Prescribing Food as Medicine

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A patient comes into your office with anemia because they did not regularly consume enough iron in their diet. As a physician, you could either recommend that your patient starts taking iron supplements or counsel the patient to obtain iron through their diet. Arguments can be made for both treatment courses. Supplements are easily obtainable, provided you have access to a pharmacy and means to purchase. Supplements also require zero preparation time. On the other hand, one could argue there is more bioactive iron in food and encouraging a patient to obtain iron through their diet would also help to increase consumption of other nutrients found in that food. Let’s assume as a provider, you counsel the patient to consume iron through their diet and start rattling off a list of iron dense foods: legumes, spinach, black beans, red beans, kale, poultry, salmon…But, obtaining these foods can be challenging — Does the patient have access to this food? Is it affordable? Do they have the means to prepare the food? Ultimately, this course of treatment is not as straightforward as it may initially seem. Recommendations mean little if your patient is unable to do anything actionable and unfortunately, as a provider you have limited means to guarantee that your patient will be able to find and purchase this food.

While this case, might seem far-fetched, it happens all too frequently. Insufficient, unbalanced diet is a major contributor to poor health. For example, a recent study looking at patients with chronic conditions, found significant association between patients reporting unmet food needs and those with hypertension, diabetes, and hemoglobin A1c > 9.0%. Overall, 40.1% of patients enrolled in the study reported unmet food needs. No individual intentionally tries to derail their own diet, let alone their family’s health. However, a myriad of factors conspire against us even at the best of times. General nutrition guidelines are hard enough on their own without adding specific restrictions or health considerations like diabetes, heart disease, anemia, or osteoporosis. Not to mention eating whole foods takes time, money, and access to food. With so many restrictions, the unhealthy food choice is often the one that people end up consuming as a last resort. Public health and medicine need to do more to addressing this pressing issue.

One solution to this problem has been the introduction of Food Prescriptions. Physicians can prescribe coupons that are redeemable for free or reduced fresh produce either directly in their clinic or through partnerships with retailers or farmers markets. Boston Medical Center and Arkansas Children’s Hospital, Food Rx in Chicago, and FVRx at Harlem Hospital Center all have Food Prescription programs.

Why shouldn’t healthcare providers have the ability to prescribe food for patients? Providers already give patients nutritional advice about what to eat or not eat without providing a way to purchase recommended food. Giving someone a prescription puts a certain gravitas behind a recommendation. Most importantly, however, the types of fresh produce that healthcare providers are most likely to recommend are also much more likely to be cost prohibitive or locally inaccessible as compared to processed alternatives. Enabling patients to use prescriptions to reduce the cost of purchasing healthy food is a great step towards making it easier to purchase whole foods and incentivize stores to carry more produce.

Of course, no solution is without flaws. Providing the financial means for food is not enough. Do patients have access to a grocery store? Do they know how to prepare the food? Do they have time to prepare the food? As a physician, do you have the knowledge to help with these issues or know what resources are available in your community? A prescription food program also requires clear rules and guidelines to determine prescription eligibility. How does food prescription eligibility, impact, if at all, eligibility for other food assistant programs such as SNAP and WIC? The sustainability of this model is also an issue. For broad program adoption to be possible outside of a select number of hospitals or nonprofits, there needs to be a reimbursement scheme that fits within our healthcare model. There also needs to be research proving short-term and long-term effectiveness of these types of programs.

Interestingly, a new mandate, 501(r), from the Affordable Care Act (ACA) might bring about greater adoption of similar programs. Under the ACA, hospitals can be exempt from taxes under IRS Section 501(c)(3), designating the hospital a charitable organization. As part of Section 501(r) hospitals are required to perform a Community Health Needs Assessments (CHNA) every 3 taxable years and adopt strategies to meet their identified needs. Meeting 501(r) is required for a hospital to maintain their 501(c)(3) status. The published final regulations specifically include “to ensure adequate nutrition,” as a potentially identifiable community health care need. In other words, a hospital program that provides food prescriptions is not just good medicine, but can also ensure that the hospital receives tax-based incentives.

Incentivizing hospitals is an excellent start to improving the sustainability of the Food Prescription model. Imagine if food education was a billable intervention under Medicare or Medicaid. That could help ensure that all physicians could counsel their patients and families about the importance of establishing healthful dietary patterns. If Medicare/Medicaid adopted the Food Prescription model, this could help pressure greater buy-in from private insurances. Educating about nutrition and ensuring patient access to healthful foods could become incorporated into the standard of care for certain diagnoses or risk factors.

While it is easy to see this idea taking off, it’s critical that we continue to have conversations about the implications of such a program. Would we have to regulate the frequency or scope of food prescriptions? Could we only prescribe un-processed food? Would the food industry be included in these types of program?

There is not one solution to food insecurity or its effect on health. We need to continue to develop and test innovative solutions to deliver proper nutrition to our patients. While we still have a long way to go, it is encouraging that institutions have developed creative and innovative methods of improving access to healthful foods.

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