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Take Two Carrots and Call Me in the Morning

Originally published by Stateline for Pew Charitable Trust on September 7, 2018. Written by Marsha Mercer.

Half a century after Americans began fighting hunger with monthly food stamps, the nation’s physicians and policymakers are focusing more than ever on what’s on each person’s plate.

In the 21st century, food is seen as medicine — and a tool to cut health care costs.

The “food is medicine” concept is simple: If chronically ill people eat a nutritious diet, they’ll need fewer medications, emergency room visits and hospital readmissions.

The food is medicine spectrum ranges from simply encouraging people to plant a garden and learn to cook healthfully, as state Sen. Judy Lee, a Republican, does in North Dakota — “We don’t do policies about gardening,” she said — to an intensive California pilot project that delivers two medically tailored meals plus snacks daily and offers three counseling sessions with a registered dietitian over 12 weeks.

The California Legislature last year became the first in the nation to fund a large-scale pilot project to test food is medicine. The three-year, $6 million project launched in April will serve about a thousand patients with congestive heart failure in seven counties.

“The state puts a huge amount of money into health care, and one of the biggest costs is medication,” Assemblyman Phil Ting, a Democrat and chairman of the Assembly Budget Committee, said in an interview. “So the hope is people will live longer and this project will also reduce the need for medication.”

The food is medicine concept has been around for a while. Since the 1980s, nonprofits such as Project Open Hand in San Francisco, Community Servings in Boston, God’s Love We Deliver in New York and MANNA or Metropolitan Area Neighborhood Nutrition Alliance in Philadelphia have provided medically tailored meals for patients with HIV, diabetes, cancer and heart disease. They are largely funded by donations and grants.

Seeing the programs’ successes, some states are taking a larger role. Massachusetts is developing a food is medicine plan with a goal of integrating programs scattered around the state so more residents can benefit. Legislative policy proposals are expected next spring.

Food is medicine goes beyond traditional advice to eat more fruits and vegetables. Projects pay for people to purchase produce and offer nutrition counseling and cooking classes, so they’ll know which foods to choose or avoid and how to prepare them. For example, watermelon is healthy for some, but not for a diabetic.  

On the local level, a community garden managed by a teenager in Sylvester, Georgia, aims — with the help of the local hospital — to improve the health of the town in the nation’s “stroke belt.”

Physicians in a dozen states write “prescriptions” for fruits and vegetables at farmers markets and groceries — scripts that can be exchanged for tokens to buy produce.

“Food is medicine is an idea whose day has arrived,” said Robert Greenwald, faculty director of the Harvard Law School’s Center for Health Law and Policy Innovation, one of the experts who testified in January at the launch of the congressional Food is Medicine Working Group, part of the House Hunger Caucus.

The Senate version of the farm bill includes Harvesting Health, a pilot project to test fruit-and-vegetable prescriptions. It’s modeled on work by Wholesome Wave, a Bridgeport, Connecticut, nonprofit that works with health centers in a dozen states where doctors write prescriptions for produce.

If enacted, the federal government would spend $20 million over five years on grants to states or nonprofits to provide fruits and vegetables and nutrition education to low-income patients with diet-related conditions.

The Supplemental Nutrition Assistance Program, the food stamp program known as SNAP, helps reduce food insecurity for 39.6 million participants, but studies do not show SNAP improves nutrition. Instead, there seems to be a correlation between long-term food stamp participation and excess weight gain.

Poor diet was No. 1 of 17 leading risk factors for death in the United States in 2016 — a higher risk than smoking, drug use, lack of exercise and other factors, according to “The State of US Health,” a comprehensive report by a team of academics published in the Journal of the American Medical Association in April.

Dr. Kumara Sidhartha, an internal medicine specialist and medical director at Emerald Physicians on Cape Cod, Massachusetts, conducted a prescription study with Medicaid participants in 2016 and 2017. In his study, he wrote prescriptions or vouchers for one group to buy $30 in produce a week at the farmers market, and gave another $30 in gasoline vouchers a week — for 12 weeks. Both groups received cooking classes and nutrition counseling.

Twenty-four people completed the program, and those who received the fruit and vegetable prescriptions showed improvements in risk factors for chronic disease — better body mass index, total blood cholesterol, LDL cholesterol, blood glucose and hemoglobin A1c, Sidhartha said.

“Patients and physicians are so used to the physician writing prescriptions for procedures and pills,” he said. “This changes the health care culture of how the prescription is used.”  

Proponents of the California project hope it will demonstrate the cost-effectiveness of including medically tailored meals as an essential health benefit covered by Medi-Cal, California’s Medicaid program.

“This is potentially transformative because the health care system has been designed to cover acute services, and not many prevention programs are covered,” said Dr. Hilary Seligman, an associate professor at the University of California-San Francisco, one of two physician researchers who will evaluate the project by tracking participants’ medical records.

“For someone with congestive heart failure, their lives depend on their capacity to eat a lower salt diet,” Seligman said. “Making the food as appealing as possible is very important.”

Some legislators are skeptical about government moving into new food delivery systems.

“We need to feed the children who are hungry now. We need the backpack programs in school, the free and reduced-price breakfast and lunches to make sure that nobody is hungry today,” said North Dakota’s Lee, chairwoman of the state Senate Human Services Committee, at a food is medicine session at the National Conference of State Legislatures (NCSL) Hunger Partnership conference in July.

“But then we need to take those same children and help them learn how to do those things for themselves,” Lee said. “Let’s have a short-term solution: Let’s feed people. And then let’s have a longer-term solution: Help them feed themselves.”

Everyone in her state could have a garden, even apartment-dwellers, and they can learn to cook, she said, adding that cooking is a skill that’s been lost since schools there dropped home economics.

“Kids can learn and a parent can learn how to make a meal,” Lee said in an interview. “I’d rather figure out a way to give them cooking lessons with food. We’re not helping children become functional adults by giving them three meals a day.”

It’s not government’s job to provide every meal, she said, adding, “That’s the good news about North Dakota, compared with the Northeast and California.” 

Georgia state Sen. Renee Unterman, a Republican and chairwoman of the state Senate Health and Human Services Committee and co-chairwoman of the NCSL hunger partnership, suggested at the food is medicine session that a community garden with a medical purpose in her state — and started by a child — could be a model.


Village Community Garden manager Janya Green was 12 when she started on the community garden as her 4-H Club project three years ago on 5 acres donated by the town of Sylvester, population 6,000, about 170 miles south of Atlanta. Anyone can pick free vegetables and fruit whenever they like. The garden features cabbage, carrots, kale, okra, bell peppers, squash, sweet potatoes, blackberries, blueberries, muscadine grapes and even bananas. Herbs are next.

A pond is stocked with fish, so residents can reel in healthy protein as well. A local county commissioner gave lumber for a 20- by 60-foot stage.

Phoebe Worth Medical Center installed an outdoor kitchen in the garden for chef-taught cooking classes. Darrell Sabbs, governmental affairs specialist at the medical center, hopes researchers from Emory University or the University of Georgia will study the health statistics of the neighborhood and gauge the garden’s health effects.

Dr. Marilyn Carter, an internal medicine physician who also trained as a pharmacist, lives in Sylvester and volunteers at the garden. She and a nutritionist wrote up health benefits of the produce for signs that will help people make smart choices.

“We’re in the stroke belt,” Carter pointed out, adding that many of her patients have heart disease and diabetes. People eat a typical Southern diet of fried foods and foods out of boxes that are high calorie and high fat, she said.

“I want people to know, ‘If I eat more kale and less white rice, my blood pressure will be better,’” she said. Her name for the garden: the Farmacy.

Food Access, Nutrition And Public Health In The Senate Farm Bill

The Senate released its draft of the 2018 Farm Bill on Friday, June 8th. This post analyzes how the Senate Farm Bill addresses FBLE’s goals and recommendations from its report, Food Access, Nutrition, and Public Health. The Senate Agriculture Committee moved the Agriculture Improvement Act of 2018 (S. 3042) out of committee on June 13th. The Senate is voting on S. 3042 this week.  


Protecting and Strengthening SNAP

Maintain SNAP’s Ability to Adapt to Changes in the Economic


The Agriculture Improvement Act of 2018 preserves the Supplemental Nutrition Assistance Program (SNAP) in its current form. By leaving the nation’s key anti-hunger program largely unchanged, SNAP will continue to serve those low-income Americans who are currently eligible to receive benefits. Specifically, in contrast to the farm bill that passed the House last week, S. 3042 would not expand work requirements for SNAP. Although FBLE recommends eliminating all work requirements that apply to “able-bodied adults without dependents” (ABAWDs) between the ages of 18-49, the Senate bill avoids putting SNAP even further out of reach for those who rely on it.  

FBLE is optimistic that additional provision in the Nutrition title will begin to address disparities between states in the quantity and quality of employment and training programs. The 2014 Farm Bill included SNAP Employment and Training (SNAP E&T) operation requirements for states surrounding job searches for unemployed individuals. The Senate bill will enhance these operations by allowing states to continue using effective SNAP E&T pilots that were authorized in the 2014 Farm Bill. Further, the Senate bill modifies the current SNAP E&T operations. These modifications to the work-related pilot projects are meant to meet the needs of individuals who are seeking work but face barriers to employment such as physical condition and personal situation when applying for a job. The Senate bill provides $185 million in addition funding to serve individuals who are struggling with barriers to employment for each fiscal year from 2019-2020. These programs are meant to assist in combating these barriers, but participation in work programs are not tied to receipt of benefits.

Enhance and Improve SNAP to Address Food Insecurity,

Revitalize Local Economies, Improve Access and

Efficiency Through Technology, and Remove Ineffective Barriers

to Food Access

While S. 3042 makes no cuts to SNAP, neither does it strengthen the program’s ability to meet its core responsibility of providing access to an adequate diet. For example, the bill does not follow FBLE’s recommendation to raise benefit levels, which currently are insufficient to meet beneficiaries diet and health needs.

However, the bill does take some steps toward utilizing technology tools to help SNAP participants. One issue SNAP applicants have is that SNAP is an income-based eligibility program. This leads to many beneficiaries having a difficult time proving their income and receiving their benefits. These challenges often result in people losing benefits, extended cost the government, and other confusion.

However, the S. 3042 takes steps to ease the barriers to entry for SNAP, by promoting cost effective and more efficient tools to verify earned  household or individual income for those receiving SNAP benefits. Further, the Senate bill instructs the USDA to allow Electronic Benefit Transfer (EBT) at farmers’ markets so that  SNAP participants can redeem benefits at multiple locations and support local food options. In its’ current form the current EBT system is often unreliable and is not always available for participants to use, therefore preventing people from getting the food they need.

Improving Public Health and Access to Nutritious Foods

Strengthen Food Assistance Programs that Promote Healthy

Choices among SNAP Participants

FBLE supports the Senior Farmers Market Nutrition Program (“SFMNP”), which awards states grants in order to provide vouchers to low-income seniors so that they can purchase foods (fruits, vegetables, honey, and fresh cut herbs) at farmers’ markets, roadside stands, and CSAs. S. 3042 would reauthorize SFMNP with $20.6 million per year in funding. Although the bill does not devote additional resources to the program, the bill would also ease the paperwork and office visit requirements on participants who are seniors or people with disabilities. This aligns with FBLE’s recommendation to strengthen SFMNP by helping to ensure that seniors receive assistance that can improve their access and health.  

FBLE also support the Food Insecurity Nutrition Incentive Program (“FINI”), which is currently a grant program that funds projects that aim to increase the amount of fruits and vegetables SNAP recipients purchase. FINI has been renamed “The Gus Schumacher Food Insecurity Nutrition Incentive Program.” FINI has been successful which led to its reauthorization and increased funding of $50 million per year, which is more than double the $100 million FINI received over the previous five years combined. FINI has also been authorized as a mandatory permanent program. This supports FBLE’s mission to devote additional resources to this program and ensure that low-income households are able to purchase nutritious food.

However, FINI is not everywhere and there needs to be improvements to the information and technology sharing across various FINI projects. FINI is often used as a pharmacy programs in states and is also used on other programs that are straight incentives for fruits and vegetables not tied to the healthcare system in any way directly.

Improve Health Outcomes of Low-Income Individuals Living with

Serious Diseases by Establishing a Food is medicine Pilot

In a farm bill first, S. 3042 embraces the concept of “Food is Medicine.” Food is Medicine describes the provision of nutritious food tailored to the medical needs of an individual who lives with one or more health conditions likely to be affected by diet, such as diabetes, heart disease, certain cancers, and HIV.

FBLE’s proposes a Food is Medicine pilot program that supports and evaluates using medically-tailored meals to support the health of low-income individuals living with diseases. The Harvesting Health Pilot Program is a positive initial effort to connect low-income patients with fresh fruits and vegetables. However, this pilot does not provide meals or other types of food, and therefore is too narrow. A recent study found that a 16% net reduction in monthly healthcare spending for individuals receiving home delivery of medically tailored meals.

The Senate bill does not adopt FBLE’s approach, but takes a first step by creating the Harvesting Health Pilot Program, a $4 million program that receives funding each year and will be administered from 2019-2023. Under the program, the Produce Prescription Pilot will provide fresh fruits and vegetables to members through financial/non-financial incentives in order for members to purchase/procure fresh fruits and vegetables.

Eligibility for the program includes nonprofit organizations or state or units of local government. Further these groups are required to partner and involve a Health Care Program (hospitals, FQHC, healthcare provider groups, VA clinic) in the development of their “produce prescription” effort. In order to receive benefits, individuals must be receiving benefits from SNAP, Medicaid, or be a member of a low-income household that suffers from, or risks developing “a diet-related health condition.” There is also a broad requirement for members to provide educational resources on nutrition to members who receive benefits.

Evaluation and administration provides data to support the long term success of Food is Medicine initiatives. FBLE recommends “rigorously evaluation” of any Food is Medicine pilot program, which probably requires an amount greater than the 10% cap on program evaluation allowed by the Harvesting Health pilot.

Looking Ahead

Overall, S. 3042 is a bipartisan effort that rejects the partisan approach taken by the House bill and aligns much more closely to FBLE’s Food Access, Nutrition, and Public Health recommendations. In fact, the bill takes important steps forward by including pilot programs that continue to assist low-income and sick individuals. Moving forward, protecting the scope and scale of the food safety net will be a contentious issue as the Senate bill passes and the farm bill process moves into conference committee, where differences between the House and Senate versions will be negotiated. FBLE will be watching the process closely, so stay tuned.

Improving Health Outcomes While Curbing Costs with Medically Tailored Meals


On May 9th, 2018, CHLPI, the Food is Medicine Coalition, Tufts Friedman School of Nutrition Science & Policy, and the House Hunger Caucus’ Food is Medicine Working Group, brought together an expert panel for a discussion on improving health outcomes and curbing costs with medically tailored meals.


Health and food are fundamentally linked. For people who are living with chronic illnesses, or have critical medical conditions, nutritious food is essential to maintaining and regaining health. Congressman Jim McGovern of Massachusetts, a founding member of the Food is Medicine Working Group, opened the briefing by addressing the nation’s lack of a comprehensive-coverage of medically tailored food and nutrition within healthcare. The Ryan White HIV/AIDs program is the only federally funded program for medically tailored meals. “The support through the program has enabled organizations across the country, like God’s Love

We Deliver in New York City and Community Servings in my home state of Massachusetts, to carry out their missions of providing nutritious food to those in need,” said McGovern. “Now the organization is serving a much broader population and federal funding should reflect that.”  McGovern hoped that leaders of the working group are able to “think concretely about what we could do at a federal level to advance this cause.”

Noting that 5% of the Medicaid population consume roughly 50% of healthcare costs, the briefing brought food and nutrition to the center of the conversation about healthcare delivery and financing. In an environment of rising healthcare costs and tight budgets, expert panelists discussed how an integration of medically tailored meals into public and private health insurances will not only improve health outcomes but also significantly reduce healthcare costs.

 Our Food:  The #1 Cause of Poor Health


“Food is the single biggest cause for poor health in the U.S.,” said Dr. Dariush Mozaffarian, Dean of Tufts Friedman School of Nutrition Science & Policy. Diet-related diseases, such as cardiovascular diseases and type 2 diabetes, can each cost up to $300 billion per year in direct health care, causing enormous economic burdens. Healthy and appropriate medically tailored food can not only prevent these fatal diet-related medical conditions but also substantially reduce the amount of dollars spent on healthcare each year.

Karen Pearl, President & CEO of God’s Love We Deliver, defined medically tailored meals (MTMs) as a highly specialized healthcare intervention that is managed by a Registered Dietary Nutritionist (RDN) and designed based on evidence-based practice guidelines to address specific complex health conditions of the individual. God’s Love We Deliver has served 1.8 million medically tailored meals per year to seven thousand people in the state of New York. “Nutrition has the ability to fight disease and help people dealing with life threatening illnesses,” said Pearl. “You can feed somebody medically tailored meal for a half of a year for the price of the night in a hospital.”

A recent-released study conducted by Dr. Seth Berkowitz, Assistant Professor of Medicine at the University of North Carolina School of Medicine, demonstrated strong positive results for high healthcare utilizing participants who received medically tailored meal intervention. Dr. Berkowitz reported that over an average of 18 months of follow-up, participants showed a decrease of 70% in emergency department use, a 50% cut in hospitalization rates, and a reduction of $220 in healthcare costs per month.

Bill George, President & CEO of Health Partners Plans, shared similar results from a program for diabetic patients who received Medical Nutrition Therapy in the form of medically tailored meals. Patients who received medically tailored meals three times a day, seven days a week for six to 18 weeks experienced a reduction of 19% in medical costs per month, as well as decreases in inpatient admission and emergency room visits by 26% and 7%, respectively. “We’re here to advocate that Food is Medicine become supported by the federal government,” said George. “But more largely, what I’m trying to advocate is for people to realize that traditional ways of managing medical conditions don’t always work, because of social determinants of health.”

For medically-complicated individuals, simply providing resources to purchase food may not be enough. Medically tailored meals can fill the gap in existing interventions for those who require a more complex healthcare delivery system. Food and nutrition innovation is essential for the future of healthcare. The inclusion of a comprehensive-coverage of medically tailored meals at the federal level maximizes opportunities to meet the needs of people living with severe medical conditions, lower healthcare costs, and improve health outcomes.

Robert Greenwald, Faculty Director of Harvard Law School’s Center of Health Law and Policy Innovation, outlined key measures that Congress must take to transform the healthcare delivery system. For example, Congress must urge the Centers for Medicare and Medicaid Services (CMS) to test the impacts of medically tailored meal on Medicare and Medicaid by launching a rigorous demonstration program. Additionally, Congress must clarify and expand Medicare and Medicaid coverage of medically tailored meals to alleviate the suffering of people living with chronic illnesses.

“For people living with chronic and serious health conditions, what should be clear is that health and food are inextricably linked,” said Greenwald. “For those people that have chronic and serious health conditions, unhealthy and inappropriate food is poison. Medically tailored meals, on the other hand, are food is medicine.”

CHLPI will work with Congressman McGovern and other congressional champions to advance the integration of medically tailored food nutrition into healthcare. Please check back for updates and watch the Briefing here!


Food is Medicine: Addressing Hunger as a Health Issue

On January 17, 2018, CHLPI’s Faculty Director, Robert Greenwald, spoke at the Food is Medicine: Addressing Hunger as a Health Issue panel discussion. The briefing kicked off the launch of a new bipartisan Food is Medicine Working Group within the House Hunger Caucus.

For over a decade, the bipartisan Hunger Caucus has served as a forum for Members and staff to discuss, advance, and engage the House’s work on national and international hunger and food insecurity issues. This year the Caucus builds upon its foundation
to bring into focus the impacts of hunger on our nation’s health. 


The event’s panel included:

  • Dariush Mozaffarian, MD, DrPH
    Dean, Tufts Friedman School of Nutrition Science & Policy; Jean Mayer Professor of Nutrition and Medicine

  • Robert Greenwald, JD
    Faculty Director, Center for Health Law and Policy Innovation; Harvard Law School, Clinical Professor of Law

  • Kathleen Merrigan, PhD
    Director, GW Food Institute; The George Washington University, Professor of Public Policy

  • Karen Siebert
    Advocacy and Public Policy Advisor, Harvesters – The Community Food Network on behalf of the Feeding America network

Congress members Jim McGovern, Lynn Jenkins, Chellie Pingree, and Dr. Roger Marshall were all on hand to lend their thoughts on the importance of the Food is Medicine movement.

Quotes from  Food is Medicine: Addressing Hunger as a Health Issue:

  • Congressman Jim McGovern – “My hope is that this working group is going to be about more than just talk, it’s going to be about action.”

  • Congresswoman Chellie Pingree – “Every conversation we have connects health outcomes to what we eat. I think it seems only logical that we should be talking about this as a policy issue. Whether it’s medically tailored meals or prescriptions for fruits and vegetables, there are a lot of good ideas out there.”

  • Robert Greenwald – “We need to start to integrate Food is Medicine into more mainstream Medicare and Medicaid programs particularly given the growing body of research that demonstrates how cost saving and not just cost-effective medically tailored meals are.”

View a recording of the congressional briefing on Facebook.

View CHLPI’s slides from the congressional briefing.