The "food is medicine" movement — which states that food can be a way to address health — has been gaining popularity in recent months, with the Biden administration voicing support for it. But the movement faces a number of obstacles, including a lack of coverage from insurers, Nicholas Florko writes for STAT.

What is 'food is medicine?'

There isn't a hard and fast definition of food is medicine, Florko writes, but it's generally considered to be anything that recognizes food as a way to address health. It describes things like premade meals designed by dieticians, cooking classes for doctors, and federal programs like WIC and SNAP that address food insecurity.

According to Florko, most experts cite three interventions as embodiments of the "food is medicine" idea:

• The delivery of meals designed by dieticians for specific conditions, also known as medically tailored meals
• The delivery of meal boxes designed for certain conditions, also known as medically tailored groceries
• Vouchers for unprepared fruits and vegetables, also known as produce prescriptions

As it stands, the strongest evidence is in favor of medically tailored meals. One study found that around 100 patients enrolled in both Medicare and Medicaid who received medically tailored meals saw 70% fewer ED visits and 52% fewer hospital admissions than the 1,002 patients who did not receive the meals.

A second study of around 1,000 adults found that the roughly 500 participants who received medically tailored meals saw 49% fewer inpatient admissions and 72% fewer admissions to skilled nursing facilities than the 500 who didn't receive the meals.

Some experts say the evidence is strong enough that medically tailored meals should be expanded nationwide. "I do think there is enough [evidence] at this point to take next steps," said Alissa Wassung, executive director of the Food is Medicine Coalition.

However, others argue more research is needed to determine logistics around medically tailored meals, including what a doctor or insurer would need to properly prescribe the meals.

"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," said Dariush Mozaffarian, dean for policy at the Tufts Friedman School of Nutrition Science and Policy. "There are a lot of very real, nuanced questions that need to be answered."

As for the other "food is medicine" interventions, less evidence exists supporting them. Early studies have suggested medically tailored groceries and produce prescriptions can help improve food security and could have an impact on some chronic conditions, including diabetes. But those studies weren't designed in a way to say the interventions had a positive impact on health, Florko reports.

For example, a recent literature review from the Aspen Institute found that of the 12 studies that analyzed medically tailored groceries, just three had a comparison group and only five had sample sizes bigger than 100. Meanwhile, of the 27 studies that looked at produce prescriptions, only five had control groups.

'Food is medicine' gains traction in Washington D.C.

The Biden administration indicated its support for "food is medicine" interventions — including a Medicare pilot of medically tailored meals for certain seniors — following a nutrition conference and national nutrition strategy released in September.

As part of the conference, a number of organizations, including the American Heart Association (AHA), the Rockefeller Foundation, and Kroger, announced a $250 million pledge to create a Food Is Medicine Research Initiative.

The initiative "will create the evidence so that this can become a standard of care in this country," according to Nancy Brown, CEO of AHA. Devon Klatell, VP of food initiatives at the Rockefeller Foundation, said a primary goal 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's no excuses."

Last year, Congress placed $2 million in a government funding package for a "food is medicine pilot program," Florko writes. And NIH is developing a $140 million grant program to designate certain research institutions as "food is medicine centers of excellence." Those institutions would receive grants to develop diet-related interventions for their city or town.

However, the "food is medicine" movement faces a major hurdle, as most insurers are either choosing not to pay for these interventions or are prevented from paying for them by law.

For example, Medicare Advantage plans are only allowed to offer food benefits and other "special supplemental benefits" to patients with severe chronic conditions that put them at a high risk of death or hospitalization.

A spokesperson for America's Health Insurance Plans (AHIP) said that food services "are not widespread in employer-provided coverage."

"There isn't the robust evidence base that we see in other parts of healthcare," said Matt Eyles, president and CEO of AHIP, adding that there's interest in developing the evidence for these programs, including from AHIP's members. "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."

There are also legal barriers, Florko reports. For example, if a Medicaid program wants to offer any food interventions, they have to ask permission from the federal government through a 1115 waiver.

What the future holds for 'food is medicine'

There's a lot on the horizon for the "food is medicine" movement, Florko writes. A few months from now, researchers from Tufts and Kaiser Permanente are aiming to publish the results of a clinical trial testing produce prescriptions in 450 Medicaid patients with uncontrolled Type 2 diabetes. Results from a 1,400-person randomized study looking at the impact of produce prescriptions on children's food security and BMI are also expected this summer.

In addition, staff from the Rockefeller Foundation said they hope to have more details on the $250 million research pledge alongside AHA and Kroger — however, studies are likely not to be completed for a few years.

Meanwhile, Congress is poised to reauthorize a package of agricultural legislation that is considered every five years known as the Farm Bill, which includes reauthorizations of several major nutritional programs, including food stamps and SNAP, and could be a vehicle for "food is medicine" policies.

Sen. Cory Booker (D-N.J.) recently said he intends to use the Farm Bill to scale up a SNAP program that allows community organizations to incentivize the use of food stamps for purchasing fruits and vegetables, and to create a program providing boxes of locally sourced produce to Medicaid beneficiaries.

However, according to Florko, there are signs that the conservative Freedom Caucus in the House of Representatives will attempt to strip the Farm Bill of programs like SNAP entirely — something they attempted in 2018. Rep. Jim McGovern (D-Mass.) said he doesn't intend to let that happen.

"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," he said. "I'm not going to vote for any Farm Bill that doesn't advance the White House's national [nutrition] strategy." (Florko, STAT, 2/16)