It’s now up to health systems to solve our food problems
The whole world is getting fat,” declared Whole Foods founder, John Mackey, in a recent interview with the New York Times. Because, he continues, “in some sense, we are all food addicts.” Mackey explains that he does not think we have a food access problem, but rather a market demand problem. “If people want different foods, the market will provide it.”
While this perspective ignores the rising wave of food insecurity across the nation, creates a false narrative of choice where there is often none and dismisses the complex relationship between food, obesity and trauma, we can’t dismiss Mackey’s comment outright.
He’s right about one thing. He said: “We have to recognize both what business can do and what business cannot do.” Stores like Whole Foods are unlikely to help households struggling to access healthy food. It’s now up to health systems to play a significant role in solving our food problems.
Food insecurity is defined by the US Department of Agriculture (USDA) as “a household-level economic and social condition of limited or uncertain access to adequate food.” Researchers estimate that during our spring COVID-19 surge, food insecurity rates doubled nationally and tripled in households with children; approximately 23 percent of households across the country currently have inadequate access to sustenance.
The relationship between COVID-19 and food insecurity is not merely that the former drives the latter. Food insecurity is associated with increased risk and poorer control of chronic diseases, which consistently have been shown to put individuals with COVID-19 infection at higher risk of complications and death. While chronic diseases have long been the leading drivers of premature death, COVID-19 takes all of our chronic diseases and makes them acute.
As with COVID-19 infection, the burden of food insecurity falls disproportionately on low-income and Black and Latinx households. Some of the highest rates of food insecurity are seen among undocumented immigrants; a recent MIRA survey found 78 percent of households with at least one undocumented family member did not have enough to eat.
Access to healthy foods is further restricted by food deserts, neighborhoods without grocery stores, and food swamps, neighborhoods saturated with fast food. To say this landscape is a result of the market disregards the policies that have stacked the deck towards our unhealthy food system: government subsidies for ingredients of processed, energy-dense foods such as corn, soybeans, dairy and livestock instead of fruits and vegetables. What we eat is impacted by availability and cost; decreasing these barriers changes our choices for the better.
Nutritional interventions can prevent, improve and even reverse chronic diseases such as obesity, diabetes, high blood pressure and heart disease. Diet is one of the most important modifiable risk factors of chronic non-communicable disease, according to the WHO. This is why simply put, food is medicine. Acknowledging food insecurity’s outsized role in driving poor nutrition and chronic disease necessitates prioritizing healthy food access for all in our response to our worsening food insecurity crisis.
Increasingly, we understand that trauma influences our food and our health. Last summer, a friend of mine became a vegetarian. That same summer, a family member of hers was murdered. Sitting under a large umbrella at a work pool party, we talked about how she was doing. “Not great,” she admitted, waving her hamburger with one hand. “I feel anxious all the time. And as you can see, my vegetarianism is out the window. I just… crave meat.”
In the setting of the COVID pandemic, we can all likely readily agree that stress influences our bodies and food cravings. And chronic trauma and stress, particularly during childhood, has a lasting influence on our neurobiology, stress hormones, food choices and weight. Increasingly, research recognizes a significant link between adverse childhood events (ACEs) and a range of chronic medical conditions including obesity. For these patients, offering a nutritional intervention alone is insensitive and will not work.
Health systems are well poised to play a strategic part in fixing our food problems due to their proximity to communities, central responsibility in treating chronic disease, the inclusion of mental health and participation in value-based payment models that incentivize addressing patients’ health-related social needs such as food.
Masshealth, the Medicaid insurance product for low-income individuals in Massachusetts, has created one of the first programs to allow health systems to partner with social service organizations and provide nutritional interventions — i.e. healthy food — on their dollar with its 149 million dollar Flexible Services Program.
Health systems ready to incorporate nutritional interventions can reference the Food is Medicine pyramid, created by Food is Medicine MA, which provides a helpful schema of evidence-based programs.
For example, nutritious food referrals, which provide vouchers for free or discounted nutrient-dense food, have been shown to improve fruit and vegetable intake, improve diabetic control and improve Body Mass Index. The most intensive program, medically tailored meals, provides prepared meals tailored to a patient’s medical conditions. Medically tailored meals have been shown to reduce ED visits by 70 percent, reduce inpatient hospital admissions by 50 percent and to reduce net healthcare costs by 14 percent.
Some may say it is not in scope for health systems to provide food for their patients. But the persistent long lines at food pantries and rise of community fridges are clear indications that we need more widespread solutions. As Congress has demonstrated by failing to renew Pandemic Unemployment Assistance, our government will not provide solutions anytime soon. Public assistance programs such as WIC, SNAP and school lunches are helpful but insufficient; eligibility and authorization requirements pose barriers to enrollment, particularly for immigrant populations.
Health systems are already increasingly harnessing available resources to tackle food insecurity for their communities. A trauma-informed food is medicine approach that has the power to transform our disease-oriented system into a health system; it’s time we fully embrace it.
Sarah Matathia, M.D., MPH, is a family practitioner at Massachusetts General Hospital and a Public Voices Fellow with The OpEd Project.