MILTON, Mass. – Standing in the doorway of his new home, Bouba Diemé, sturdy and 6 feet 8 inches tall, doesn't look medically fragile.
But Diemé, a program manager and father of three, has been waiting six years to reach the top of the local heart transplant list.
And when he finally gets there – which could happen at any time – his body has to be ready for the surgery.
That's why once a week for the past four years, Diemé, the driver of a refrigerated van, has dropped off five days' worth of "medically tailored meals" at his house.
Diemé is one of about 2,000 people across Massachusetts and parts of Rhode Island who receives a weekly meal delivery catered to his taste and medical requirements. Many recipients are elderly, coping with multiple illnesses, and unable to shop or cook on their own. Others are children fighting cancer whose parents don't have time or resources to make sure every calorie will support their fragile health.
The idea of delivering regular meals to people with health problems began at scale during the early days of the HIV/AIDS epidemic when young men were dying alone of malnutrition because of their disease.
Community Servings, which feeds Diemé, was born 32 years ago to fill that need and has provided meal deliveries since from its commercial kitchen in the Jamaica Plain neighborhood of Boston.
It's a model that nutrition experts hope will become a staple of the American system of social benefits.
The White House Conference on Hunger, Nutrition and Health, held Wednesday, recommended a pilot program to study covering medically tailored meals as part of Medicare Advantage plans.
Expanding medically tailored meals is one of a laundry list of new plans from the Biden administration to "end hunger and reduce diet-related diseases and disparities." And private sector and nonprofit organizations pledged more than $8 Wednesday toward nutrition support programs, including medically tailored meals.
The last such conference, held more than a half-century ago during the Nixon administration, led to the expansion of food stamps and other food supports that dramatically reduced starvation in one of the richest countries on earth.
Congressional approval will be required for some of the Biden administration's priorities, including the medically tailored meals pilot, investing in parks, and expanding food stamps with a focus on access to fruits and vegetables. Other programs, such as voluntarily reducing salt and sugar and placing nutrition labels on the front of packages, may call for private sector support.
Revised food programs are urgently needed, experts said, at a time of rampant inflation and growing chronic health issues. At least 10% of the American public is "food insecure," meaning they're not sure where their next meal is coming from. And more than 40% of Americans have obesity, in part because the most inexpensive, readily available foods contribute to weight gain and poor metabolic health.
Medically tailored meals like those offered by Community Servings, can help address both problems in the short run, with other programs needed to address hunger for the longer term, said Dr. Dariush Mozaffarian, dean for policy at the Tufts Friedman School of Nutrition
Mozaffarian, one of the co-chairs of the task force that made recommendations to the White House conference, said he expects medically tailored meals and similar programs will be a centerpiece of any new national strategy to come out of the conference.
"I would be shocked and disappointed if 'food as medicine' weren't a prominent part of it," he said. "It's so promising."
Today, a small percentage of Americans with the most serious health problems use up almost half of the country's health care resources. They are admitted to a hospital, discharged to a nursing home, sent home, and then end up back in the hospital or nursing home several times a year.
"Medically tailored meals have been shown to break that negative, vicious cycle," Mozaffarian said. "They use the emergency room less, they get admitted to the hospital less, they go to nursing homes less, they feel better."
Plus, he said, although Medicaid and Medicare haven't been allowed to fund medically tailored meals programs, such approaches could save the government money. "Even accounting for the cost of the food, the cost of a hospitalization or nursing home or emergency room visit is so much – is so wildly expensive, that just paying for the food is much more effective."
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'You are not forgotten'
Community Servings runs a busy operation. Every morning, dozens of volunteers get a quick course on how to properly keep bacteria away from food. Then they don customized caps and wash up along a wall of stainless steel sinks.
In one area of the kitchen, volunteers, under the watchful eye of a trained chef, chop onions and celery for soups and salads. Another weighs out precisely 4 ounces of barbeque chicken. Someone else nestles broccoli and a generous slice of cornbread into a container with the chicken.
"Two things we learned early on," said David Waters, Community Servings' CEO: People who are ill have no appetite. And "if you bring them mediocre food, they're not going to eat it." So Community Servings makes sure its offerings are well above what he was served in his high school cafeteria.
Every day, multigallon soup pots are filled with produce unsold at local farmer's markets or gleaned from fields within a few hours' drive. Stacks of yeasted dough rise while waiting to be handmade into rolls.
Since its earliest days, Community Servings has been about helping people who feel sick, scared and isolated.
"It's sending the message: 'We see you and you're not forgotten,'" Waters said.
Volunteers pack shopping bags with a week's worth of meals. People who can eat only soft foods might get one set of options, while those with a heart condition like Diemé will get another, and a person who is malnourished, perhaps fighting cancer, might get a third, with extra protein and calories.
"Health care says to the patient: 'This is what you need to do,'" and maybe hands the patient a piece of paper explaining the diet they need to follow, Waters said. But even those with a lot of privilege would struggle to meet such requirements. For a high-needs patient that's simply impossible: "The system sets them up to fail."
Research shows bringing nutritionally tailored healthy meals to people with critical and chronic illnesses can save money.
In one 2018 study, people on medically tailored meals cost the health care system 16% less than those who didn't receive the meals. The cost for six months of meals roughly equals one night's stay in a hospital, Waters said.
"Medically tailored meals are a very effective food insecurity intervention," said Dr. Seth Berkowitz, who helped lead that study and is now at the University of North Carolina School of medicine.
But there are still unanswered questions about how best to use medically tailored meals to improve health outcomes, he said via email: "I think there is still more we can learn about what combination of medical and social conditions medically tailored meals work best for, along with questions about the ‘dose,’ ‘duration’ ."
Originally funded through federal HIV spending via the Ryan White Act, philanthropy has helped Community Servings thrive and expand, and now the nonprofit also holds contracts with the state and 18 insurance companies.
The typical Community Servings recipient lives below 200% of the poverty level and needs anywhere from 2 weeks' worth of meals at the end of life, to a decade of food for someone living with HIV or severe diabetes, Water said.
The aim is to get them over a crisis, model what healthy eating and portion control looks like, and stabilize them, "so they can go back to being independent," Waters said. "We don't want to create a dependent culture, but we want to make sure whatever their crisis is that we can support them through it."
Fighting disease with food
A handful of nutrition and hunger experts said they're not really sure what to expect from the White House Conference, but they hope the outcome will include more support for food as medicine.
"The role of nutrition in disease is poorly understood and not widely recognized," said Dr. William Dietz, who directs the Sumner M. Redstone Global Center for Prevention and Wellness at the Milken Institute School of Public Health at George Washington University.
"If that is an important emphasis that emerges from the conference, that could really open the door for a broader application of food as health and disease in the U.S.," he said, including, he hopes, an expansion of food stamps and free school meals for every child.
"Medically tailored meals and its use in patients is really a microcosm of the broader need for a more balanced diet with an emphasis on fruits and vegetables for the general population," Dietz said.
Nicole Heckman, vice president of benefits access for the AARP Foundation, said she sees medically tailored meals as an essential stop-gap for people in crisis.
But they generally last just six months. Follow-on programs like food stamps are also needed, she said, to enable people to "continue purchasing the food they were introduced to" when on medically tailored meals, she said. The food stamp program, now known as the Supplemental Nutrition Assistance Program "is absolutely critical for folks with low income to be able to consistently afford the food they need to live a healthy and active life."
More than 16 million older adults don't know that they're eligible for food stamps, she said, and 3 million of them missed out on more than $200 a month in benefits in 2018.
And more than 37 million Americans over 50 live in poverty or "one life event away from slipping into it," Heckman said. Older adults on fixed incomes are particularly vulnerable to inflation, she said, and in today's economic climate, "many older adults are being forced to choose between the medicines they need and essentials like food and rent."
Managed health care giant Kaiser Permanente has seen the benefits of medically tailored meals, said Pamela Schwartz, Kaiser's executive director for Community Health.
"We, like others in health carte, know that being healthy isn't just the result of high-quality medical care," Schwartz said. "When people are hungry or they lack proper nutrition or can't get the food they need for a particular medical need, they're less likely to get or stay healthy."
During the pandemic, Kaiser led a study of 2,000 high-risk adults recently discharged from five of its hospitals. After 90 days, patients diagnosed with heart failure were less likely to return to the hospital if they had been receiving medically tailored meals.
"It was a rigorous study with a very compelling finding," Schwartz said.
There was no change seen in patients' conditions like kidney disease or diabetes, which Schwartz said might have been a result of the short time frame of the study.
"Future trials are needed to really understand what works best here and under what conditions," she said.
The national dialogue that's happening now about food as medicine is unprecedented, with momentum and openness at the national level to talking about the role "food plays in improving health outcomes and costs," Schwartz said. "I've never seen a moment like now."
The next big push has to be increasing the scale of food as medicine, said Dr. Jason Langheier, founder and CEO of Foodsmart, a digital network of registered dietitians and food retailers.
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Foodsmart teaches people how to make healthier food choices and helps ensure they are receiving the government benefits they're due. He's not selling food, but helping health insurers save money – $40 per member, according to one internal study – by training people to eat better and helping them access healthier food.
"There's actually ample resources available to change a family's life forever, but you have to do the right steps in the right order," Langheier said.
He predicts that by 2030, many people will leave their doctor's office with not just a prescription for medication, but one for food, as well.
Mozaffarian said he expects the conference will lead to changes in the government's position on "food as medicine."
Medicare and Medicaid have not formally made a decision that food is a medical treatment, he said, but all it would take is the signature of the Health and Human Services secretary to say it's appropriate for them to pay for evidence-based food treatments.
Making someone 10 customized meals a week costs about $93, Mozaffarian said, or $4,500 a year, compared with a single hospital stay, which can easily run $20,000. About 6.3 million Americans would be eligible for medically tailored meals, he said, based on having a "nutrition-sensitive disease" and some limitation of their daily activity, such as not being able to shop or cook for themselves.
Estimates suggest these programs could provide a net savings of about $185 billion over 10 years, Mozaffarian said: "It's a no-brainer."
Delivering healthy food
On a recent morning in Community Servings' teaching kitchen, a chef was preparing to show a crew of trainees how to make cream puffs.
Up to a dozen trainees at a time spend 12 weeks learning kitchen basics. They might have been recently released from prison, struggling with mental health challenges or homeless. But here, they don chefs aprons and learn nutrition, job readiness skills and financial literacy.
"They need a safe place to get on their feet," Waters said. The message trainees get is, "we need you as much as you need us."
Mostly urban dwellers, trainees might never have seen food come out of the ground before, so in an adjacent garden, they learn to grow herbs, tomatoes, and cucumbers used in the kitchens.
The teaching kitchen is also fitted out with cameras. Lessons there are posted live on Facebook and YouTube in English, Spanish and Portuguese. The foreign-language classes are the most popular among the 500 to 700 weekly viewers.
Larry Williams started working at Community Servings nine years ago. A driver for most of that time, he was promoted this month to delivery manager, responsible for running the 12- to 15-person crew, hiring drivers, and making sure deliveries are made regularly and when clients need them.
Short-staffed, he spent a recent day making deliveries himself – which he said he's happy to do.
Even though drivers hand off most of the meals at a client's front door, they still form a bond, Williams said. He realized the importance of his work when one regular client called him part of her family. "It was so new for me to be that big in somebody's life."
Diemé, 35, said the food deliveries have helped expand his diet and been extremely helpful in maintaining his transplant readiness.
"It's one less variable to think about," he said. "If I'm not eating properly, it can undo all the good work."
A native of Mali in West Africa, Diemé met his wife, Desirée Allen, in South Africa when he was a business student. The couple were visiting relatives in her native Boston in 2016 when his heart, which was malformed at birth, began to give out. They settled near family with their young son and in 2018, had twin boys.
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To keep his blood flowing properly and to be ready for surgery, Diemé needs to keep his weight stable and his vitamin K within a narrow range, which means tightly controlling his consumption of green vegetables like lettuce, spinach and broccoli, as well as soybean and canola oils.
"My medical team loves it," he said of his meals.
If he doesn't like one of the offerings, he can just let Community Servings know, and they will adjust. He appreciates the variety of the offerings. The controlled portions have taught him appropriate portion size, said Diemé who has started his own nonprofit, Heart of a Giant, to promote heart health. He makes sure eligible people are aware of Community Servings:
"We want more people to have it."
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This article originally appeared on USA TODAY: Medical tailored meals part of Conference on Hunger, Nutrition, Health