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Could We Prescribe Meals as Medicine?

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The staccato, ephemeral blips of an EKG monitor are no match for the deafening crunch of potato starch meeting tooth enamel. So naturally, the first thing I noticed about Cindy when I walked into her hospital room was the family-sized bag of Lays in her hands.

Cindy (not her real name) was suffering from congestive heart failure (CHF); the muscles in her heart were too weak to effectively pump blood through her body. The bag of chips was just one of the snacks that her husband bought from a nearby convenience store minutes before I arrived to take her medical history. As a Medicaid family, the two of them were living paycheck-to-paycheck and stacked multiple part-time jobs to make ends meet. Because of the uncertain duration of Cindy’s stay in the hospital, her husband wanted to give her the most caloric food he could with the little money they received each month from federal food stamps.

Cindy, like most patients with CHF, was likely told by her physicians to eat a low-sodium diet. Because her heart was weak, blood was prone to backing up into the vessels of her lungs and limbs. High levels of salt pull fluid into the bloodstream and increase pressure inside the vessels. As blood pressure rises, the excess fluid is forced into the lungs, displacing oxygen and making it difficult–if not impossible–to breathe.

Cindy excitedly told me that she was leaving the hospital the next day. My preceptor and I mentioned the chips to one of her nurses, and hoped that she’d receive some diet counseling from a nurse or her physician before she was discharged. Cindy must have known better. What could have compelled her husband to buy a bunch of junk food over a few apples? Whatever benefits they were receiving from the federal food stamp program, SNAP, clearly weren’t enough for Cindy’s health.

One week later, while moving from room-to-room to find a patient to interview, I was surprised to see Cindy back in the hospital. I asked the floor nurse why she had been readmitted. Cindy had experienced severe shortness of breath from a buildup of fluid in her lungs, symptoms likely due to her salt intake at home. I found her–anxious and unsettled–lying in a hospital bed; once again hooked up to an EKG monitor. There weren’t any chips by her bedside today.

Along with Cindy and her husband, more than 42 million people–one in eight Americans–receive food stamps. However, the impact of budgetary squabbles over food stamp spending is most often manifested inside the walls of America’s academic medical centers. Food insecurity, the lack of access to nutritionally adequate food, has been linked to higher risks of developing hypertension, heart disease, stroke, cancer, diabetes, arthritis, kidney disease, and hepatitis, among others. While helpful, the limited purchasing power of food stamp recipients means they often have to turn to the cheapest calories, usually processed foods made from refined sugars and oils. It’s no wonder, then, that America’s poorest families have much higher obesity rates relative to the rest of the U.S. population.

Cindy was put on furosemide, a drug that helps the body remove excess water and salt by increasing urine output. Her legs shrunk and her breathing slowly returned to normal. If the rest of her tests came back normal, she would be set to go home within a few days. I wondered if she’d ever return. Doctors can manage the worst manifestations of chronic disease in the hospital, but the environment that these patients return to once they leave–block corner convenience stores, cheap junk food, and limited options for nutrition–only exacerbates their conditions. The furosemide was treating a symptom of Cindy’s disease, but left the underlying cause unaddressed. Could smarter food policy be a better medicine?

Hospitals took the lessons learned from patients like Cindy into their own hands. The Geisinger Health System in Pennsylvania piloted a program to ‘prescribe food as a specialty drug’ for patients with Type 2 diabetes. The program provided fresh fruits and vegetables, whole grains, and lean proteins to feed each program participants’ entire household with two healthy meals for five days per week. After 18 months, this approach of ‘meals as medicine’ led to a drop in HbA1c levels from an average of 9.6% initially to 7.5% after the program. To put this in context, diabetes patients taking multiple medications for blood sugar management can expect their HbA1c to drop somewhere between 0.5 to 1.2%. Geisinger also tracked how total health care spending for 37 of their patients on the program changed over the course of 18 months. Costs for those patients dropped by a staggering average of 80%, from $240,000 per member per year to $48,000 per member per year. In nearby Philadelphia, the Metropolitan Area Neighborhood Nutrition Alliance has been delivering free meals to low-income patients with serious illnesses for nearly thirty years, showing annual reductions in health care spending of 55% of patients who receive meals compared to those that don’t. Fundamentally, the types of foods that patients ate had a significant and clinically observable impact on their health outcomes.

California policymakers took notice. Rising costs for Medi-Cal, the state’s Medicaid system that covers over a third of its population, and a high burden of chronic disease and food insecurity among Californians made Geisinger’s pilot the perfect experiment to bring out west.

The California pilot program, which officially launched this month with support from state senator Ben Allen along with California assembly members Blanca Rubio and Richard Bloom, provides $6 million in funding over three years to six nonprofit organizations to offer diet guidance and deliver free meals to Medi-Cal patients that need special diets to manage certain medical conditions. The ‘Food is Medicine’ pilot program will deliver meticulously formulated meals to 1,000 people with congestive heart failure over a 12-week span.

As the first state-sponsored prescription of meals as medicine, the spillover effects of success in California could be tremendous, and potentially entwine food policy with health care debates on Capitol Hill. With both sides of the aisle harping on deficits and health care prices, why not follow the evidence? Including meals as a part of federal Medicaid coverage could both give our most vulnerable population more financial freedom to make healthier choices and reduce long-term spending on expensive treatments for chronic disease. For patients like Cindy, an apple a day really could keep the doctor away.

Nisarg Patel is a student at Harvard Medical School and the Harvard School of Dental Medicine, and cofounder of Memora Health.

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