The idea of food as medicine is certainly nothing new. You've probably heard the saying, "Let food be your medicine." This is usually attributed to the ancient Greek writer and physician Hippocrates. Although this phrase does not actually appear in his written texts, he did believe that food and nutrition play a key role in health and medicine.
And now, 25 centuries later, the Food as Medicine movement is gaining momentum as the organizing principle of medicine. While I think the movement is well-intentioned, I would like to push back on the idea that food is medicine.
Reducing food as medicine
As you are no doubt aware, non-communicable diseases such as cancer, heart disease, type 2 diabetes and obesity account for a huge portion of our society's medical burden. These diseases are often referred to as "lifestyle diseases," a term I despise. As if suffering from these diseases is just a matter of not being able to make better choices, or that a healthy lifestyle is equally available to everyone. (As an aside, I've noticed that most proponents of "lifestyle medicine" tend to live very comfortable lifestyles that include a refrigerator full of healthy food, a kitchen to prepare it in, time to shop, cook, meditate, and go. going to the gym are all guaranteed. But I digress.)
Correlation between diet quality and disease risk
It's true that poor diet and nutrition are correlated with an increased risk of many of our most common diseases. So the idea that a better diet could prevent or even treat these conditions is understandable.
But our current healthcare system is not focused on improving nutritional quality. It is also not very focused on disease prevention. Most insurers cover medications and hospital admissions, but not salad bars. Which seems absolutely shortsighted. Imagine how much more cost-effective (not to mention more humane) it would be to take on the cost of a healthy diet instead of the cost of medications, surgeries, and medical equipment!
But, for better or for worse, we are dealing with a profit-driven medical system here in the US. If we want to change the system, we have to show the receipts. If we could show that writing prescriptions for products reduces the burden of disease, we could theoretically convince insurers to do more.
Unfortunately, pilot prescription programs (say, three times fast!) haven't paid off, so to speak. Not that you would know that from the press releases.
The issue of product prescription programs
At the beginning of 2023 a study of 9 product prescription programs was billed as "the largest evaluation of product prescriptions and health outcomes to date, increasing the statistical power to detect impacts on nutritional intake, health outcomes and other clinically relevant endpoints."
Unfortunately, the observed effects were of questionable validity. First, there was no control group, so it is impossible to attribute the improvements to product prescriptions, as opposed to other factors. And the improvements observed were only significant in certain subgroups of the population that had the worst values at baseline.
When you measure things in a large population, outliers will always move toward the mean over time. This effect is known as "regression to the mean" and could fully explain the modest improvements detected in this analysis.
How do you clean your products? Bloggers recommend everything from bleach to baking soda. Food safety experts emphasize that tap water is all you need. What's the best way to kill germs on fresh produce? Monica shares her thoughts in the next episode; listen below.A randomized 'Gold Standard' trial and its surprising results
A much better study was published last month. This was a randomized controlled trial (the "gold standard"). The study enrolled 500 patients suffer from type 2 diabetes and divided them into two groups. The control group was placed on a waiting list. Meanwhile, the intervention group did not only receive written recipes for fruit and vegetables. Participants received ten healthy meals a week for a year, enough for the whole family.
If there was a study that should have documented the impact of improved nutrition on diabetes control, this should have been it. And people in the intervention group showed improved glycemic control at the end of the study. But that also applied to the people in the control group. To the researchers' surprise, there was no statistical difference between the groups that did and did not receive the product prescriptions.
Food as medicine and policy change
That's not to say that the people who got the healthy food didn't benefit from it. Or that increasing access to (and demand for) healthy food is a bad idea. But if we bill food as medicine and hope insurers will pay for it, we must be able to demonstrate medical benefits.
I've written before about our tendency to exaggerate the impact of diet and nutrition on health and disease. Prudent diet and lifestyle choices can reduce our risk of disease. But not to zero. You can do everything 'right' and still end up with type 2 diabetes, cancer or heart disease. This is because there are so many other factors at play, including some that we actually have no control over, like our age, gender, environment, genetics and just the luck of biological attraction.
To me, writing prescriptions for products is a gimmick that confuses health care policy with food policy. In a country as prosperous as ours, we absolutely need to implement a food policy that makes healthy food more widely accessible. However, simply irrigating the so-called food deserts with vegetable stalls is not enough.
Education and dietary diversity
We also need to educate people about both the benefits and joys (as well as the practicalities) of nutritious diets. And all this must be done in an atmosphere of respect and inclusivity. The Mediterranean diet isn't the only game in town. You can just as easily create a healthy diet with traditional foods from Africa, Asia, South America, Scandinavia, Eastern Europe or indigenous cultures.
If we could increase access to and appreciation for healthy food choices across all levels of society, medical expenditures could potentially decrease. But even if that weren't the case, I still think it would be worth doing. Because food is not medicine. Food is food. And its purpose is not to reduce medical spending. The goal is to provide nourishment and pleasure and to promote healthy bodies and communities.
Even if I could wave my magic wand and everyone magically ate five servings of vegetables every day, people would still be diagnosed with type 2 diabetes, heart disease, and cancer. People would still need medical care. And our ability to diagnose, treat and cure disease is truly miraculous.
Conclusion: food is food, medicine is medicine
Let us not diminish the need for, or the power of, actual medicine by confusing it with food and nutrition. And let's not judge food solely based on its impact on disease risk.
Food is food. Medicine is medicine. We need both.
