Food as medicine? It’s not as simple as it sounds.

Food as medicine? It’s not as simple as it sounds.

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Ever since I was a doctor fresh out of residency, I have been prescribing food for my patients to prevent and treat chronic health problems, such as diabetes and heart disease. But health insurance has never covered the cost of healthy food, which means some patients can’t afford the healthy diet I give them.

That recently changed in California and a handful of other states, where Medicaid now covers certain foods targeted at patients with diet-related conditions. As a result, I now prescribe “medical maintenance food,” or MSF, for some patients—a weekly bag of groceries or up to three meals a day—paid for by insurance as if it were medicine.

This move to embrace “food as medicine” is supported by research showing that food prescriptions by medical professionals can reduce health care costs and improve well-being, especially for those who lack the resources to access healthy food.

In a recent studyresearchers estimated that offering a national benefit of “medically informed nutrition” to people with conditions such as heart disease, cancer and diabetes could save $185.1 billion in medical costs and prevent more than 18 million hospitalizations over a 10-year period.

For those who view food as an integral part of healing, this is a huge step forward. But prescribing food is not as easy as it sounds.

Food is more complicated than any pill. This makes it difficult for doctors and patients to know which medically tailored foods are the best medicine and which providers can best deliver these edible therapies.

First, there is the real challenge of determining which vendors provide the most nutritious food. A pharmaceutical drug, whether generic or brand name, has almost identical ingredients regardless of who makes it. But food varies dramatically in nutrient content depending on seeds, season, agriculture and processing method and how long it was stored before being eaten. Combine foods to make a meal and the variability of nutrients becomes even greater.

The lack of standardization made it difficult, for example, for Dennis Hsieh, a physician and chief medical officer of California-based Contra Costa Health Plan, to choose among the food providers bidding to fill the food prescriptions for his plan’s participants.

Hsieh has extensive experience in contracting with medical supply companies for drugs and other healthcare products, but this is his first foray into the food sector. He said he received little guidance from the California Department of Health on what to buy. It is politics the guideline simply suggests that it should offer “appropriate dietary therapies based on evidence-based dietary practice guidelines.”

“After all, my main criteria [for vendors] is that they deliver the food to the patients and that they don’t give them McDonald’s and charge us for it,” he said.

In the end, Hsieh contracted with six suppliers. He said he hopes these vendors will offer meals and groceries that replicate the cost savings and health benefits of “food is medicine” studies, but he doesn’t “have the experience” to judge which providers will achieve this.

Michelle Kuppich, registered dietitian and director of California Food is Medicine Coalition is also concerned about the quality of some of the foods entering this growing medical market.

“There are a lot of new companies entering this space because there is money and people want the health care dollars,” Cupich said. She said she suspects some of them “started selling ready meals for weight loss and then rebranded.”

Kuppich found it challenging to get information on the nutritional value of some of the foods being sold. “There is a lack of transparency about the ingredients,” she said.

Some of the vendors offer food that is just as much ultra-processed such as fast food dishes that Hsieh hopes to avoid. Ultra-processed foods are associated with chronic disease and a higher risk of early death.

What are ultra-processed foods? What should I eat instead?

For example, GA foodsFlorida-based provider of medically supportive food offers over 50 “nutritionally balanced” meals that contain additives including corn syrup and other sweeteners, food coloring, flavoring additives, hydrolyzed protein and preservatives. “We follow the guidelines from the top organizations for each disease state and update the guidelines as they are published,” said Mary O’Hara, senior marketing manager for GA Foods. “Our medical meal portfolio is constantly evolving to meet patient needs and new health and wellness innovations.”

And Tracy Smith, vice president of marketing for mom’s food an Iowa-based company that serves more than one million meals a week nationwide said some of its meals include a micronutrient blend of magnesium, zinc, iron, calcium and vitamins C, B1 and B6 to “ensure that the food fully corresponds to one-third of that of a person Dietary Reference Intake. We do this rather than include extra servings of food that will then take that meal above the recommended calories, sodium or carbs per serving, for example.

Fortifying foods with vitamins and minerals can prevent anemia and other diseases associated with deficiency of certain nutrients, but cannot replicate the more complete nutrition offered in whole foods. One carrot, for example, has all the nutrients in Mom’s Meals, plus dozens of additional disease-fighting compoundswhich work together to influence our health.

Catherine Koch, Founder and CEO of Ceres Community Project, a nonprofit MSF supplier based in Sonoma County, California, said, “We use high-quality, nutrient-dense food and do not need to add anything to meet the nutritional requirements of our customers.” Couch said that sourcing food at a regional level and limiting storage and transit times helps ensure higher nutritional quality. (It can also help the local economy and reduce the environmental footprint.)

Healthcare providers also face the challenge of identifying which vendors offer food that appeals to the taste buds—and the soul.

“None of these nutritional interventions work if people don’t want to eat the food,” said Seth Berkowitz, a researcher who has led some pilot food and drug trials and is now an associate professor of general medicine and clinical epidemiology at the University School of Medicine in North Carolina. He describes food as offering gastronomic pleasure, cultural connection and family memories.

Berkowitz said national vendors offer “economies of scale” that keep costs low, but the pilot studies he participated in in Boston that showed positive results got their food from a nonprofit organization that says it serves ” made’ meals and buys from local farmers.

“Mission-driven organizations can offer benefits,” Berkowitz said. “It remains to be seen whether the secret sauce that made these small efforts work can be scaled.”

Nutrition and lifestyle coaching

In addition to food delivery, MSF providers in California are expected to offer nutrition and lifestyle education to their clients, as research shows that combining food aid with education is more likely to promote healthy eating patterns.

As with food, these services vary. Some providers give enrollees access to a quick nutrition consultation or healthy eating app, while others provide real-time cooking and shopping lessons.

“The number one thing I hear from our customers is, ‘I learned how to use a knife,'” said Sarah Nelson, CEO of 18 reasons an MSF provider in the San Francisco Bay Area. She has found that her clients are more willing to try new vegetables if they are given a recipe and practice cooking them in a group setting.

“Nutrition education and counseling is just as important as food so that people can prepare healthy meals after their prescription expires,” Kuppich said.

How it works in a doctor’s office

I recently wrote a food prescription for a 50-year-old woman with poorly controlled type 2 diabetes. She was enrolled in MediCal, California’s health insurance program for children and adults with limited income and resources.

I tried my best to direct her to the vendor who would deliver the most delicious, nutrient-dense, and culturally appropriate food. But even with my nutritional know-how I had a hard time figuring out what it could be.

She ended up choosing a non-profit that sources most of her food locally and delivers it to her doorstep. Two months into her prescription, her blood sugar improved and I called her to let her know The good news. I asked her what she thought of the meals. “They’re so nice, it’s really nice to see them,” she said.

It took me a while to figure out that he meant the caterer, not the food.

Her comment made me wonder what caused the positive change in blood sugar. Was it from the food? The social connection? Both?

Regardless, it was a bracing reminder that food is not a pill, but a much more complex medicine.

At any age, eating healthy can extend your life

Daphne Miller is a family physician and clinical professor at the University of California, San Francisco, and a researcher at the School of Public Health at the University of California, Berkeley. She is also the founder of the Health From the Soil Up Initiative.

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