelerated talks in Washington about how to better integrate food into medical practice.

“There’s just this whole new energy and the whole new focus on this topic — which gives me great hope that we will make progress,” McGovern said. “I’ve never felt more hopeful that we are going to make progress than I do right now.”

Late last year, legislators tucked $2 million into a government funding package to pay for a forthcoming “food is medicine pilot program,” overseen by the federal health secretary.

The National Institutes of Health is also developing a $140 million grant program that would designate certain research institutions “food is medicine centers of excellence.” Those centers, once chosen, would receive grant funding to develop diet-related interventions for their city or town. That program cleared a major procedural hurdle late last month when NIH officials voted to allow the program to move forward.

Is ‘food is medicine’ actually being integrated into medicine?

There’s undoubtedly excitement around “food is medicine” among hospitals, health care providers, and the private sector more generally, but these services are still the exception, rather than the norm.

In recent years, several hospitals, like Chicago’s Rush University Medical Center and Boston’s Mass General, have set up their programs to provide healthy food to their patients. Grocers like Kroger are launching partnerships with private Medicare insurance plans to provide a stipend for healthy foods at their stores. And employers, like engine manufacturer Cummins, are providing their workers with food as medical services, like access to cooking classes and physicians trained in nutrition.

Medicaid beneficiaries in some states, like Oregon and Massachusetts, can also now have meals delivered to their homes.

Investor money is flowing too: A coalition of investors announced earlier this year that it would invest $2.5 billion over three years in food and nutrition startups.

But food is medicine isn’t fully integrated into the health care system, largely because most insurers are choosing not to pay for it, or are barred by law from paying for it.

These benefits are most common in so-called Medicare Advantage plans, which are offered to seniors by private insurers. But these services are still the exception. Just 14% offered a food and produce benefit for the chronically ill last year.

Even then, Medicare Advantage plans are only able to offer food benefits and other “special supplemental benefits” to seniors with severe chronic conditions that put them at an outsized risk for death or hospitalization.

Coverage is even less likely for those with commercial insurance. STAT contacted several industry groups representing employer-sponsored health plans, which were unable to point to employers that offer such benefits. A spokeswoman for AHIP, which lobbies for insurance plans in Washington, acknowledged that services “are not widespread in employer-provided coverage.”

The main issue, insurers and supporters of the idea said, is the lack of data.

“There isn’t the robust evidence base that we see in other parts of health care,” said Matt Eyles, the president, and CEO of AHIP, who added that there is interest, including from his members, in developing that evidence. “If you compare just the volume of evidence that is available around food and nutrition, compared to prescription drugs, vaccines, devices … where you have a randomized controlled trial — we don’t have that breadth out there.”

Insurers say other legal barriers have prevented certain plans from providing these services, even if they wanted to.

For Medicaid programs to offer these services, for example, they have to ask the federal government for permission through a so-called 1115 waiver.

Private insurers offering plans directly to consumers say that existing regulations make it difficult for them to provide these services, too. The AHIP spokeswoman noted, for example, that insurers offering plans on the individual market “cannot target services or benefits based upon a person’s health status,” making it difficult to offer tailored services like meals.

What’s next?

It’s going to be a busy summer for the food is medicine movement.

In the next few months, researchers from Kaiser Permanente and Tufts School of Nutrition hope to publish results from a large clinical trial testing the impact of so-called produce prescriptions in 450 Medicaid patients with uncontrolled Type 2 diabetes. Researchers will also likely publish results from a 1,400-person randomized study testing the impact of produce prescriptions on children’s food security and BMI even earlier this summer, according to the study’s principal investigator.

Staff for the Rockefeller Foundation also told STAT they hope to have more details this spring about their $250 million research push alongside the American Heart Association and Kroger, though their studies likely won’t be completed for a few years.

In Washington, Congress will be gearing up for the reauthorization of a major package of agricultural legislation considered every five years known as the Farm Bill. The measure, which includes reauthorizations for several major federal nutrition programs, including food stamps or SNAP, could be a natural vehicle for advancing food medicine policies; legislators and advocacy groups have already begun readying their asks.

Sen. Cory Booker (D-N.J.), the head of the Senate agriculture committee charged with nutrition policy, for example, recently held a committee hearing on food is medicine at which he proclaimed two of his top priorities for the Farm Bill were scaling up a program in SNAP that allows community organizations to incentivize the use of food stamps for the purchase of fruits and vegetables, and creating a program to provide boxes of locally sourced produce to Medicaid enrollees.

But most policy wonks are reluctant to predict what will be included in the legislation – or whether lawmakers will even pass the package. Already there are signs that the conservative Freedom Caucus in the House of Representatives will try to strip the legislation of nutrition programs like SNAP entirely, as they previously tried to do the last time the bill was reauthorized, in 2018.

If they do, McGovern is ready to try to torpedo the entire thing.

“If they want to screw around … you know what, I’m going to fight like hell to make sure we don’t get a Farm Bill,” said McGovern, the Massachusetts lawmaker. “I’m not going to vote for any Farm Bill that doesn’t advance the White House’s national [nutrition] strategy.”