How to Integrate Food as Medicine into Existing Care Models

By Irene Yeh 

At this month’s Food as Medicine Summit, there were many conversations surrounding getting payers involved in expanding food as medicine into healthcare and how to expand programs to patients from various backgrounds. There is one question that still needs to be addressed: How do we embed food as medicine into our current models of care?  

A panel consisting of Ajay Joseph, M.D., FACC, DipABLM, medical director of lifestyle medicine at St. Francis Health System; Susan Spratt, M.D., senior medical director of Duke Population Health Management at Duke Health; and Jon Van Der Veer, D.O., founder and CEO of Hy-Vee Health Exemplar Care, gathered to discuss how to integrate food as medicine into existing care pathways. Moderated by Sunny Sharma, M.D., FACP, DipACLM, CMD, RMO, internal medicine and lifestyle medicine physician, MDVIP physician, and regional medical officer for Ascension Medical Group of 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.  

Incorporating Food as Medicine into Existing Care 

There is a need for normalizing food as medicine, according to Joseph. Food as medicine is viewed as something different or even going against the grain, but he pointed out that every guideline—medical society, hypertension, diabetes, etc.—has diet and lifestyle listed as the first recommended change.  

“We’ve just been skipping that most important guideline for the past 40 years, and we ask ourselves why we’re having bad outcomes,” said Joseph. Whether it’s physicians, medical societies, or referring providers, food as medicine should be treated as something that is already part of the protocol. “You’re just doing the basic steps.” 

Persistence is key to normalization so that people’s perspectives on food can change. However, there are a few obstacles to this. Sharma explained that physicians who have decades of practice are often too deep into their habits and may be more focused on patient turnaround. Fortunately, Sharma expressed that as medical spaces shift toward value-based care, it provides the opportunity to continue pushing for change. 

Another obstacle is the lack of funding. Being from North Carolina, Spratt talked about how the General Assembly cut Medicaid funds for food boxes and housing, decreasing people’s access to healthy foods. Luckily, the assembly approved funding for Meals on Wheels, a community-based program that delivers nutritious meals for homebound seniors and individuals with disabilities. But getting that information out is difficult.  

“We were able to send 900 referrals, but … we missed 2,100 people who were eligible because I can’t be at every patient’s bedside saying, ‘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 every patient will receive a text notifying them of their eligibility. “But I’m waiting for funding.” 

Spratt also mentioned the Healthy Opportunity Pilot (HOP) in North Carolina that saved thousands of dollars per member every year compared to patients not enrolled. This decreased cost was attributed to the positive impact of healthy food on cardiometabolic disease. HOP not only addressed food insecurity; it also addressed housing insecurity and care management. The program is no longer funded. 

Long-Term Patient Adherence and Engagement 

“Nutrition is very personal,” Spratt commented. “To be able to personalize 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. Every patient has unique circumstances. Joseph recounted an experience with a diabetic patient who had a mother with advanced pancreatic cancer. “For me to ask her to go home and eat a Mediterranean diet, that’s just not going to happen, and it’s borderline insensitive.” 

Instead, he focused on other issues his patient was going through, such as trouble with sleeping. Joseph focused on her sleep problems and gave her small goals to work toward and adjusted what she could accomplish that week. The principle is the same when it comes to diet. By focusing on small and realistic goals and laying down specific measures, the chances of changing someone’s diet are more likely. Joseph also encouraged family to be involved, as that creates a support system—and subsequently, a community—for the patient.  

Community was stressed during the discussion. Sharma shared his experience of using social media to connect with younger demographics. While social media allows anyone to post anything, Sharma emphasized using evidence to support what he is including in his posts.  

While online platforms can provide valuable sources of information and community, Van Der Veer urged connection and community through face-to-face in-person conversations. “It has been proven time and time again that [online platforms] are not an adequate community [compared] to real human connection and communication.”  

For some people, they struggle with fear of self-consciousness, making them reluctant to step out of their comfort zone, according to Sharma. But he encouraged the audience, “You’re not doing this battle alone, and there are other people with you.” 

Personalized, Scalable, and Provable Programs 

Before starting any program, Joseph recommended starting off with small pilots due to the logistics that occur when a program expands and becomes official. Starting small also allows easier collaboration between different specialties, disciplines, and dieticians. Relating back to community, it takes “a village” to create something sustainable and effective. 

There also needs to be proof that these programs work. Van Der Veer used himself as an example. Having lost 40 pounds from the previous year, he provides patients with tangible proof of the effectiveness of the programs he is prescribing or informing them about. They have a real-life example they can follow and stay motivated. “When we start designing health plans, you have to practice what you preach.” 

Incidentally, patient empowerment can determine the effectiveness of programs. Van Der Veer discussed using a color-coded scoring system that could motivate patients to purchase healthier options. For example, a bag of candy could have a low score of four whereas a healthier option may have a score of 68. To gain a “higher score,” patients may choose the healthier options instead. And while the costs of their items increase, it is not a significant amount, and the consumer is healthier.  

“You’re a customer and patient,” said Van Der Veer. “You have agency and power, and you can make these decisions on your own. Here’s a tool that will bump you in the right direction.” 

With that said, there are still unanswered questions on the best way to design food-based interventions. According to Spratt, there are mixed results for different health conditions. There is a reduced rate of readmission and heart failure, but diabetes shows a mixed bag. Additionally, some studies did not show an impact on A1C.  

Spratt also expressed concern around studies only looking at a certain type of intervention and applying it to a group of patients that need several types of interventions, resulting in negative results and dismissing that specific intervention’s potential. 

The Double Standards 

While more payers are showing increasing interest in food as medicine programs, evidence is needed. Van Der Veer mentioned how there still needs to be “double-blind, randomized, controlled seven million patient population” trials that prove they can save costs per patient, which can be a tall order. 

Joseph recalled an experience where a patient with badly controlled diabetes was getting a stent procedure every six months. He joined Joseph’s team’s culinary pilot program in 2022, after which his A1C levels decreased. Importantly, the patient no longer needed stent procedures, each of which cost about $25,000. The patient saved about $150,000 out of pocket, and the culinary pilot program only cost $500 to implement. 

“The bar is set so high for us. You have to prove it at a multi-center, million-dollar randomized controlled trial [level] to show that this works. And that’s, I would say, double standards,” said Joseph. He argued that the way research is conducted and how studies are approached need to change since scientific consensus and extensive research show that a nutritious diet generally pays off with better health and a longer life.