What Would It Take to Provide All People With Medically Supportive Food and Nutrition?

What Would It Take is a series of short-form, podcast-style recorded conversations with problem-solving change agents committed to putting science to work for society. 

This is a transcript of episode three in a pilot season focused on projects designed to improve health outcomes. It features Lisa Goldman Rosas of Stanford University’s Food for Health Equity Lab and SIL's Kate Green Tripp discussing the question What Would It Take to Provide All People with Medically Supportive Food and Nutrition?

We invite you to listen to the recorded conversation or read the transcript below.

Episode 3: Transcript

Kate Green Tripp: Welcome to episode three of What Would It Take?, a conversation series from Stanford Impact Labs designed to expose and explore what it looks like to tackle social problems with a solutions-focused orientation and a dedication to partnership. 

I'm your host, Kate Green Tripp, and this is episode three of four in a pilot series focused on projects designed to improve health outcomes.

Today, we are joined by Lisa Goldman Rosas, an assistant professor in the Department of Epidemiology and Population Health as well as the Department of Medicine at Stanford School of Medicine. An epidemiologist by training, Lisa's research focuses on addressing disparities in chronic disease. And as part of that, she pays particular attention to the role of food and nutrition.

Lisa leads Stanford's Food for Health Equity Lab, which strives to generate evidence that community health centers can use to improve people's nutrition and health.

Thank you for joining us, Lisa. It is a pleasure to speak with you today.

Lisa Goldman Rosas: Thanks so much for having me.

Kate: I'd love to start our conversation by establishing a definition. When we talk about medically supportive food and nutrition and/or the concept of food as medicine, what does that mean?

Lisa: Yeah, thank you for asking that. So the definition of food is medicine (food is medicine or food as medicine, people use those interchangeably) is the provision of healthy food and nutrition education to prevent, manage, or treat specific conditions in a way that's integrated into healthcare. So it's the integration between healthcare and nutrition.

Kate: And that is distinct from the notion of medically supportive food and nutrition?

Lisa: Yeah. So food as medicine is really an umbrella term that encompasses many different approaches to support healthy eating and food security to prevent, treat, or manage clinical conditions. And at the very base, we have nutrition education and referral to government programs that you might be familiar with, like SNAP or food stamps and WIC. But it also includes increasingly intensive approaches of supporting nutrition and food security, like, for example, medically supportive foods, which could be provision of healthy foods to support someone's health goals. 

It could also be a produce prescription, which is like medically supportive foods, but includes only produce. It could also be medically tailored meals, which would be prepared meals for patients who might benefit from having that additional support. So it's a whole range of interventions.

Kate: Thank you for that context. When we think about the need for medically supportive food and nutrition, what does the data suggest?

Lisa: Well, not meeting recommendations for healthy eating such as, for example, consumption of fresh fruits and vegetables is one of the leading risk factors for the major causes of mortality and morbidity in the United States and internationally. 

So most of the chronic conditions that are related to our diet (like heart disease, diabetes, some cancers) can be traced back to not meeting recommendations for healthy diet, and food as medicine is a recognition that within the health care sector we can do more to support people's health by focusing on nutrition, as opposed to downstream approaches such as medication and so on.

Kate: So I'm wondering if you can maybe share some particulars, whether that's numbers or anecdotes or just helpful ways to kind of visualize what becomes possible as more programs at the intersection of nutrition and health care evolve?

Lisa: Yeah, I mean, there's estimates that something like 90% of Americans are not meeting U.S. recommendations for a healthy diet. It's quite dramatic. And I think that the healthcare sector has really not been making efforts over the years. Physicians report not being trained in nutrition. Our healthcare system is really not set up to focus on prevention and management in that way. And when it's such a major risk factor, it's an incredible opportunity really to start focusing more on those upstream kind of risk factors.

Kate: So, Lisa, you're part of a team here at Stanford deeply immersed and thinking about this space. I'd love for you to tell us more about the Food for Health Equity Lab.

Lisa: Yes. Thanks for asking. So the Food for Health Equity Lab conducts research to produce evidence that community partners can use to implement food as medicine to address health disparities and nutrition related conditions like diabetes and cardiovascular disease. So we test a number of different models with different food partners and different populations in different health care settings to understand really what food as medicine programs work for what types of patients in what settings.

We primarily focus on patients who are disproportionately impacted by chronic conditions related to their nutrition, like diabetes, heart disease, and some cancers. And we partner with healthcare systems that serve that safety net.

Kate: And one of the models your lab looks at, evaluates, and works with is called a Recipe4Health. Is that right?

Lisa: Yes. One of the models we look at is called Recipe4Health, which is a produce prescription program. We have another model called Vida Sana y Completa, which looks at medically supportive food provided by a food bank partner. We have another program that combines fiber rich foods (which we think to be important for a number of conditions, including diabetes and heart disease) that includes produce and whole grains.

And we use a number of different partners. I mentioned the food bank, we also work with local farms, and we also work with the commercial sector like grocery delivery companies.

Kate: Wow. So lots of different approaches when it comes to getting the food and nutrition to the people who need it. Let's take a closer look at Recipe4Health.

Lisa: Sure. So Recipe4Health is one of the food as medicine approaches that we've been evaluating in our lab. 

Recipe4Health really includes three important ingredients. As you might imagine, we love analogies to food. So the first ingredient has to do with changing healthcare systems. Changing healthcare systems includes training of staff in food as medicine. It also requires resources like changes to the electronic health record to support workflows where physicians and healthcare staff can recognize food insecurity and needs for nutrition support and easily refer patients to get that kind of support. So once you have the healthcare system set up, the second ingredient is the food. And in this case, Recipe4Health relies on locally grown, organic, regeneratively grown produce from a local food partner, a farm actually—an urban farm.

Originally, before the pandemic, the idea was to set up farmer’s market style stands in health care clinics, and patients could access it that way. The pandemic forced us to pivot to something that we've actually sustained, which is weekly home deliveries of produce. So it gets delivered

12 weeks for patients who are referred, and they can repeat that if their physician thinks that it's necessary.

So the food is the second main ingredient and kind of the star of the show, but it couldn't happen without that first ingredient of setting up the healthcare system to be able to implement this. And then the third and final ingredient is what we call a behavioral pharmacy.

So whereas the food might be the food pharmacy, we know that patients need support to take that food and make it into meals and to also support their chronic care management and chronic disease management or other health care goals through support from health coaches and peers.

So the behavioral pharmacy can provide one-on-one coaching or group medical visits to help patients kind of translate the food as medicine into their health outcomes that we hope to see.

Kate: And is part of that intention that if the prescription for the food delivery element maybe sort of ends or gets to a place where it's no longer happening that way, folks can kind of continue this on their own.

Lisa: Absolutely. A lot of people ask us about sustainability: What happens after patients finish their produce prescription? And we really view that produce prescription as a window of opportunity to increase engagement with that patient and the healthcare system and to set that patient up to access long-term resources that can support their nutrition. 

So actually, we live in counties here in the Bay Area where patients are not utilizing important resources like food stamps or SNAP (here in California called Cal Fresh or WIC) for a number of reasons and helping patients to first access food and then get them set up to continue accessing that food when that prescription is over we have found to be an excellent way to promote healthy nutrition sustainably. 

One of my colleagues likes to call it: try it, like it, find it. So we give you kind of a risk-free opportunity to try some foods that maybe your budget wouldn't have allowed in the past and then help you to be able to find that food sustainably in your community, whether it's through using government resources or accessing the charitable food network.

Kate: Got it. So when it comes to reaching people, particularly at, as you say, the “try it” stage, how are you getting prescriptions into the hands of the people who need them?

Lisa: So I think that partnering with the healthcare system that’s serving patients at greatest need is one of the promising strategies that we've used in Recipe4Health. 

Recipe4Health partners with all the federally qualified health centers in their county to implement this program and reach patients who we think are at the greatest need. Those may be those patients who have a higher prevalence of food insecurity and are also disproportionately burdened by chronic conditions that are related to poor nutrition, such as diabetes and heart disease. Federally qualified health centers serve those patients and are excellent partners for implementing food as medicine.

Kate: And what blockers do you face? What are some of the challenges in trying to make Recipe4Health available?

Lisa: Yeah, so Recipe4Health is a produce prescription that's partially funded through the U.S. Department of Agriculture, which has also funded produce prescription programs across the country. Actually, using funding from Stanford Impact Labs, we were able to interview a wide swath of produce prescription programs in different geographies that serve different populations and have different role structures of how they do it to really get what are those barriers from implementing food as medicine.

And one thing we have found is that developing the partnerships between healthcare and the food system is time consuming, challenging, and largely unfunded by any policies or programs that are existing to support food as medicine today. And those can really be the key to success of making food as medicine work. If you don't have a strong partnership, providers can't refer patients and farms can't serve patients who really need it. And so we’ve seen that as a real major barrier.

Kate: That makes sense. 

So you've helped us kind of dial in and understand one model (Recipe4Health) and articulated some of the challenges. So if we think about more programmatic capacity to deliver medically supportive food and nutrition, in your view, what would it take? 

What would it take to provide all people with the food and nutrition they need?

Lisa: There are a number of things that we would need to be able to implement food as medicine more widespread. So one is we need to figure out how to connect all patients who need food with the correct food as medicine program. 

In many cases now, research is testing one food as medicine program for one type of patient. But healthcare systems don't only see one type of patient. Healthcare systems see a large variety of patients who have varied needs—and we need to be able to efficiently and quickly connect patients with their varied backgrounds and characteristics and resources for preparing foods with the right food as medicine program that can really help them meet their goals.

We need an efficient way of developing networks between health care systems and food systems that, you know, really serve to support the healthcare system efficiencies that they're looking for and also supporting local food systems. 

We've seen there's a lot of food partners who would love to take part in food as medicine. It's an excellent market for local agriculture, but oftentimes hard to make those partnerships work in a way that will be sustainable from an economic perspective for those farms.

I think there is a concern that food as medicine might drive the, you know, lowest price, lowest quality food if we don't pay attention to the local food environment and what's really needed there. So I think those are some of the things we would need to get in place. 

Clearly, you know, training of healthcare staff and physicians in food as medicine is really critical to sustaining this support for the health education that needs to happen, that patients need to turn food into meals and healthy behaviors over the long term – also really important.

Kate: Lisa, thank you so much for being here today. It was a pleasure to speak with you.

Lisa: Thank you. I really enjoyed it.

Kate: Thanks for listening to What Would It Take, a conversation series from Stanford Impact Labs. To learn more about Stanford Impact Labs and how we partner with communities to put social science to work for society, please visit impact.stanford.edu.