Symposium 28: Designing, Implementing, and Evaluating Food is Medicine Interventions to Inform Policy and Promote Health Equity

Designing, Implementing, and Evaluating Food is Medicine Interventions to Inform Policy and Promote Health Equity
Symposium Chair: Lisa G Rosas
Symposium discussant: Amy Yaroch
Overall abstract

The purpose of this symposium is to share best practices and lessons learned in designing, implementing, evaluating, and scaling Food is Medicine interventions in diverse communities and contexts to inform policy and promote health equity. The landmark White House Conference on Hunger, Nutrition, and Health in September 2022 underscored the urgency of improving food and nutrition security in the US as a fundamental strategy for promoting health equity. Profound and persistent disparities in food access exist across social groups including by race/ethnicity and income among others. Food insecurity disproportionately impacts Black (22%), Latinx (21%) households compared to non-Latinx white (9%) households. Food insecurity directly leads to poor diet quality, which is a significant contributor to the leading causes of mortality and morbidity in the US such as cancer, heart disease, and diabetes. Furthermore, diet-sensitive chronic conditions disproportionately impact the same demographic groups who are most likely to experience food insecurity. For example, nationwide, 12% of Black and Latinx adults have been diagnosed with diabetes, compared to 7% of non-Latinx white adults. To address the interrelated challenges of food and nutrition insecurity and health equity, healthcare organizations are increasingly turning to Food is Medicine, the integration of food-based nutrition interventions with healthcare to prevent, manage, and treat diet-sensitive chronic conditions and address food insecurity. Despite their proliferation, promise for improving health outcomes, and support from the current administration, there remain significant opportunity to apply behavioral science principles to the design and implementation of Food is Medicine interventions as well as research methods to support rigorous and community-centered evaluations of effectiveness. Additionally, it is critical to work closely with policymakers to ensure that research can inform the rapidly changing policy landscape with respect to Food is Medicine. In this symposium, researchers will share their extensive experience designing, implementing, and evaluating Food is Medicine interventions in diverse communities. Additionally, a policy expert will share their vision for how Food is Medicine can build on existing research and scaled across diverse geographies and populations. The goal is for attendees to use this information to advance the science of Food is Medicine with a behavioral medicine lens to inform policy.

Individual abstracts:

Abstract 1: Lessons Learned from Developing, Implementing, and Evaluating Food is Medicine Interventions Across Diverse Communities and Geographies
Marcela Radtke, Wei-ting Chen, Lisa G. Rosas


Food is Medicine (FIM) is an emerging strategy to prevent, manage, and treat diet-sensitive chronic diseases, such as obesity, cardiovascular disease, and type 2 diabetes, by incorporating nutrition and behavioral lifestyle interventions into existing healthcare infrastructure. The prevalence of diet-sensitive chronic diseases disproportionately impacts underrepresented and low-income populations, highlighting the importance of developing, implementing, and evaluating FIM for diverse populations. The Food for Health Equity Lab at Stanford University School of Medicine has conducted several multicomponent FIM interventions, including produce prescriptions and medically supportive groceries, in conjunction with behavioral lifestyle programming, in diverse patient populations. The study designs have included qualitative formative research, one-arm pilot studies, quasi-experimental with propensity score matching, and large randomized controlled trials to assess the effectiveness of various FIM implementation strategies across different populations and geographies. The FIM interventions feature various food partners, such as food banks, local farms, and commercial providers. The patient populations have varied from primary care patients with diverse clinical, demographic, and socioeconomic characteristics. Lessons learned include those for developing FIM interventions and conducting research to evaluate these approaches:
Development: Dedicate time and resources to sustaining community-academic partnerships; engage patients in developing FIM interventions that are culturally tailored to the population’s needs; integrate evidence-based behavioral intervention to support behavior change; support and grow the local food environment; build an intervention team that reflects the population served
Evaluation: Embrace the advantages of real-world data for generating evidence of community-based programs; consider creative options for control groups such as active treatment and wait list controls; offer flexible data collection options like videoconference and home visits; ensure evaluation meets the needs of community partners
During this presentation, additional lessons learned and best practices in the development, implementation, and evaluation of various FIM implementation models will be shared to support the central to the goal of scaling and sustaining FIM interventions for long term health equity.


Abstract 2: Harnessing the Power of Food as Medicine: The Food and Resources Expanded to Support Health and Type 2 Diabetes (FRESH-T2D) Study
Melanie Hingle, Douglas Taren, Denise Roe, Rob Blew, Holly Bryant, Joy Mockbee, Chad Stecher, Sarah Cohen, Emily Diana, Nicole Peña

Food insecurity, poor nutrition, and economic disadvantage are critical social determinants of health that contribute to disparities in type 2 diabetes mellitus (T2DM). The goal of the Food and Resources Expanded to Support Health and Type 2 Diabetes (FRESH-T2DM) is to test whether an intervention designed to improve food and nutrition security among low-income persons with T2DM is feasibly delivered by personnel at Federally Qualified Health Centers (FQHCs), acceptable to patients seeking care in the medical home, and capable of producing clinically relevant changes in T2DM endpoints. The 12-month randomized wait-list controlled study recruited 60 adult FQHC patients with T2DM to receive a 6-month intervention consisting of bimonthly high-fiber, low-refined carbohydrate food packages, recipes, and diabetes self-management education resources. Participants additionally received up to four, 30-minute visits with an FQHC Registered Dietitian Nutritionist and Certified Diabetes Educator. Measurements (food and nutrition security, diet quality, hemoglobin A1c) were conducted at baseline, 3 months, 6 months, 9 months, and 12 months by trained researchers. Health care utilization data were obtained from State Medicaid claims data. FRESH-T2DM was created through an ongoing research collaboration with an FQHC serving >120,000 low-income patients in Tucson, Arizona, and the Community Food Bank of Southern Arizona, a regional food bank serving 200,000 Arizonans across 5 counties. Expected outcomes include an understanding of intervention dose relative to diabetes outcomes; potential for cost recovery of FQHC time and resources; and healthcare utilization as a function of intervention participation, including types of healthcare encounters and prescription use. Our long-term goal is to produce a tested, efficacious model of coordinated care capable of replication and scaling across other FQHCs and food bank networks.

Abstract 3: Scaling Food is Medicine Across Geographies and Populations

Katie Ettman, Katie Panarella, Wei-ting Chen, Christy Lau, Lisa G. Rosas

Background: To support the implementation of Food is Medicine, some US states (e.g., California, Massachusetts) have implemented 1115/1915(b) Medicaid waivers that allow reimbursement for medically supportive food and nutrition services (e.g. medically-tailored meals, produce prescriptions), for Medicaid beneficiaries. However, there has been very low uptake of this opportunity for providing Food is Medicine among the populations that need it most. Our community-university partnership came together to address this under-utilization and support the successful scaling of Food is Medicine.
Methods: We formed a community-university partnership that included researchers with experience in Food is Medicine, healthcare payors, policy experts, and social care organizations. The partnership identified key program partners and convened a ‘Food is Medicine Network’ that directly overcomes the challenges with widespread implementation and scaling. The Food is Medicine Network receives referrals from healthcare organizations, identifies the appropriate Food as Medicine program (e.g., medically tailored meals, medically tailored groceries, produce prescription), connects patients with the food organization that provides that program, and processes the reimbursement from the indicated health plan.
Results: The community-university partnership identified key challenges to scaling Food is Medicine including making referrals easy, establishing partnerships with diverse food organizations that can support the diversity of patient needs, establishing clinical guidelines for Food is Medicine, and processing Medicaid reimbursements. To address these challenges we conducted a series of workshops to establish a Food is Medicine Network of providers. We also conducted an adapted Delphi process with a panel of 12 experts to establish clinical guidelines for matching patients to the best fit Food is Medicine intervention. Finally, we identified a lead entity for the network that could receive patient referrals from multiple healthcare organizations, connect patients with diverse Food is Medicine programs, and process the reimbursement with Medicaid.
Conclusions: Establishing a Food is Medicine network requires engaging diverse stakeholders including healthcare, food organizations, and healthcare payors. Identifying a lead entity that can receive referrals is a key feature of the network because this overcomes many of the challenges of scaling.

Chair - Lisa Goldman Rosas PhD, MPH, FSBM  Student
Stanford University School of Medicine

Discussant - Amy Yaroch PhD, FSBM  Student
Gretchen Swanson Center for Nutrition

Presenter - Marcela Radtke PhD  Student
Stanford University School of Medicine

Presenter - Melanie Hingle PhD, MPH, RDN  Student
University of Arizona

Presenter - Katie Ettman MPA  Student
Fullwell

Designing, Implementing, and Evaluating Food is Medicine Interventions to Inform Policy and Promote Health Equity
Symposium Chair: Lisa G Rosas
Symposium discussant: Amy Yaroch
Overall abstract

The purpose of this symposium is to share best practices and lessons learned in designing, implementing, evaluating, and scaling Food is Medicine interventions in diverse communities and contexts to inform policy and promote health equity. The landmark White House Conference on Hunger, Nutrition, and Health in September 2022 underscored the urgency of improving food and nutrition security in the US as a fundamental strategy for promoting health equity. Profound and persistent disparities in food access exist across social groups including by race/ethnicity and income among others. Food insecurity disproportionately impacts Black (22%), Latinx (21%) households compared to non-Latinx white (9%) households. Food insecurity directly leads to poor diet quality, which is a significant contributor to the leading causes of mortality and morbidity in the US such as cancer, heart disease, and diabetes. Furthermore, diet-sensitive chronic conditions disproportionately impact the same demographic groups who are most likely to experience food insecurity. For example, nationwide, 12% of Black and Latinx adults have been diagnosed with diabetes, compared to 7% of non-Latinx white adults. To address the interrelated challenges of food and nutrition insecurity and health equity, healthcare organizations are increasingly turning to Food is Medicine, the integration of food-based nutrition interventions with healthcare to prevent, manage, and treat diet-sensitive chronic conditions and address food insecurity. Despite their proliferation, promise for improving health outcomes, and support from the current administration, there remain significant opportunity to apply behavioral science principles to the design and implementation of Food is Medicine interventions as well as research methods to support rigorous and community-centered evaluations of effectiveness. Additionally, it is critical to work closely with policymakers to ensure that research can inform the rapidly changing policy landscape with respect to Food is Medicine. In this symposium, researchers will share their extensive experience designing, implementing, and evaluating Food is Medicine interventions in diverse communities. Additionally, a policy expert will share their vision for how Food is Medicine can build on existing research and scaled across diverse geographies and populations. The goal is for attendees to use this information to advance the science of Food is Medicine with a behavioral medicine lens to inform policy.

Individual abstracts:

Abstract 1: Lessons Learned from Developing, Implementing, and Evaluating Food is Medicine Interventions Across Diverse Communities and Geographies
Marcela Radtke, Wei-ting Chen, Lisa G. Rosas


Food is Medicine (FIM) is an emerging strategy to prevent, manage, and treat diet-sensitive chronic diseases, such as obesity, cardiovascular disease, and type 2 diabetes, by incorporating nutrition and behavioral lifestyle interventions into existing healthcare infrastructure. The prevalence of diet-sensitive chronic diseases disproportionately impacts underrepresented and low-income populations, highlighting the importance of developing, implementing, and evaluating FIM for diverse populations. The Food for Health Equity Lab at Stanford University School of Medicine has conducted several multicomponent FIM interventions, including produce prescriptions and medically supportive groceries, in conjunction with behavioral lifestyle programming, in diverse patient populations. The study designs have included qualitative formative research, one-arm pilot studies, quasi-experimental with propensity score matching, and large randomized controlled trials to assess the effectiveness of various FIM implementation strategies across different populations and geographies. The FIM interventions feature various food partners, such as food banks, local farms, and commercial providers. The patient populations have varied from primary care patients with diverse clinical, demographic, and socioeconomic characteristics. Lessons learned include those for developing FIM interventions and conducting research to evaluate these approaches:
Development: Dedicate time and resources to sustaining community-academic partnerships; engage patients in developing FIM interventions that are culturally tailored to the population’s needs; integrate evidence-based behavioral intervention to support behavior change; support and grow the local food environment; build an intervention team that reflects the population served
Evaluation: Embrace the advantages of real-world data for generating evidence of community-based programs; consider creative options for control groups such as active treatment and wait list controls; offer flexible data collection options like videoconference and home visits; ensure evaluation meets the needs of community partners
During this presentation, additional lessons learned and best practices in the development, implementation, and evaluation of various FIM implementation models will be shared to support the central to the goal of scaling and sustaining FIM interventions for long term health equity.


Abstract 2: Harnessing the Power of Food as Medicine: The Food and Resources Expanded to Support Health and Type 2 Diabetes (FRESH-T2D) Study
Melanie Hingle, Douglas Taren, Denise Roe, Rob Blew, Holly Bryant, Joy Mockbee, Chad Stecher, Sarah Cohen, Emily Diana, Nicole Peña

Food insecurity, poor nutrition, and economic disadvantage are critical social determinants of health that contribute to disparities in type 2 diabetes mellitus (T2DM). The goal of the Food and Resources Expanded to Support Health and Type 2 Diabetes (FRESH-T2DM) is to test whether an intervention designed to improve food and nutrition security among low-income persons with T2DM is feasibly delivered by personnel at Federally Qualified Health Centers (FQHCs), acceptable to patients seeking care in the medical home, and capable of producing clinically relevant changes in T2DM endpoints. The 12-month randomized wait-list controlled study recruited 60 adult FQHC patients with T2DM to receive a 6-month intervention consisting of bimonthly high-fiber, low-refined carbohydrate food packages, recipes, and diabetes self-management education resources. Participants additionally received up to four, 30-minute visits with an FQHC Registered Dietitian Nutritionist and Certified Diabetes Educator. Measurements (food and nutrition security, diet quality, hemoglobin A1c) were conducted at baseline, 3 months, 6 months, 9 months, and 12 months by trained researchers. Health care utilization data were obtained from State Medicaid claims data. FRESH-T2DM was created through an ongoing research collaboration with an FQHC serving >120,000 low-income patients in Tucson, Arizona, and the Community Food Bank of Southern Arizona, a regional food bank serving 200,000 Arizonans across 5 counties. Expected outcomes include an understanding of intervention dose relative to diabetes outcomes; potential for cost recovery of FQHC time and resources; and healthcare utilization as a function of intervention participation, including types of healthcare encounters and prescription use. Our long-term goal is to produce a tested, efficacious model of coordinated care capable of replication and scaling across other FQHCs and food bank networks.

Abstract 3: Scaling Food is Medicine Across Geographies and Populations

Katie Ettman, Katie Panarella, Wei-ting Chen, Christy Lau, Lisa G. Rosas

Background: To support the implementation of Food is Medicine, some US states (e.g., California, Massachusetts) have implemented 1115/1915(b) Medicaid waivers that allow reimbursement for medically supportive food and nutrition services (e.g. medically-tailored meals, produce prescriptions), for Medicaid beneficiaries. However, there has been very low uptake of this opportunity for providing Food is Medicine among the populations that need it most. Our community-university partnership came together to address this under-utilization and support the successful scaling of Food is Medicine.
Methods: We formed a community-university partnership that included researchers with experience in Food is Medicine, healthcare payors, policy experts, and social care organizations. The partnership identified key program partners and convened a ‘Food is Medicine Network’ that directly overcomes the challenges with widespread implementation and scaling. The Food is Medicine Network receives referrals from healthcare organizations, identifies the appropriate Food as Medicine program (e.g., medically tailored meals, medically tailored groceries, produce prescription), connects patients with the food organization that provides that program, and processes the reimbursement from the indicated health plan.
Results: The community-university partnership identified key challenges to scaling Food is Medicine including making referrals easy, establishing partnerships with diverse food organizations that can support the diversity of patient needs, establishing clinical guidelines for Food is Medicine, and processing Medicaid reimbursements. To address these challenges we conducted a series of workshops to establish a Food is Medicine Network of providers. We also conducted an adapted Delphi process with a panel of 12 experts to establish clinical guidelines for matching patients to the best fit Food is Medicine intervention. Finally, we identified a lead entity for the network that could receive patient referrals from multiple healthcare organizations, connect patients with diverse Food is Medicine programs, and process the reimbursement with Medicaid.
Conclusions: Establishing a Food is Medicine network requires engaging diverse stakeholders including healthcare, food organizations, and healthcare payors. Identifying a lead entity that can receive referrals is a key feature of the network because this overcomes many of the challenges of scaling.

Chair - Lisa Goldman Rosas, PhD, MPH, FSBM, PhD, MPH, FSBM,
Stanford University School of Medicine

Discussant - Amy L. Yaroch, PhD, FSBM, PhD, FSBM,
Gretchen Swanson Center for Nutrition

Presenter - Marcela D. Radtke, PhD, PhD,
Stanford University School of Medicine

Presenter - Melanie D. Hingle, PhD, MPH, RDN, PhD, MPH, RDN,
University of Arizona

Presenter - Katie Ettman, MPA,
Fullwell