Comments on Preventive Services Research
Bi-State Primary Care Association has submitted comments on the U.S. Preventive Services Task Force’s Draft Research Plan on Preventive Services in Food Insecurity.
The Food Access and Health Care program is a project of Bi-State Primary Care Association and does not include advocacy or federal comments in its scope of work; these comments were submitted on behalf of Bi-State and do not necessarily reflect the opinions of the consortium membership.
The federally qualified health centers (FQHCs) that make up the majority of Bi-State’s membership have a long history of food insecurity work, in fact the first FQHC model included a farm used to write produce prescriptions. Our need to invest in nutrition security as a key part of prevention remains as strong as ever. However, the need to also invest in food security as part of treatment has grown seemingly exponentially, putting stress on the network of prevention focused programs, as noted in our comments:
Food insecurity has a unique status in primary care in that it is both a social risk factor and an indicated treatment for our most common, expensive, deadly, and inequitably distributed health conditions.
A generation ago we might have reasonably viewed food security as primarily a prevention issue. Today, available health data shows that it might more accurately be viewed as a key limiting factor in patients’ options for treatment. The Centers for Disease Control and Prevention reports that in 2018, 42% of American adults had obesity (up 19% over the decade) and predicted this proportion to have risen to exceed 50% over the pandemic. CDC data also reveals a dramatic turning point for Type 2 Diabetes, already our nation’s most costly illness, accounting for 1 in 7 health care dollars spent. The CDC reports that the age of onset is now shifting from adult to become a juvenile disease. Looking to older demographics, over 80% of participants in Meals on Wheels programs report doing so with the goal of managing chronic health conditions. We know that diet-related illnesses are the leading cause of death in the U.S. In recent years we saw a stark example of diet’s impact. Diet-related conditions increase the risk of death from COVID-19 by a factor of 12, with the NIH and AHA reporting evidence that 66% of COVID-19 hospitalizations in 2020 could be attributed to complications from diet-related conditions. We can add to these statistics scenarios in which food access is integrated into acute treatment. The Food Is Medicine coalition reports Medicare Advantage Plan data showing Medically Tailored Meal interventions lead to 72% fewer skilled nursing facility admissions and reduce length of hospital stay by 30%. Hospital practices have started to integrate dietitian services, culinary medicine programs, and food access to help reduce post-operative complications through lowering BMI and shifting away from dependence on opioids alone to manage pain. In other words, we have reached the treatment stage of the American dietary crisis.
Along the way to our present situation, a trend emerged of saddling prevention-focused food security programs with evaluation metrics better suited to treatment. Food based interventions can be a powerful preventive tool, changing the course of a patient’s health, and quality of life, over years and even across generations. Food based interventions can also be effective treatments for particular conditions, with clinical results that appear over the course of weeks and months, not years. We have neither the evidence base, nor the logical framework, to assume that the two types of intervention look the same. By bundling them under the broad header of “health care-related food intervention” for research purposes, we do a disservice to both.
The full comments, found here, detail ways that the underlying research literature may not support the information that we need today.
Bi-State is working on the challenge of understanding the impact of food insecurity work in today’s health care environment. A Healthy Rural Hometown Initiative grant is currently supporting food interventions and data collection work at three FQHCs (Lamoille Health Partners, Little Rivers Health Care, and NOTCH). This funding allows us to develop a theoretical model for how to test and improve the efficacy of programs designed to reduce the risk of cardiovascular disease. We are also recording what data gaps need to be solved on the ground when implementing this model, and what data access and support elements we offer Bi-State members may not be available to other practices in other contexts.
This level of detailed review at the individual practice level helps us interpret other work trying to create the appropriate evaluation structure for health care related food interventions, such as the research agenda proposed by the Gretchen Swanson Center (under their contract for evaluating USDA-funded food intervention programs), the recent Food Is Medicine Research Action Plan, and the National Institutes of Health’s Strategic Plan to Accelerate Nutrition Research. We look forward to continuing this conversation.