The future of food security
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You could imagine like produce prescriptions where your physician says, I really want you to be eating more fruits and vegetables. I'm going to write you a prescription for produce. That prescription goes to a local farm or a food bank or an organization that will either give you a voucher or deliver produce to your door or, you know, have a pickup location near your house or something like that.

And that's really appropriate for people who are like preventing disease or maybe have one chronic disease or something like that. And eating more produce would be really effective for them. This is Stanford Engineering's The Future of Everything, and I'm your host, Russ Altman. If you're enjoying the show or if it's helped you in any way, please consider sharing it with friends, colleagues, family, anybody you like. Because personal recommendations are the best way to spread word about the podcast and the future of everything.

Today, Lisa Goldman-Rosas from Stanford University will tell us that many people in the United States do not have the resources to eat healthy. And as a result, they are at increased risk for many diseases and the health care costs go up. It's the future of food security. Before we get started, a reminder to tell your friends, neighbors, family, anybody you like about the Future of Everything podcast and your enjoyment of it. Personal recommendations are the best way to spread the news.

Everybody knows that when you're hungry, you have to eat. But the quality of the food that is available to you can be correlated to your resources. Of course it is. And so there are folks, it's estimated about 14% of U.S. households that do not have enough resources to buy and eat healthy food. This leads to choices that are totally understandable to just get the calories anyhow.

Anyhow they can do it. And that leads to choices about food that are often high salt, high fat, low fiber, and just not healthy. Okay, so that's unfortunate. Too bad. It's more than that. These households are at increased risk for many diseases, including cardiovascular disease, diabetes, even some cancers, and yes, mental health disorders. It all contributes to their high stress and food decisions that are not optimal for their health.

Well, Lisa Goldman-Rossas is a professor of epidemiology and population health, medicine, and pediatrics at Stanford University, and she's an expert at food medicine, food as medicine, food with medicine, and food security and food insecurity.

She has studied the chronic disease consequences of lack of access to high quality food, but more importantly perhaps, she's been part of programs to try to address this. You won't be surprised to learn that when people are given a trial of healthy food, some incentives, they try it, many times they like it, they learn new habits, it helps their health.

In addition, there are both state programs and local programs that can incentivize healthy eating and help people address their food insecurity. Lisa, to start out, why did you decide to focus your career on food, food medicine, and food insecurity?

Well, thanks so much for that question, Russ. That's actually kind of an interesting story. You know, as an undergraduate, I cared a lot about the environment and I majored in environmental science. And I was really excited about that until I started doing research in environmental science and realized it was a little isolating. There was a lot of counting bugs. There was a lot of wading in rivers. And, you know, I realized I really wanted to do something with people.

And I speak Spanish. And so I went to my career center and said, you know, what can I do in public health? And, you know, I speak Spanish. Is there anything I can do? And I ended up in this job working as a community outreach worker with migrant farm workers and their families and actually followed the migrant stream. You know, I was in the northern part of the East Coast in the summers. And then I would go down to Florida in the winter, much like, you know, folks from Michigan might go down and stay.

and spend the winter in Florida. And, you know, certainly I spent a lot of time doing education around pesticide safety and working with farmers and things like that. But what really impacted me was that the folks who were harvesting the fruits and vegetables that we enjoy here in the United States don't actually have access to them. And predominantly they're impacted by diet related chronic diseases like diabetes and heart disease.

which is actually true of most of America. And so that was so poignant to me that access to fruits and vegetables and healthy foods is actually such a challenge that it led me down this path to focus on food insecurity, diet, and diet-related chronic disease, what I've been doing ever since.

That is a great story. And I'm just going to insert that today is the 90th birthday of my father-in-law, who was a migrant worker as a kid. Wow. So shout out to father-in-law. You know who you are. OK, so that's a great that's a great setup. So and you and you said so many interesting things there. So do we need to define what food security or food insecurity is just for the conversation?

I think so because we live in the United States and it might seem hard to believe that people would be going hungry. And in fact, that might not be the case like it would have been many decades or centuries ago. So food insecurity refers to having access to the food you need to live a healthy life. It's generally about quantity, but it also has to do with maintaining your health.

And I think that focus on health is why we have started to refer to a new term called nutrition security. This is really just emerging in the last few years, but nutrition security builds on that idea around food insecurity and adds that component of preventing chronic disease, managing any chronic diseases or health issues that you have, and even potentially being able to effectively treat some of your conditions.

We don't really monitor nutrition security like we have over many decades, food insecurity in the United States, but I think that might be coming.

Okay, so I know that in the world, in the general world, there's definitely people who are literally at risk for starving. And I can imagine that in the United States, I'm sure there are some people like that. But I think there's a middle tier or a different tier of people, like the ones you described, who maybe the balance of their diet wasn't good or the choices of food. So can you paint? So this becomes real because we're going to then talk about the diseases that you're an expert at that result. Okay.

Paint up one or two scenarios of the types of foods or food habits that people might have that you as a researcher and a person looking at them says, okay, this is not ideal. Sure. So, you know, when a household, and we actually measure it at the household level, when a household is classified as food insecure, meaning they don't have enough access to the healthy foods they need to support their activities, right?

It usually means that they're reaching for those calories that are the cheapest possible, which is totally understandable. That is what any logical person would do. What we know in the United States is that cheap calories are usually unhealthy calories. So you can imagine calorie per dollar, you know, Cheetos are going to be much more cost effective than buying carrots and broccoli.

Yes, of course. Yeah. The other thing that happens is food insecure families tend not to have enough time to turn healthy foods into meals for their family. They might be managing multiple jobs. They might have multiple priorities that they're dealing with.

I think the other thing that happens is that you can go through these kind of binge cycles where you have resources and you can buy a lot of food and you're motivated to buy those cheap calories so that you have access to them for longer periods of time. And that's generally not going to be the healthy foods we might imagine like fruits and vegetables.

Gotcha. Okay. So that is, thank you. That gives me the picture of the type of decisions and pressures that would be on these folks. So now let's go to the medicine part. I know you've also, and I want to get to food as a medicine, which is a very intriguing idea, but let's talk about the consequences of a food insecurity for the people who are experiencing it. And I know you've studied many areas. Some of them are quite surprising where the manifestations of this disease

then display themselves as medical diagnoses. So how would you kind of describe the risks that are associated with these diets? Sure. So, you know, there's a lot of data that shows us that coming from a food insecure household increases your risk for what we call diet related chronic conditions. That'll be like diabetes, heart disease, you know, for example, hypertension, you can kind of imagine that.

What I think is more surprising is that they're strongly correlated with mental health outcomes as well. So anxiety and depression, you might not think of those as diet related chronic conditions. But certainly you can imagine if you're stressed about where your next meal is going to come from, you know that that could lead to anxiety and depression. Yeah.

Have people studied if there's a causal relationship between the food and the mental health or if they're like both the results of a very stressful life? Yeah, I mean, people certainly have. And I think it's difficult epidemiology to disentangle, of course.

And, you know, I think there are likely multiple paths through which food insecurity leads to those mental health outcomes. I think you also have to think about kind of a life course perspective. So if you're exposed to food insecurity as a small child, how does that set you up for life to think about, you know, what your thoughts are about?

where your next meal is going to come from and how you approach eating. Yes, yes. Okay, great. And so are there particular mental health disorders that are more common in these settings? You know, the ones that we measure most frequently are anxiety and depression because we're usually measuring these in general healthy adults. So you can measure increased symptoms of both anxiety and depression associated with kind of moderate levels of food insecurity and certainly more severe levels.

And I've also noticed you've done some writing about sleep and insomnia. Yeah. So that's a complicated one, right? Yeah. So sleep can be impacted by a number...

number of factors as probably you have experienced. A recent guest on the future of everything was talking to us about it. Yeah. Yeah. So sleep can be impacted by a number of things. You know, first of all, not having enough time to sleep because you're, you know, busy working multiple jobs to make ends meet can also be related to other socioeconomic conditions and living conditions.

I'm not sure if anyone's documented like a direct tie between food insecurity and sleep quality or quantity, but I can imagine that they really co-occur.

Yes, yes, me too. And of course, if you're very hungry, that's an easy one. But even if you're taking in bad calories, high salt, high fat, you could imagine all kinds of interactions. Okay, so that was very helpful. So now we understand what food insecurity is. And you've painted a picture of what kind of eating patterns we might be seeing and some of the health issues.

consequences. Okay. So now I know you're also interested in being part of the solution. So what, what can we do? What can the healthcare system do or society or whoever, what are, what are the things that need to happen? And what, what are the advances we've been making, if any?

Yeah, absolutely. I'm so glad you asked that question. So I think there's a number of things we can do from a policy perspective. And so if you can think about it as kind of a range of interventions from, you know, very high level policies we can do to more individually focused interventions that we need to be thinking about.

And, you know, the nutrition experts across our country have been working on this for decades. It's not entirely new. But at a fundamental level, we need to make sure that all Americans have access to the resources they need to buy the food to support their health. Right. So programs like SNAP or here in California, it's called CalFresh. Some people think of them as food stamps.

are really critical for supporting resources that families have to purchase food. The Special Nutrition Program for Women, Infants, and Children is perhaps another one to mention, a really important policy focused specifically on pregnant women, moms, and young children.

And so those are kind of some examples of higher level policies for the whole population to ensure that-

So food stamps has some regulations. You can't buy anything you can find in a supermarket, but they don't restrict, for example, the types of calories like it doesn't restrict whether you can only buy produce or only whole grains, for example.

And you really could imagine people being very irritated if you were overly invasive about, you know, they have enough issues in their life. Please just let me buy my food. And but on the other hand, right, then you want to say, but can we nudge you in certain directions? Absolutely. Absolutely. And so WIC is an example where only specific foods are supported by the

the WIC program. Um, and they do have wonderful incentive programs, um, to, you know, double your bucks to be able to buy food at, at farmer's markets and things like that, um, to supplement those programs. So they use more of the carrot, uh,

I suppose the stick, if you want to say. Carrot, very beautiful word. Yeah. Great. Okay, so please. Yeah, so moving from policy, then we can think about programs that might be supporting families or individuals. And that's where food as medicine is kind of this new term that people are using, honestly, for programs we've been doing for a long time. Yeah.

A little rebranding every now and then is okay. It's very effective. And what I really like about the term is it explicitly focuses on the connection between healthcare and nutrition programs. And I think healthcare has really been left out of the nutrition focus for a long time. For example, physicians hardly get any training on nutrition when they're in medical school. I can vouch for that.

Yes. And I actually had the chance last week to join a class at Stanford in culinary medicine where some of our medical students were learning how to cook whole grains and plant-based entrees, which was really amazing. So I think that's changing. But nevertheless, most physicians in practice today didn't get a lot of training in nutrition.

And so Food is Medicine is addressing that by saying, okay, we get it. You know, we're not going to solve all your nutrition programs in that short time you have with the physician, but we can support referral to nutrition programs based on the health needs that you have, which I think is just excellent.

So it's really an umbrella term for nutrition programs in conjunction with health care. And, you know, you can think of it as kind of a tiered system. I hate to use the pyramid because, you know, we had our... Food pyramid. There were a lot of questions in third grade about the food pyramid. And then I was told that the food pyramid wasn't a thing anymore. It's not a thing anymore. And I said, I memorized it.

It's not a thing anymore. But, you know, I think nutrition experts are a little stuck with the pyramid. So you can imagine it like a pyramid where at the base we have programs that are really effective for everybody. Actually, the Women, Infant and Children WIC program is kind of like the original food as medicine program because you usually get referred during prenatal care.

So anyway, you could imagine like produce prescriptions where your physician says, I really want you to be eating more fruits and vegetables. I'm going to write you a prescription for produce. That prescription goes to a local farm or a food bank or an organization that will either give you a voucher or deliver produce to your door.

or have a pickup location near your house or something like that. And that's really appropriate for people who are preventing disease or maybe have one chronic disease or something like that. And eating more produce would be really effective for that. Yes, yes. I love this. I love this. I've always thought when I was practicing medicine more often, I was always impressed that some patients, if you just gave them a prescription, even for something ridiculous, like not a medication, but like carrots. Go to a walk.

Yeah. Go on a walk. A motivated patient can use that and they can wave it in front of other people to kind of help get what they need. I, one time I prescribed a baseball game because it's a long story. I won't tell it, but I decided that it was in the end.

It was in the interest of the patient to watch a San Francisco Giants game. And I wrote it on the prescription. The nurses, it was a hospitalized patient. They couldn't believe what they were seeing, but they did it. It was, you know, the patient and the family appreciated it. And then the local news found out about it. So now there is a videotape of young Russ Altman explaining why he prescribed baseball. But I am a big fan that food, prescribing food sounds like a great idea to me.

Absolutely. And I think the other end of the spectrum that you're probably familiar with is like medically tailored meals is the technical term. But imagine like Meals on Wheels. We know that homebound seniors or potentially people coming out of the hospital, you know, they might benefit from having some meals delivered at least for some short period of time. Yeah.

And then, you know, I think a question that's logical to follow, okay, you give these patients some produce, you give these patients some medically tailored meals, it's only a short time. Right, right, right. And I think we like to think about it as like a, you know, critical window or a unique teachable moment. Let's say we're giving you produce for 12 weeks.

That's a time where you can try out some new vegetables kind of risk-free. We know individuals who have limited income, limited resources for food, they're not going to risk it on buying an unknown squash or a beet or a couscous or whatever it is. Because who knows if their kids are going to eat it and then they've wasted it.

But this gives you kind of a window to try out some new things, see what you like, and then we can help you connect to resources in the community to find them later. So we call it Try It Like It, Find It. And that's kind of our goal during the time period that you're getting the food as medicine. And I like the 12 weeks that you pointed out. That seems to be enough time that if it increases your sense of well-being and your sense of health, that might be enough time where you would notice that. You would notice like –

your bathroom habits might be better or whatever that means. And everybody knows what it means. And, or, or you feel better or you feel more energy in the morning. And so I love this idea of a trial period. And then especially giving them the, the tools and knowledge to how do you extend this beyond where we can help you explicitly. Exactly. This is the future of everything with Russ Altman. We'll have more with Lisa Goldman Rosas next.

Welcome back to the Future of Everything. I'm Russ Altman, and I'm speaking with Professor Lisa Goldman-Rossas from Stanford University. In the last segment, we defined what food insecurity was. We looked at all of the diseases that are increased in patients who don't have good food security, and we learned about some of the programs that exist to try to help folks out. In this segment, we're going to learn about an exciting program called Recipe for Health,

which prescribes food, gets food, and teaches healthy living behaviors. And guess what? It works. We're also going to talk about some diseases that cause food insecurity because they're so expensive. And then finally, we'll end up with some tips for anybody who wants to think about how to improve their own food security.

In this segment, I wanted to ask you about an exciting program that I saw in your work called Recipe for Health with a four as a number. Tell me about Recipe for Health.

Yeah, I'm so glad you asked about that. So Recipe for Health is a comprehensive produce prescription program. I think it's a great example of the food as medicine programs that we were talking about. And you've seen that nutrition folks love food analogies. So I'll tell you it has three ingredients. So Recipe for Health. Stay on brand. I love it.

It starts with the health clinics and does work with the staff and the providers to train them how to incorporate nutrition in the work that they do. They also do some alterations in the electronic health record to make it super easy to press a button and refer patients to Recipe for Health.

And then Recipe for Health has two components. So it has a food pharmacy. That's pharmacy with an F like pharmacy. Oh, my goodness. Which is a produce prescription from a local farm. So they get fruits and vegetables. We often say vegetables and fruit because it's mainly vegetables that are grown here locally. Right.

And then behavioral pharmacy in which they get kind of health coaching to support their health goals, help them learn how to take that produce and turn it into meals.

And so we've been implementing it in Alameda County. They've really been at the forefront in Alameda County of implementing food as medicine. And this has been amazing to see. And we got the opportunity to evaluate their program, which was really great. And we're continuing to evaluate it to this day. But in our first evaluation, we found that

Participants in Recipe for Health increased their fruit and vegetable consumption. They actually increased their physical activity as a result of participating in the health coaching. They decreased their food insecurity, so that went significantly down. And we were even able to look at labs in the electronic health record and see that improvements in hemoglobin A1C, improvements in their lipid levels increased.

you know, decreases in healthcare utilization that we don't want to see. So really exciting preliminary outcomes from that study that we're continuing to follow up on.

Yeah, that is exciting. And of course, I'm sure that the expense of it is important. But knowing that there are grocers who are selling more vegetables gives you hope that there can be an economic model that works for everybody. Absolutely. I think it's important to think about the economics more broadly, like the local farms who are getting to serve more folks. And some of those folks even continue buying the produce from those farms after the program, which is insane. Right.

So I wanted another thing that you've written a little bit about is how sometimes we've been talking about how food insecurity can cause health problems. But I know that you also think about how health problems can cause food insecurity. So what's that all about?

Yeah, that's another reason I think food as medicine is so important is for patients who are dealing with costly chronic conditions. And diabetes is a good example. But you could also think about cancer, very costly treatment for many cancers. That can actually cause folks to become food insecure and have to make really tough choices about medicine and food or housing and utilities and food. And so it's a really good...

complex cycle that you have to think about, which is why I think it makes sense for healthcare to be getting involved in addressing food insecurity. Yeah, that really makes sense, especially with the cost of some of the new diabetes medications, which are very effective but very expensive. Anybody with cancer knows that the chemotherapy is a huge financial burden. And of course, that rent and food would be the things that would be threatened, is my guess, and then many other things as well.

You mentioned all these programs, WIC and its siblings. I was wondering if there were any other kind of policy level innovations that have happened that give you kind of hope as you look at food insecurity as a systemic problem.

Yeah, so Recipe for Health wouldn't be continuing, I don't think, without the support of some state-level policies. So many states, California included, have what's called a Medi-Cal waiver, which allows Medicaid funding to go towards food. Well, actually go towards many community supports, food being one of them.

And so when a provider says, you know, I think you need a produce prescription and writes you that prescription for your fruits and vegetables for the week, that can actually be reimbursed as a Medicaid expense. And so I think that will support a lot of communities in implementing food as medicine more widely. Wow. And did you say how many states have done this? So I believe it's 14 states now. Okay. So this is a good chunk. Yeah.

Absolutely. And it's increasing all the time. And they will be telling their fellow states whether it's working or not. And, you know, they're looking at the state expenditures on health care. So they will benefit from effective interventions. Absolutely. One other systemic question I wanted to ask was and I could guess this answer, but I don't want to guess. I want to ask you.

We've been talking about governmental interventions, but there's also private industry. And in fact, there's some people making a lot of money selling food, not always the most healthy food. Do you see any movement in those companies towards helping with food insecurity? Or is that just too much to ask or just not happening for whatever reason? Yeah.

You know, I think it would take pressure, you know, government, uh, and, and consumer pressure to do more right now. We do see that some of those big, um, uh, food companies are getting in the business of food is medicine. Uh,

Which does push them to think about which foods would be healthier. So we have a project with Instacart and one of the great things that they've done on their platform is indicated which foods are eligible for food as medicine by calling them fresh funds.

And so this tells the consumer, you know, that's generally a healthy food that you can choose. And so these are small, you know, changes that are being made. Yeah, no, labeling at a minimum, like that's easy and it helps. That's great. That's a great example where, you know, some of your food is going to maybe be reimbursed by this program, but we're going to help you know which it is so you can just make these choices easier. It just lubricates. Okay, that's great. I'm glad I asked. So

Finally, we have a couple minutes. I just wanted to ask if you have advice for people. So everybody lives on a spectrum, right? And some people have – they don't have any financial barriers, but for whatever reason, they're maybe not eating as well as they'd like to. So they're acting like they're food insecure even though they're not money insecure. And then there are people who are truly –

resource insecure and they have challenges that may even be similar. And so I'm just wondering if through your work, there are like tips for people who want to think about eating more healthy, pushing back all of these disease associations that they don't want to get. How should they approach this and kind of take personal responsibility for some of this?

This is such a great question. And we get this all the time. I mean, this is what we're in the business for. And, you know, I always say don't let perfect be the enemy of the good. So some people think I need to eat all fresh produce. I need to make sure it's organic and so on. And actually, you know, you can get the same nutrients and you can make it taste really good by buying frozen produce, which is a lot more cost effective.

You can also think about which ones do you really want to spend money on being organic. You know, if you're going to peel the banana or peel the orange, maybe it's not as important. Yes. And the other thing is always to start small. Don't think you have to do everything all at once. If you want to eat more whole grains, try replacing just one meal a day whole grains instead of refined grains.

That's fantastic. And the only other thing I'll ask in case there's anything is what about different demographics? There's been a lot in the news about elderly eating protein for breakfast type things, you know, and don't ask me why I know that. But but are there important like age specific things that you would want to get out to the public as? Yeah, this really is something worth worrying about. Or do you think a lot of this is a little bit not important?

Yeah, I think in our work, what we're really trying to do is focus on these larger shifts of getting people to eat more produce, more plant-based foods, as opposed to getting into the nitty gritty of you need to eat 100 grams of protein, which, by the way, you probably don't. Exactly, exactly.

So focus more on, think of my plate, make half your plate fruits and vegetables, a small piece of protein. Think about a couple of times a week, not having it be meat and think about whole grains instead of refined grains. Okay. So then this will be my final question. What is it about those vegetables and fruit that is so good?

So tons of vitamins and minerals, lots of fiber, helps your gut, really important low calorie so you're getting full on fewer calories. Thanks to Lisa Goldman Rosas. That was the future of food security.

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