The global pharmaceutical industry is worth hundreds of billions of dollars, but over recent years, a somewhat unlikely challenger to its all-encompassing market domination has emerged: fresh produce. Buoyed by proponents from medical professionals to produce advocates, the concept of the ‘medicinal value’ of produce has gathered momentum.
Known as ‘Food is Medicine’ or ‘Food as Medicine’ — a subtle grammatical shift that reflects different takes in the U.S. and Europe — the concept rushed to the forefront in 2023, thanks to the efforts of organizations like the American Heart Association and the International Fresh Produce Association (IFPA), although both are approaching the debate from slightly different directions.
But how to define Food is Medicine? Volkert Engelsman, co-founder and chief executive of Utrecht, Netherlands-based importer-distributor Eosta, which markets products under its Nature & More label, has been one of the most vocal and visible proponents of the approach to selling fresh produce.
He defines the concept as having three principal characteristics. “It shouldn’t pollute or poison you,” he says. “Absence of glyphosate and other pesticides helps.” Glyphosate is a widely used and controversial herbicide that some claim can cause cancer and other illnesses.
“Secondly, fruits and vegetables are a carrier for health in general,” he says. “This is intimately related to nutrient density. There seems to be an immediate connection between nutrient density on the one side — we have lost 70% of the nutrients in our fruit and vegetables over the past 70 years — and that looks very much like the 70% biodiversity loss over the same period.”
Eosta is currently participating in a €200 million ($219 million) research study with the University of Amsterdam into gut microbiology, which appears to show a direct connection between diversity and vitality at three levels — in soil, in plants and in the human gut.
“The higher the diversity, the greater the pest and disease resistance in nature, but also the greater the resilience and ability of intestinal flora to regenerate itself in the human gut,” says Engelsman. “This demonstrates we do need to pay attention to how fruits and vegetables are grown because diversity is key and soil versatility is key for human health.”
The third characteristic identified by Engelsman is Food as Medicine in a more “traditional sense,” which he defines as the particular health benefits of consuming certain food types, such as ginger and turmeric, that can be “used as medicines.”
“Our grandmothers maybe knew something about these in old, traditional cultures, but that knowledge seems to me to have been lost,” he says.
Eosta’s involvement in the Food as Medicine debate has been longstanding. As far back as 2017, the importer worked with Triodos Bank and accountants EY on a pilot study entitled, ‘True Cost Accounting in Finance, Food and Farming.’ Among other findings, researchers concluded that in the case of organic apples, the benefit to consumer health is €0.14 ($0.15) per kilo compared with conventional apples.
Engelsman notes further research, carried out by the World Health Organization (WHO), examining the link between food and the DALY (Disability-Adjusted Life-Year) measurement for disease-linked health loss.
Applying the DALY formula, where one DALY represents the loss of the equivalent of one year of full health, Engelsman says it is possible to monetize the effects of pesticides on fruits. “If you look at the database kept by the European Food Safety Authority and you run organic apples and conventional apples, then you see a tremendous delta in terms of pesticide residues,” he says. “By applying this data to the DALY calculation, you come up with the finding that organic apples’ benefit to consumer health is €0.19 per kilo compared with conventional apples. That equals about 27 sick days per hectare per year.”
Cost-Effective Health Solutions
Another vocal proponent of the Food is Medicine concept is the American Heart Association (AHA). The organization, which is dedicated to fighting heart disease and stroke, recently embarked on a research initiative that it believes can prove the viability of the approach, with the first results expected in early 2024.
According to Mitch Elkind, chief clinical science officer for the Dallas-based association, the goal of the research is to show that different types of Food is Medicine interventions can be “effective and cost-effective in reducing cardiovascular disease outcomes.”
Elkind envisions Food is Medicine interventions including produce prescriptions, grocery prescriptions as well as medically-tailored meals. To prepare the ground, so to speak, he says the AMA is currently conducting early implementation studies to see how the enrollment, engagement and adherence of participants in a Food is Medicine initiative could be maximized.
Although Elkind says the planning for the initiative is still at a relatively early stage — emphasizing that diet recommendations would come from participating nutritionists and dietitians — he thinks fresh fruits and vegetables will likely be central.
“When we do recommend diets, we recommend those that are close to the Mediterranean diet in which fruits and vegetables play an important part,” he says. Despite this, Elkind emphasizes that the initiative is not aimed at “determining what healthy foods are,” but rather looking at the most cost-effective ways of encouraging people with diabetes or cardiovascular diseases to adopt diets that have proven to be beneficial.
In particular, he thinks some of the anticipated benefits that can be expected by adopting the Food is Medicine approach include improvements to some of the biomarkers associated with heart disease and diabetes, including high blood pressure and blood sugar (determined using the hemoglobin A1C test).
“We hope to show that these interventions improve diet quality, improve people’s quality of life and lead to less food and nutrition insecurity,” notes Elkind. “We are recognizing the increasing rates of obesity and diabetes in the U.S., and the Food is Medicine approach refers to the connection between healthy food and the healthcare system. It’s a way of using the healthcare system to try to facilitate getting healthy food to patients with heart disease and diabetes.
“In other countries, there are ways or social safety net programs that may allow people to get healthy food, but this initiative is built around the idea that there are health-related social needs, including access to healthy food, that the healthcare system can play a role in.”
Food-Based Treatments
The Food is Medicine approach has also received backing from official levels of the produce sector. Speaking during a recent industry event, the 2023 Agri-Pulse Ag & Food Policy Summit, Cathy Burns, chief executive of the IFPA, spoke of a “clear and significant role” for food interventions in the healthcare system.
With nine out of 10 Americans failing to meet the government’s recommendations for fruit and vegetable consumption, Burns thinks the use of “produce prescriptions” could be transformational for the trajectory of human health in the United States.
“You go to the doctor, you get a diagnosis, and they give you a prescription for fruits and vegetables to treat your condition,” she said. “Imagine a world where your diagnosis is being treated by what’s on your plate, not by what’s in a pill.”
Citing the examples of four states that are already running produce prescriptions through Medicaid — California, North Carolina, Oregon and Massachusetts — Burns argued that such initiatives could impact a significant share of the U.S. population.
“If you take Medicare alone, we can approximate that around 30 million enrollees would be eligible to participate due to diet-related disease and food insecurity,” she said. “Assuming a modest $40 per month for a produce prescription benefit per person, this could translate to $14.4 billion annually in fruits and vegetables just in Medicare. If you replicate that across federal healthcare systems and then have private insurers mimic that because they see the benefits, we are talking about something transformational.”
Also speaking at the same event, on the theme of “The Future For Prescribing Food As Medicine,” was Steve Brazeel, founder of Costa Mesa, CA-based SunTerra Produce. SunTerra is currently working with Medi-Cal healthcare professionals and patients to develop and deliver medically-tailored grocery boxes.
The company began delivering produce boxes as part of a USDA’s pandemic-era program, but was subsequently approached by Medi-Cal in Orange County, CA to supply medically-tailored meals to residents across the region. “We had to figure out how to specially tailor every box to every person’s individual health condition,” he said.
Working with a small team of registered dietitians, Brazeel estimates the company has delivered some 4m produce boxes since the beginning of the pandemic, adding that the program is already proving fruitful. “We’re seeing phenomenal results in terms of improvement in health and reductions in hospitalizations and doctor visits,” he said.
Burns added: “The easiest way we’re going to help farmers is to drive sales. The easiest way we’re going to grow prosperity is to sell more products. And by the way, we have the opportunity to change the trajectory of human health. I think that’s worth getting up for in the morning.”
Question Marks Over Results
However, the Food is Medicine approach does have its critics. The journal Health Affairs has labeled the idea a “temporary fix,” claiming it could be financially costly to patients. Although the authors conceded that medically tailored meals have been well documented as leading to reductions in healthcare use, they claimed the approach does not allow for developing — and maintaining — new culinary skills and dietary habits. Rather, they argued participants may well revert to former eating habits once the program ends.
A recent study published in the JAMA Internal Medicine journal also questioned the effectiveness of the strategy, particularly for patients with diabetes. The first randomized clinical trial on the approach — whose results were published as ‘The Effect of an Intensive Food-as-Medicine Program on Health and Health Care Use: A Randomized Clinical Trial’ — purported to show a very modest impact.
As part of the study, participants with Type 2 diabetes — the most common form of the condition — were given food to make 10 nutritious meals per week over a six-month period. However, blood sugar levels were only found to have dropped by 1.5% compared with 1.3% in the similar control group.
Despite the criticisms, advocates like Engelsman are adamant that Food is Medicine can make a difference if all contributing factors are considered. “I understand where the criticisms come from, but the reality is that if you are a medical professional then how many hours of lectures do you get on food per week? The answer is none,” he argues. “We have agronomists who talk about agriculture and medical professionals who talk about health, but mutually blaming each other doesn’t help.
“What’s needed is co-creation. We need to sit together with lifestyle experts, medical experts, microbiology experts, food dietitians and agronomists, in order to explore something that we have probably forgotten. Health is not a single-issue challenge. It is related to food, medicine and lifestyle.”
Elkind from the AHA agrees. “Food is Medicine has become something of a movement now in the U.S., but the key issue is really using the healthcare system to connect people with diet-related medical conditions to healthy food,” he says. “This is one way that we can do it most effectively.”
At the same time, Elkind is conscious that further research is required to provide unassailable scientific backing to the approach. “We think it will take several years to get definitive evidence of the effectiveness and cost-effectiveness of these programs,” he admits. “Just like we are still studying cholesterol treatment, I think we’ll still be studying Food is Medicine for decades to come.”
But it is Engelsman who perhaps deserves the last word. “We strongly believe that farmers not only produce a commodity, but they also produce ecosystem, social and health services,” he says.
“We see the farmer as a future pharmacy, and we recommend consumers think twice before they embark on the next round of pills. Instead, we recommend they see the greengrocer and preferably buy organic.”
