Food Is Medicine: A Clinical and Policy Imperative for 21st Century Health Systems
A special communication published in JAMA Health Forum provides a comprehensive framework for integrating food-based nutrition interventions into health care delivery—outlining the policy landscape, health system implementation strategies, and the critical role of physicians in addressing the root causes of cardiometabolic disease.
Background: The Diet-Disease Burden and the Case for Action
The magnitude of diet-related disease in the United States demands a systemic response. Cardiovascular disease, type 2 diabetes, obesity, hypertension, stroke, and chronic kidney disease are all substantially influenced by dietary quality, and the economic consequences are staggering. CVD, type 2 diabetes, and stroke collectively account for nearly 90% of the global macroeconomic burden attributable to poor dietary quality, generating a direct and indirect cost of $1.1 trillion annually for CVDs alone. Despite this evidence, food and nutrition remain critically underprioritized in clinical practice.
A special communication published in JAMA Health Forum by Shah, Aggarwal, Aspry, and colleagues from Tufts University, Brown University Health, Albert Einstein College of Medicine, and National Jewish Health presents a detailed and actionable framework for addressing this gap through the Food is Medicine (FIM) movement. The authors define FIM as a movement that integrates food-based nutrition interventions into health care delivery to prevent, manage, and treat diet-related chronic diseases—a definition that spans a five-tiered pyramid of population-level policies, federal nutrition assistance programs, and targeted clinical interventions.
What Is Food Is Medicine? A Clinical Framework
FIM encompasses three core categories of clinical intervention deployed in coordination with health systems: produce prescriptions (PRx), medically tailored groceries (MTGs), and medically tailored meals (MTMs). These are layered above federal food assistance programs such as SNAP, WIC, and school meals, which serve foundational population-level roles. Nutrition education and counseling cut across all tiers.
The eligibility model for clinical FIM interventions typically pairs a diet-related diagnosis—diabetes, hypertension, heart failure, chronic kidney disease—with a health-related social need, most often food insecurity. The authors emphasize that this targeting makes FIM not only clinically appropriate but also economically defensible. Simulation models project that national expansion of MTM coverage would be net cost-saving in nearly all states, with return-on-investment ratios ranging from cost-neutral to greater than 3:1.
The Federal and State Policy Landscape
Federal momentum behind FIM has grown substantially in recent years, though coverage pathways remain fragmented. The 2022 White House Conference on Hunger, Nutrition, and Health—only the second of its kind in more than five decades—established a National Strategy that explicitly identified FIM interventions as health system priorities. The Centers for Medicare & Medicaid Services now allows Medicare Advantage plans to deliver nutrition services and has created pathways for state Medicaid programs to fund FIM through Section 1115 waiver demonstration projects and In Lieu of Services (ILOS) authorities.
Sixteen states are currently approved for or pending 1115 waivers that include FIM-related services, and 10 of 25 states using ILOS authorities have done so to address food and nutrition security—including provision of MTMs, groceries, fruit and vegetable vouchers, and nutrition education. The federal government allocated $142.2 billion to 16 food and nutrition assistance programs during fiscal year 2024, though the authors acknowledge that FIM-specific clinical interventions represent only a small fraction of this investment.
The article notes a telling fiscal signal for health system leaders:
"During fiscal year 2024, federal outlays for health care programs and services rose to 27% of total federal spending."
This trajectory, the authors argue, makes investment in preventive food-based interventions a matter not only of health equity but of fiscal sustainability.
Health System Implementation: A Physician-Led Model
The authors are explicit that clinicians are not passive recipients of policy change—they are essential architects of FIM delivery. The barriers to implementation are well characterized: limited physician nutrition training, poor integration of nutrition screening into clinical workflows, absence of guideline-based FIM care pathways, and lack of reimbursement for FIM services in fee-for-service settings. The article frames these as solvable problems, and offers a concrete, EHR-enabled six-step pathway for clinical integration.
The proposed workflow begins with systematic screening using the USDA Hunger Vital Sign tool and Z-code documentation, progresses through risk stratification and EHR-triggered referral to the appropriate FIM tier, incorporates patient education and dietary behavior support, and closes the loop with outcomes monitoring and quality improvement reporting. The authors describe this design as iterative, allowing practices to refine eligibility criteria, intervention dose, and referral workflows based on real-world outcomes data.
The article is direct about what this requires from individual physicians:
"Clinician trust can be leveraged by presenting nutrition and FIM referrals with the same clarity and confidence as medication recommendations, thereby supporting patient engagement and adherence."
The analogy to pharmacotherapy is deliberate and substantive. Just as a cardiologist would not hesitate to prescribe a statin for a patient with LDL above guideline thresholds, the authors argue that FIM referrals should carry the same clinical authority and systematic follow-through—particularly given that many patients on GLP-1 receptor agonists for obesity and metabolic syndrome still lack dietary and lifestyle support that would amplify their pharmacological gains.
Multidisciplinary Teams and Health IT as Infrastructure
Effective FIM delivery depends on multidisciplinary infrastructure: physicians, registered dietitian nutritionists (RDNs), nurses, social workers, community health workers, and health IT personnel working in concert. A randomized clinical trial of a clinic-based FIM program for adults with diabetes and food insecurity demonstrated improved outcomes versus usual care, underscoring the clinical efficacy of team-based approaches.
On the technology side, the authors describe a vision for closed-loop electronic referral systems that integrate FIM order sets with vendor fulfillment platforms, track produce prescription redemption and meal delivery, and surface outcomes dashboards for continuous quality improvement. EHR platforms including Epic, Cerner, and athenahealth are specifically cited as implementation targets. FHIR-based data models for screening, orders, and program dose, combined with AI-enabled decision support to match patients to FIM tiers, represent the frontier of this work.
The authors summarize the opportunity for systems transformation:
"Using implementation strategies that harness clinical information systems, collaborative care, and the transition to population health management, clinician teams now possess the systems tools needed to make FIM a foundational component of 21st century health care delivery."
Research Gaps and the NIH Investment Challenge
Despite growing clinical evidence, FIM research remains underfunded relative to the scale of the problem. The NIH funded 13 FIM research projects totaling $6.9 million in 2022 and 14 projects totaling $8.5 million in 2023—figures that stand in stark contrast to the $1.1 trillion annual economic burden of diet-related cardiovascular disease. The authors call for more robust study designs focused on comparative effectiveness across FIM doses, durations, and delivery models; standardized outcome measures; and long-term follow-up stratified by diagnosis severity and social needs.
Critically, the authors also identify an unexplored frontier in pharmacological integration. The research agenda includes 2×2 factorial trials pairing GLP-1 receptor agonist therapy with FIM interventions—examining outcomes in weight, HbA1c, adherence, health care utilization, and per-member-per-month cost. As the authors note:
"Despite expanded glucagon-like-peptide-1 receptor-agonist use, many eligible patients still lack diet and lifestyle support, even though pharmacotherapy, when paired with lifestyle interventions, plays a pivotal role in disease management."
The Physician as Advocate
The article closes with a direct call to clinical action that extends beyond the exam room. Physicians are positioned as essential voices in the policy debate over FIM reimbursement, coverage expansion, and legislative advocacy. The authors recommend that clinicians write op-eds, testify before state and federal legislators, participate in stakeholder coalitions, and work with professional society policy committees. The argument is not merely ethical—it is strategic. As value-based care models proliferate and population health metrics shape reimbursement, FIM offers a measurable, scalable pathway to improving quality metrics while reducing high-cost utilization.
Poor diet remains the single largest modifiable driver of cardiovascular morbidity and mortality in the United States. The policy environment is shifting, the technology infrastructure is maturing, and the economic case is compelling. What remains is the clinical will to integrate food as medicine with the same rigor and confidence that physicians currently bring to the prescription pad.
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