Food as medicine: Programs, doctors look to fill nutrition prescription

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Every week at her standing doctor’s appointment, Candace Blanchette is told the same thing: If she eats healthier, that if she loses weight, she’d feel better.

By now, the 38-year-old is well-versed in the many ways a healthier diet could help. On TikTok, she scrolls through images of rainbow-coloured 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 rent for her Toronto apartment, and the hundreds she spends for out-of-pocket prescriptions, her grocery budget is usually the only place left to cut.

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

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

Early in the pandemic, health care workers identified Ms. Blanchette as food insecure, meaning she has inadequate access to food because of financial constraints. She was placed in a University Health Network (UHN) and FoodShare Toronto program, which began sending a box of fresh fruits and vegetables to her door every two weeks.

The program is called “Food Rx.” As the name suggests, it’s part of a growing movement in health care to take seriously the role of food – as seriously as prescription medicine. By treating food as a significant determinant of health, it compels doctors to recognize that nutrition interventions prevent health care problems – and costs – down the road. In 2015, diet-related disease was found to cost the health care system $26-billion each year.

And in cases such as Ms. Blanchette’s, where doctors now also ensure patients have access to a healthy diet, it’s an important recognition of the critical link between food security and health.

Since she started receiving the boxes, Ms. Blanchette’s health has improved. Her migraines are less frequent. Her mental health, too, has improved – the anxiety and depression exacerbated by working at a vaccine booking call centre, where she is regularly subject to abuse.

But by the end of this month, the program’s funding – from the McConnell Foundation and the Arrell Family Foundation – will end.

The idea of returning to discount shelves fills Ms. Blanchette with dread – the feeling of standing in the grocery aisle, knowing she can’t afford 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 gather data and prove the food-prescription model works.

“When you look at medicare, it will fund hospital stays and access to physicians, but not many of the things that we know are so integral to population health, and for peoples’ well-being,” said Dr. Andrew Boozary, executive director of health and social policy at UHN, one of the program’s architects.

He hopes the program will create a sense of shared accountability around food insecurity. It’s a problem that affects one in eight households in Canada. That figure rose to one in seven at the start of the pandemic. And, with the rapid rise in food costs, it’s a problem that’s likely to worsen.

But the answer – on whether the prescription model works – depends on which problem they’re looking to solve.

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

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

Approaches like Dr. Sievenpiper’s, who also has a PhD in nutrition, are the anomaly. The foundation of medicine, and what sets physicians apart from other health care professionals, is pharmacology and the ability to prescribe drugs. As such, decades of curriculum at medical schools have been devoted almost exclusively to it.

This has led to generations of doctors who report feeling ill-equipped to give nutrition advice, said Dr. Sievenpiper. Dietitians, meanwhile, are often siloed off – working separately from primary care providers, their work treated as an afterthought.

That’s changing slowly. At the University of Toronto, where Dr. Sievenpiper teaches in the faculty of medicine, students are now introduced to “culinary medicine.” Medical schools at Stanford and Harvard University also teach healthy eating and cooking.

Much of the food-as-medicine movement came out of the United States, part of a growing belief that food –and more specifically, nutritious food – should be a basic right. It’s the reason many charities have stopped describing the problem as one of hunger, and instead as “food insecurity” – or, increasingly, “nutrition insecurity.”

Recognizing this, Wholesome Wave, a U.S. non-profit, created in 2007 a voucher model to give those on lower incomes access to fruits and vegetables at farmers’ markets. The hope was to find a healthier, more dignified experience than at food banks. That evolved into “prescription” produce boxes. One 2017 study out of the U.S. found that even a small, 10-per-cent subsidy on fruits and vegetables could prevent more than 150,000 deaths there from heart disease.

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The idea has spread to Canada. In B.C., farmers’ markets, working with the provincial government, provide vouchers to those on low incomes. SEED, a non-profit in Guelph, Ont., is running its second Fresh Food Rx program, another voucher system. And in 2020, Community Food Centres of Canada, another non-profit, 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 get affordable fresh produce to those living on low incomes.

But in order to convince policy makers, they need data. And quality data in the nutrition sciences have, historically, been a challenge.

The cost of conducting randomized control trials – the type pharmaceutical companies run to prove their drugs work – is beyond what academic institutions and community groups can shoulder. And studies funded by the food industry raise questions 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 discussions even in the scientific realm about what is the right diet. You have scientists who don’t agree,” Dr. Sievenpiper said. “There is a messiness there.”

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

As such, researchers across the board agree that such programs are helpful – at least for health.

For Debbie Valentini, every two weeks for the past 18 months has been like Christmas. Each time her food box arrives, “I’m just 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 stuffed cabbage casserole, lentil soup with kale, and banana bread. Ms. Valentini, whose chronic fatigue syndrome has long prevented her from working, relies on a pension and a patchwork of social programs. She’s grown accustomed to living below the poverty line, and stretching her income as far as she can.

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

Every once in a while, like after catching a glimpse inside a friend’s refrigerator, Ms. Valentini will remember – feel surprised, even – that she’s poor. She tries not to feel shame, because she knows it’s not her fault. She caught a virus, and now she’s ill.

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

Food-prescription programs confuse the symptom for the problem, said Valerie Tarasuk, a University of Toronto professor who studies food insecurity. In fact, all of the organizers The Globe and Mail spoke with acknowledged the need to address income as the fundamental problem.

Prof. Tarasuk said those facing food insecurity also likely face a list of other challenges: chronic disease, mental illness, and the inability to pay for rent and medications. It’s also a problem that disproportionately affects Black, Indigenous and other racialized communities.

“It’s reducing their struggle to a box of produce,” she said. “The response to the problem is miles apart.”

She said as well-meaning as organizers may be, the health care system is not set up to deal with food insecurity – and in fact may divert resources away from other organizations that could have a more meaningful impact.

The ultimate responsibility lies with provincial and federal governments, she said, whose policies around minimum wage, working conditions and social assistance are insufficient to keep up with living costs.

“We have no evidence to suggest that if we gave these people more money, they wouldn’t be able to go and buy the food they need,” she said. “Why is this a box of food, and not a bag of money?”

But it’s because of the governments’ inaction that others say they have to step up. “It’s not an either-or,” said Kathryn Scharf, chief program officer at the Community Food Centres Canada, which also advocates for income-based policies. “It’s a yes, and.”

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

They’re hoping that the food-box program might still be renewed. But they’re both well aware of how few it helps compared with the many in need.

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

A beat later, she caught herself. “But should it be that way?”

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