Food is Medicine Interventions and Climate Change

Abstract

Food is Medicine (FiM), also known as Food as Medicine, integrates food and nutrition interventions into health care delivery with the primary goal to improve population health and address diet-related health conditions. To date, there has been little focus on the relation between FiM and climate change despite FiM’s involvement with 2 key drivers of climate change: health care delivery and food systems. FiM may be able to advance lifestyle medicine and population health objectives, as well as mitigate some of the health care and food-related drivers of climate change, by focusing on 4 key areas: (1) Increasing the absolute number and proportion of patients who follow plant-based diets; (2) reducing food waste; (3) reducing unnecessary health care utilization; and (4) lowering transportation-related greenhouse gas emissions related to food procurement. Measuring the ecological impact of FiM alongside clinical, utilization, and financial measures will require a different analytical approach than that used traditionally in health care. Ultimately, thoughtful, data-driven, and urgent interventions that span the food and health care sectors are needed to sustainably support not only FiM, but human, environmental, and planetary health as well.

“Measuring the ecological impact alongside clinical, utilization, and financial measures of FiM requires a different analytical approach than that used traditionally in health care.”

Intoduction

Food is Medicine (FiM), also known as Food as Medicine, integrates food and nutrition interventions into health care delivery with the primary goal to improve population health and address diet-related health conditions.^1-3 FiM works chiefly through the delivery of medically tailored meals, medically tailored groceries, and produce prescriptions. ⁴ As a health care activity, FiM has received a great deal of attention recently, including at the White House Conference on Hunger, Nutrition, and Health, where more than $8 billion was pledged to end hunger and reduce diet-related disease by 2030. ⁵

Surprisingly, however, there has been little focus on the relation between FiM and climate change, which is regarded as a medical emergency ⁶ and the greatest threat to global health. ⁷ Of the more than 60 financial commitments made at the White House Conference, only 2 (3.3%) mentioned climate. ⁵ Yet, to combat potentially catastrophic climate change effects and keep global temperatures to less than 2°C above pre-industrial levels, experts have made it clear that global greenhouse gas (GHG) emissions must be reduced by nearly 50% over the next decade. ⁸ Greater attention to climate change mitigation in relation to health care is needed ⁹ and FiM is uniquely positioned to affect 2 key drivers of climate change—namely, the delivery of health care services and food systems.

The manner in which health care delivery drives climate change has been widely reported.^8,10 On a global scale, health care produces 4.4%–4.6% of total net carbon emissions. ¹¹ In the United States health care produces an even higher proportion of total emissions, 7.6%, and is continuing to rise.^11,12 Direct emissions from health care facilities (“Scope 1”) constitute approximately 7% of the health care sector’s emissions, emissions from its purchase of energy (“Scope 2”) is roughly 11%, and all other supply chain emissions from the health care sector (“Scope 3”)—chiefly pharmaceuticals and other chemicals—are responsible for the sector’s largest share of emissions, about 82%. ¹¹ Health care may thus be considered a major contributor to the climate crisis. ¹² However, given the variation in state-level GHG emissions per capita is not highly correlated with health system quality, the health care sector’s emissions can likely be reduced without compromising the quality of care delivered. ¹¹

The manner in which the food sector drives climate change has also been well characterized.^13-15 The food sector generates 34% of total global greenhouse gas emissions, with nearly three-quarters of it coming from agriculture/land-use activities and the balance from the supply chain.^16,17 Agriculture and land use largely include the release of methane from cattle digestive processes; nitrous oxide from fertilizers used for crop production; carbon dioxide from felled forests used to expand farmland and concomitant loss of carbon sinks; and the release of carbon dioxide from the use of fuel on farms. ¹⁸ Emissions from the supply chain include those released from “retail, transport, consumption, fuel production, waste management, industrial processes, and packaging.” ¹⁶

Health care and food systems not only drive climate change but also stand to suffer greatly from climate change. Severe weather events—anticipated to occur more frequently with climate change—shut down medical facilities, leaving patients without care, as has been seen already in several instances with wildfires and hurricanes. ¹⁰ Climate change may also lead to an array of new health care needs, including but not limited to: heat-related illness and death; acute and chronic cardiovascular and respiratory disease and death; vector-borne, food-related, and water-related infectious disease; malnutrition and food-related diseases; distress, grief, and behavioral-health disorders.^13,19 Food and nutrition security also likely will be threatened by climate change through decreases in food and nutrient availability, price increases, altered food-transportation systems, and diminished food safety.^13,14

Against this backdrop and these potential threats to health care and the environment, FiM may be uniquely positioned to advance both lifestyle medicine and population-health goals, as well as mitigate some of the health care and food-related drivers of climate change. To accomplish this, FiM will need to focus on 4 key areas:

Increase the Adoption of Plant-Based Diets

Plant-based dietary patterns have been repeatedly associated with improved health^20-23 and replacing animal-based proteins with plant-based proteins is endorsed by the American College of Lifestyle Medicine, ²⁴ as well as organizations such as the American Heart Association, ²⁵ the American Institute for Cancer Research, ²⁶ the Academy of Nutrition and Dietetics, ²⁷ and the Food and Agriculture Association of the United Nations/World Health Organization. ²⁸ They have also been shown to reduce the prevalence and risk of chronic disease in under-served communities. ²⁹ In addition to their healthfulness, plant-based diets have been found to have a significantly lower environmental impact compared to those that are not plant-based.^19,30 Animal-based foods, by contrast, and especially red meat, dairy, and farmed shrimp, are generally associated with the highest greenhouse gas emissions. ¹⁸

Importantly for lifestyle medicine providers, engaging patients in FiM interventions has been shown to improve their ability to follow dietary recommendations by helping them to access and afford the recommended foods. ² And although sustaining dietary change can be difficult, strategies which emphasize that plant-based options are available, nutritious, and flavorful, and which focus messaging on health rather than on environmental impact, can help. ³¹ Lifestyle medicine practitioners, Registered Dietitians, nutritionists, trained community health workers, and community-based organizations may also help shape and sustain culturally sensitive, plant-based FIM interventions for diverse patient populations. ³² Companies such as Practice Greenhealth, which has helped to increase the number of hospital systems that serve local, plant-forward dishes, ³³ and Better Food Foundation, which reports a reduction in GHG emissions in the over 900 academic and hospital institutions that have employed its methods, ³⁴ may also play an important role.

Reduce Food Waste

FiM may play an important role in diminishing the quantity of food that is wasted at the consumer level, thus alleviating some of the health, ecological, and economic losses that result. Between 30 to 40% of food is wasted in the U.S. ³⁵ and nearly 13% of U.S. households are food insecure, including just over 17% of households with children. ³⁶ Uneaten food costs households hundreds of dollars every year ($1500 for a household of 4) ³⁷ and also results in a “waste” of resources, including labor, land, water, greenhouse gas emissions, and energy, and accounts for 2% of U.S. GHG emissions, which is nearly half that of the aviation sector.^33,38

FiM efforts to reduce food waste without compromising population health may leverage lessons learned from the inpatient health care space, where personalizing meals, active involvement of clinical nutrition staff, and monitoring of intake have shown success.^39-41 In-hospital “room service” meal-order systems, whereby patients choose food items in select amounts at desired times from a therapeutic diet menu have been shown to not only improve patient satisfaction and both macro- and micro-nutrient intake, but also significantly reduce food waste and hospital food-related costs.^39,42,43 Clinical staff and automated tools may have a particularly important role to play: for instance, by helping patients in a FiM program remember to use food in a timely manner and to store food properly. ⁴⁴ Staff and automated tools can also help patients understand appropriate portion sizes and ingredient selections, enabling patients to sustain dietary change and reduce waste. ⁴⁵

Reduce Unnecessary Health Care Utilization

By reducing unnecessary health care utilization, or the overuse of health care, FiM may promote population health while helping to reduce the health care sector’s contribution to climate change. ¹⁰ Encouragingly, FiM interventions have demonstrated success in reducing health care utilization. For example, participation in a medically tailored meal (MTM) program was associated with fewer emergency department (ED) visits, inpatient admissions, and use of emergency transportation, while participation in a non-tailored food program was associated with fewer ED visits and uses of emergency transportation. ⁴⁶ MTMs have also been associated with fewer skilled nursing admissions and less overall medical spending ⁴⁷ as well as lower mortality for patients following hospitalization for heart failure and other acute medical conditions. ⁴⁸ Given MTMs may contribute to the use of petroleum-based, single-use plastics, MTM programs may consider transitioning to paper goods or to bio-based plastics.^15,49,50

FiM interventions may work by improving patients’ diet quality, leading to decreased disease complications, and/or they may lead to fewer trade-offs for certain patients who otherwise would have to choose between food and medication purchases.^41,42,51 If clinical staff interactions associated with FiM utilize telemedicine, replacing in-person health care visits, this swap—while it may not alter utilization metrics—may facilitate a significant 40-70 times reduction in carbon emissions. ⁵²

Lower Transportation-Related Emissions Related to Food Procurement

In the delivery of food and meals to patients, FiM has important choices with respect to the type and frequency of transportation employed. It has been shown that, depending on the home delivery model used, one may reduce the GHG emissions generated by grocery shopping by 18% to 87% compared to individuals shopping for themselves. ⁵³ Delivery trucks can provide emissions benefits where customer density is high (e.g., urban areas) and when the emissions of the truck approaches that of the passenger car, ⁵⁴ although refrigeration can increase fuel consumption. ⁵⁵ Interestingly, the delivery of meal kits has been found to lead to 33% lower GHG emissions when compared to the same ingredients bought at the grocery store, a result of a more efficient direct-to-consumer supply chain (skipping the retail stage), reduced food waste (2% from meal kits vs 10% from a grocery store meal), and lower “last-mile” transportation emissions (eliminating passenger vehicles from making a trip to the grocery store): collectively, these efficiencies may even offset emission increases seen from meal kit packaging.^56,57 When delivering food or meals, FiM may wish to pay particular attention to grouping orders together, leveraging low-emission vehicles, and limiting or eliminating cooling units or refrigeration on certain routes. ⁵¹

Notably, while there is a growing body of research to inform the design and implementation of FiM efforts, there are no best practices yet. ³² Additionally, measuring the ecological impact alongside clinical, utilization, and financial measures of FiM requires a different analytical approach than that used traditionally in health care. Life-cycle analyses of the FiM program may play a role. ⁵⁸ There may also be learnings from environmental impact assessments that can be used to understand the joint impact of FiM on health and the environment.^59,60 Novel databases, such as EDGAR-FOOD which houses a global emission inventory of GHGs and air pollutants from the food systems, may also be considered. ⁶¹

Ultimately, thoughtful, climate-focused, and data-driven interventions that span the food and healthcare sectors are urgently needed. Ongoing research should not impede action but should inform rapid and ongoing progress. Throughout, we are all well served to remember^62,63 that the ultimate determinant of human health is planetary health.

Appendix.

List of Abbreviations

FiM

Food is Medicine

GHG

Greenhouse Gas

ORCID iD

Adam Bernstein https://orcid.org/0000-0003-2425-2256