Food as Medicine: Programs and Physicians Seek to Fulfill Nutritional Prescriptions

Debbie Valentini received boxes of food from “Food Rx,” a program run by UHN and Foodshare.Fred Lum/The Globe and Mail

Every week, during her permanent doctor’s appointment, Candace Blanchette is told the same thing: If she eats healthier, it’s if she loses weight, she will feel better.

By now, the 38-year-old is well aware of the many ways a healthier diet could help. On TikTok, she scrolls through images of rainbow-colored smoothie bowls and crisp green salads. But until recently, she couldn’t afford to eat that way.

Ms. Blanchette works full-time and is supplemented by the Ontario Disability Support Program. Between the rent on her apartment in Toronto and the hundreds she spends on prescriptions out of pocket, her grocery budget is usually the only place to cut.

“On $2,000 a month, you can’t afford to eat $3 cucumbers,” she said. “It’s a real reality.”

Most of the time, a meal consisted of a chocolate bar from Dollarama. She couldn’t remember the last time she ate three meals a day.

At the start of the pandemic, health care workers have identified Ms. Blanchette as food insecure, meaning she has no access to food due to financial constraints. She was placed in a University Health Network (UHN) and a FoodShare Toronto program, which began sending a box of fresh fruits and vegetables to her doorstep every two weeks.

The program is called “Food Rx”. As the name suggests, it’s part of a growing movement in healthcare to take the role of diet seriously — as seriously as prescription drugs. By treating diet as an important determinant of health, it forces physicians to recognize that nutritional interventions prevent health problems – and costs – along the way. In 2015, diet-related illnesses were found to cost the healthcare system $26 billion a year.

And in cases like that of Ms. Blanchette, where doctors now also ensure that patients have access to healthy eating is an important recognition of the essential link between food security and health.

Since she started receiving the boxes, Mrs. Blanchette’s health has improved. His migraines are less frequent. Her mental health has also improved – anxiety and depression exacerbated by working in a vaccine booking call centre, where she is regularly abused.

But by the end of this month, funding for the program — from the McConnell Foundation and the Arrell Family Foundation — will end.

The thought of going back to discount stores fills Ms Blanchette with dread – the feeling of standing in the grocery aisle, knowing she can’t afford to buy what she needs .

“It makes me feel like I haven’t done enough,” she said. “Every day I struggle with this feeling.”

In the meantime, researchers are working quickly to collect data and prove that the dietary prescription model works.

“When you look at medicare, it will fund hospital stays and access to doctors, but little that we know is integral to population health and people’s well-being,” said Dr. Andrew Boozary, Executive Director. of Health and Social Policy at UHN, one of the architects of the program.

He hopes the program will create a sense of shared responsibility around food insecurity. It is a problem that affects one in eight households in Canada. This figure rose to one in seven at the start of the pandemic. And, with rapidly rising food prices, this is a problem that is likely to get worse.

But the answer—whether the prescription model works—depends on the problem they’re trying to solve.

When patients leave Dr. John Sievenpiper’s clinic in Toronto, it is often with two prescriptions: one for the pharmacy, another for food.

“In clinical practice, too often [nutrition] gets lip service,” Dr. Sievenpiper said. A written prescription “communicates to the patient that we think it is important”.

Approaches like that of Dr. Sievenpiper, who also has a doctorate in nutrition, are the anomaly. The foundation of medicine, and what distinguishes physicians from other medical professionals, is pharmacology and the ability to prescribe medication. As such, decades of medical school curricula have been devoted almost exclusively to it.

This has led generations of doctors to report feeling ill-equipped to give nutrition advice, Dr Sievenpiper said. Dietitians, on the other hand, are often isolated – working separately from primary care providers, with their work treated as an afterthought.

It is slowly changing. At the University of Toronto, where Dr. Sievenpiper teaches in the medical school, students are now being introduced to “culinary medicine”. Stanford and Harvard University medical schools also teach healthy eating and cooking.

Much of the food-as-medicine movement originated in the United States, as part of a growing belief that food – and more specifically nutritious food – should be a basic human right. This is why many charities have moved away from describing the problem as a hunger problem, and instead as “food insecurity” – or, increasingly, “nutrition insecurity”.

Recognizing this, Wholesome Wave, an American non-profit organization, created a voucher model in 2007 to give low-income people access to fruits and vegetables at farmers’ markets. The hope was to find a healthier and more dignified experience than at food banks. This evolved into boxes of “prescription” products. A 2017 US study found that even a small 10% subsidy on fruits and vegetables could prevent more than 150,000 heart disease deaths there.

Candace Blanchette with her dog Neeaira on February 14.Fred Lum/The Globe and Mail

The idea caught on in Canada. In British Columbia, farmers’ markets, in conjunction with the provincial government, offer vouchers to low-income people. SEED, a nonprofit in Guelph, Ontario, runs its second Fresh Food Rx program, another voucher system. And in 2020, Community Food Centers of Canada, another nonprofit, received $1.5 million from the federal government to expand its Market Greens program to 30 communities. In total, the organization is spending $3.1 million to find a scalable model to bring affordable fresh produce to low-income people.

But to convince policy makers, they need data. And quality data in nutritional science has historically been a challenge.

The cost of conducting randomized controlled trials — the kind pharmaceutical companies conduct to prove the effectiveness of their drugs — is beyond what academic institutions and community groups can afford. And studies funded by the food industry raise issues of conflict of interest.

Instead, researchers often rely on smaller studies that find correlations and associations, rather than causation.

“It allows for a lot more discussion, even in science, about what the right diet is. You have scientists who disagree,” Dr. Sievenpiper said. “There is a mess there. -low.”

Yet the science that exists (for example, around the Mediterranean diet) overwhelmingly points in the same direction: eating more plants – including fruits and vegetables – and avoiding highly processed foods, is beneficial.

As such, researchers of all persuasions agree that such programs are helpful, at least for health.

For Debbie Valentini, every two weeks for the past 18 months has felt like Christmas. Every time her box of food arrives, “I’m so happy. It’s such a joyful thing,” the 60-year-old said.

As with Ms. Blanchette, Ms. Valentini’s problem is not a lack of knowledge. A few days after receiving her box this month, she had already made a casserole of stuffed cabbage, a lentil soup with kale and a banana bread. Ms. Valentini, whose chronic fatigue syndrome has long kept her out of work, depends on a pension and a patchwork of social programs. She has become accustomed to living below the poverty line and extending her income as much as she can.

The problem, for Ms. Valentini and many others, is income.

Occasionally, like after glimpsing the inside of a friend’s fridge, Mrs. Valentini will remember – even feel surprised – that she is poor. She tries not to be ashamed, because she knows it’s not her fault. She caught a virus, and now she’s sick.

“People need to be aware that bad things happen to good people,” she said.

Food prescription programs confuse symptom with problem, said Valerie Tarasuk, a University of Toronto professor who studies food insecurity. In fact, every organizer the Globe and Mail spoke to recognized the need to address revenue as the fundamental issue.

Professor Tarasuk said those facing food insecurity are also likely to face a list of other challenges: chronic illnesses, mental illness and the inability to pay rent and medicine. It is also a problem that disproportionately affects Black, Indigenous and other racialized communities.

“It reduces their struggle to a box of products,” she said. “The answer to the problem is miles apart.”

She said that, however well-meaning the organizers may be, the health care system is not designed to deal with food insecurity – and in fact may divert resources from other organizations that could have an impact. more significant.

The ultimate responsibility rests with the provincial and federal governments, she said, whose minimum wage, working conditions and welfare policies are insufficient to meet the cost of living.

“We don’t have any evidence to suggest that if we gave these people more money, they wouldn’t be able to go buy the food they need,” she said. “Why is it a box of food and not a bag of money?” »

But it is because of the inaction of governments that others say they must intervene. “It’s not a choice,” said Kathryn Scharf, senior program officer at Community Food Centers Canada, which also advocates income-based policies. “That’s a yes, and.”

That leaves people like Ms. Blanchette and Ms. Valentini waiting.

They hope that the food box program could still be renewed. But they are both well aware of how little help they provide compared to the large number of people in need.

“When I get this box, it’s like, ‘My fridge is full! This is so exciting,’ Ms Valentini said.

A moment later, she caught herself. “But should it be so?”

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