THE POTENTIAL OF FOOD-AS-MEDICINE FOR THE TREATMENT OF CHRONIC CONDITIONS IN THE VETERAN POPULATION
Spartan Medical, Inc. is a service-disabled, veteran-owned small business (SDVOSB) which, in collaboration with Tangelo, developed the Veteran HealthPak®️ Medically-Tailored Meals program to dramatically reduce healthcare spending while simultaneously improving veteran care by utilizing a unique Food-as-Medicine approach to treat Veterans suffering from chronic health conditions.
The President’s Make America Healthy Again (MAHA) Executive Order of February 13, 2025, leads with the issue that the majority of Americans have at least one chronic health condition.1 Within the veteran community specifically, both chronic conditions and food insecurity are higher than the American average, representing a largely unseen crisis in veteran healthcare. In part for that reason, the Secretary of Veterans Affairs has been appointed as a member of the MAHA Commission. A startling 11% of working-age veterans currently suffer from food insecurity.2 Directly correlated3 to these nutritional deficiencies, 72% of veterans currently suffer from one or more chronic health conditions,4 44% higher than the national average.5 More than 1 million veterans are both food-insecure and diagnosed with a chronic condition. The impact of these paired conditions is devastating to veteran health: food insecurity alone is predictive of a 45% increase in annual healthcare costs,6 and veterans who are both food insecure and suffer from a chronic condition are the single most costly patient cohort in the Veterans Health Administration (“VHA”).
Food-as-Medicine Can Address the Veteran Healthcare Crisis
Among veterans suffering from chronic conditions, their nutritional intake averages far below the USDA’s medical guidance.7 On average, veterans diagnosed with chronic conditions consume 40% fewer vegetables (amounting to roughly 1 serving per day) and 50% fewer fruits (also roughly 1 serving per day) than the amount recommended by the federal government.8,9 This malnutrition is particularly detrimental to the rates of disabling symptoms, morbidity, and mortality as a result of each of these veteran’s chronic conditions. And while we have a moral obligation to provide the best possible care for our veterans, the ongoing reality of budgetary pressures will create massive challenges to the VHA’s future capability to provide optimal support for the most cost-intensive category—veterans suffering from long-term chronic health conditions.
Any pragmatic analysis of these dueling challenges reveals that a comprehensive, preventive, Food-as-Medicine treatment of Veterans with chronic conditions may be the only financially and medically viable solution moving forward. The VHA, recognizing this opportunity, has issued two VHA Directives that provide a policy foundation for such a program:
VHA Directive 1438, Clinical Nutrition Management and Therapy (Sept. 30, 2022) (Establishing VHA policy for Nutrition and Food Services (NFS) “to fulfill its mission of providing comprehensive medical nutrition services for those requiring preventive care or who are nutritionally compromised or have an unresolved nutrition diagnosis.”)10
VHA Directive 1120.02, Health Promotion and Disease Prevention Core Program Requirements (Sept. 19, 2019) (“VHA’s preventive care programming is designed to ensure that veterans receive comprehensive health education, appropriate clinical preventive services, support for self-care that includes health behavior change, and support for self-management of chronic conditions….”).11
Food-as-Medicine Programs More than Pay for Themselves
Medially-Tailored Meal programs have been shown to generate healthcare cost savings of between $4 and $16 for every $1 invested,12,13 saving hundreds to thousands of dollars in healthcare costs per patient, per month.14,15,16 A 2022 study published in the Journal of the American Medical Association found that providing Medically-Tailored Meals to patients with chronic conditions averted an average of $18.89 in health care costs per meal provided, significantly more than the cost of the Medically-Tailored Meal delivery program. Similarly, a 2023 study published in the Journal of the American Heart Association found that averted healthcare costs exceeded the cost of a comprehensive Medically-Tailored Meals program. Surprisingly, these savings materialize rapidly—one study found that after just 6 months on a Medically-Tailored Meal program, the rate of hospitalization was reduced by 50% and Emergency Department visits were reduced by 70%.18
The Veteran HealthPak®️ (powered by Tangelo) was specifically optimized to capture these savings—it provides chronic-condition-specific Medically-Tailored Meals (MTM) with at least two supplemental servings of fruits and vegetables per day at a cost significantly below the avoided healthcare costs as identified by these studies. While the prospective economic savings alone support MTM treatments like the Veteran HealthPak®, the most compelling argument is the potential to dramatically improve the quality of life of veterans with chronic conditions by preventing debilitating health consequences before they occur.
Food-as-Medicine Has the Potential to Dramatically Improve Veteran Health Outcomes
Addressing these deficiencies in fruit and vegetable consumption as well as optimizing macro- and micro-nutrient deficiencies in diet has been shown to decrease all-cause mortality by up to 56%.19,20 When enhanced by specific foods medically-tailored to best address each veteran’s chronic condition(s), the potential success in minimizing future symptoms of their chronic conditions, hospital admissions, as well as general morbidity and mortality for each individual enrollee is substantial. A brief review of the benefits, as derived from published literature, of the tailored increase in the intake of fruits and vegetables directly supports the efficacy of this methodology:
Arthritis: A significant increase in fruit and vegetable consumption, as facilitated by MTMs, can decrease the risk of developing inflammatory polyarthritis by 300%.21
Asthma: Higher fruit and vegetable intake, as provided by MTMs was associated with a 24% lower risk of asthma exacerbation.22 Similarly, the nutrient profile in apple consumption alone reduced risk of asthma by 32%.23
Atrial Fibrillation: Consuming a diet high in fruits and vegetables—as provided by MTMs, was associated with a reduction in the risk of atrial fibrillation by as much as 22% compared to those consuming less than the recommended amount.24
Cancer: Those consuming five servings of fruits and vegetables per day (as facilitated by existing diets supplemented by MTMs) have a 10% lower risk of breast cancer compared to those consuming only 2 servings daily.25
Chronic Kidney Disease: A single additional serving of fruits or vegetables per day has been shown to reduce the risk of kidney failure by 11% to 15%.26 Medically Tailored Meals may provide approximately double this increase in fruits and vegetables.
COPD: Severity of COPD symptoms were reduced an average of 24% by increasing one additional serving of fruit per day.27 Medically Tailored Meals may provide approximately double that amount of tailored fruits and vegetables per day, potentially increasing that benefit.
Depression: A single additional serving of fruits or vegetables per day reduces the risk of ongoing depression by 3%,28 statistically more significant than most FDA-approved SSRI medications.29 Medically Tailored Meals may provide approximately double this increase in fruits and vegetables.
Diabetes: Consumption of one additional serving of green vegetables per day (through MTMs provide approximately double this amount) was associated with a 14% lower risk of type 2 diabetes,30 with each additional serving of fruits or vegetables associated with a further 7% lower risk of type 2 diabetes31—suggesting Medically Tailored Meals could reduce the risk of type 2 diabetes by 21%.
Heart Disease: Two additional servings of fruits or vegetables per day, approximately what is provided by MTMs, was associated with reducing the relative risk of coronary heart disease by 8%-32%.32
Hepatitis: Consumption of a diet high in fruits and vegetables, as facilitated by MTMs, was associated with a 16%-32% lower risk of liver fibrosis.33
HIV/AIDS: Under-consumption of a diet high in fruits and vegetables, remediated by MTMs, constitutes the second most common cause of cardiovascular risk in HIV-positive patients.34
High Cholesterol: A systematic review found that consuming an additional two servings of fruits and vegetables per day (approximately the amount provided by MTMs) led to an average reduction of 6.2 mg/dL in LDL cholesterol.35
Hypertension: A meta-analysis found that increase of only one serving per day of fruits or vegetables was associated with a 4% reduction in risk of hypertension,36 and a diet with a high overall consumption of fruits and vegetables (total of 5 servings per day) was associated with a 20% lower risk of Diastolic blood pressure over 90 and a 17% lower risk of Systolic blood pressure over 140.37 With MTMs providing an additional 2.5 servings of fruits and vegetables per meal, 5 servings is a readily attainable goal.
Osteoporosis: Consuming a diet high in fruits and vegetables, as facilitated by the MTMs, was associated with a 12% lower risk of osteoporosis-related fractures.38
Stroke: Two additional servings of fruits or vegetables per day as provided by MTMs was associated with a reduction in the relative risk of stroke by 8%-26%.39
The risk of chronic conditions being exacerbated by poor nutrition is even further amplified among the 1.5 million veterans of working age currently suffering from food insecurity. Fruits and vegetables tend to be among the most expensive foodstuffs per calorie, with inflation increasing prices by over 25% since 2019.41 As a result, the food-insecure consume even fewer servings of fruits and vegetables per day than the already deficient consumption of the average veteran with one or more chronic conditions.With the potential to dramatically improve health outcomes while simultaneously generating substantial fiscal savings, Medically-Tailored Meals program, like the Veteran HealthPak®, provides a comprehensive solution to dramatically reduce healthcare spending while simultaneously improving chronic health conditions plaguing the Veteran population. It is directly aligned with the President’s Make America Healthy Again policy and provides a common-sense, non-partisan solution to the most pressing issue in veteran health today.
REFERENCES
1. Executive Order of February 13, 2025, available online at: https://www.whitehouse.gov/presidential-actions/2025/02/establishing-the-presidents-make-america-healthy-again-commission/
2. See https://www.ers.usda.gov/webdocs/publications/101269/err-829.pdf?v=6133.1 at iii.
3. See SNAP is Linked with Improved Nutritional Outcomes and Lower Health Care Costs, https://www.cbpp.org/sites/default/files/atoms/files/1-17-18fa.pdf (collating correlations of rates of food insecurity with rates of chronic condition diagnosis as cited herein).
4. See Prevalence and Costs of Chronic Conditions in the VA Health Care System, https://pubmed.ncbi.nlm.nih.gov/15095551/
5. See The Relation of the Chronic Disease Epidemic to the Health Care Crisis (viz, 50% US population suffers from one or more chronic conditions (72 = 50 * 1.44), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7077778/
6. Ibid. at p.1, (noting increase in medical spending of the food-insecure after controlling for other variables).
7. See the USDA’s and HSS’s “Dietary Guidelines for America,” https://www.dietaryguidelines.gov
8. Ibid., US Government’s “Dietary Guidelines for Americans” recommends 2 servings of fruits and 1.6 servings of vegetables per day, https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf
9. See Changes in Self-Reported Fruit and Vegetable Intake following Nutritional Modification in High Risk Older Veterans, J Nutr Gerontol Geriatr. 2021, https://pubmed.ncbi.nlm.nih.gov/33439791/
10. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=8512
11. https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=5965
12. Nutrition Therapy Cost-Effectiveness Model Indicating How Nutrition May Contribute to the Efficiency and Financial Sustainability of the Health System, M. Correia, et al., J. Parenter Enteral Nutr., Dec. 2020, available online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC8697995/
13. Cost Effectiveness and Return on Investment of a Scalable Community Weight Loss Intervention, T. Michaud, et al., Prev. Med., Oct. 2017, available online at: https://pmc.ncbi.nlm.nih.gov/articles/PMC5918290/
14. Meal Delivery Programs Reduce the Use of Costly Health Care in Dually Eligible Medicare and Medicaid Beneficiaries, S. Berkowitz, et al., Culture of Health, Apr. 2018, available online at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0999
15. After “accounting for implementation costs, the projections indicated that MTMs would generate net cost savings” of $6,219 per year in Connecticut. See https://nutrition.org/study-suggests-states-could-cut-healthcare-costs-by-delivering-patient-tailored-meals/
16. A Colorado study documenting actual health care costs incurred showed that patients receiving Medically-Tailored Meals had $1,142 lower total health care costs per month, accounting for the cost of meals and delivery. See https://gazette.com/opinion/guest-column-whole-person-care-supports-patients-saves-money/article_5e68f1a8-a4cd-11ee-a9e4-efd46896e071.html#google_vignette
17. “Health and Economic Impacts of Implementing Produce Prescription Programs for Diabetes in the United States: A Microsimulation Study,” L. Wang, et al., JAHA vol. 12, no. 15 (2023), available online at https://www.ahajournals.org/doi/10.1161/JAHA.122.029215
18. See https://fimcoalition.org/research/existing-research/
19. Reduction in all-cause mortality from increased consumption of fruits and vegetables (Fruit and Vegetable Consumption and Mortality from All Causes, https://pubmed.ncbi.nlm.nih.gov/25073782/ ), including studies demonstrating reduction in all-cause mortality from 15% to 56% (Diet quality as assessed by the Healthy Eating Index: a systematic review and meta-analysis of cohort studies, https://pubmed.ncbi.nlm.nih.gov/25680825/ ).
20. Fruit and vegetable consumption and mortality from all causes: systematic review and dose response meta-analysis of prospective cohort studies, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115152/
21. Pattison, D. J., Silman, A. J., Goodson, N. J., Lunt, M., Bunn, D., Luben, R., ... & Khaw, K. T. (2004). Vitamin C and the risk of developing inflammatory polyarthritis: Prospective nested case-control study. Annals of the rheumatic diseases, 63(7), 843-847, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1755070/
22. Garcia-Larsen, V., Del Giacco, S. R., Moreira, A., Bonini, M., Charles, D., Reeves, T., ... & Bonini, S. (2017). Asthma and dietary intake: an overview of systematic reviews. Allergy, 72(4), 433-452, https://core.ac.uk/reader/54610613?utm_source=linkout
23. Shaheen, S. O., Sterne, J. A., Thompson, R. L., & Songhurst, C. E. (2001). Dietary antioxidants and asthma in adults: population-based case-control study. American journal of respiratory and critical care medicine, 164(10), 1823-1828, https://pubmed.ncbi.nlm.nih.gov/11734430/
24. Risk of Atrial Fibrillation in a Population Without Known Cardiovascular Disease, Garg, MD, et al., J Am Heart Assoc., 2018 (increased servings of fruits and vegetables per day improves patient’s “Life Simple 7 Score,” with each LS7 point improvement correlating with an 11% lower rate of AFIB), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015412/
25. Farvid, M. S., Chen, W. Y., Rosner, B. A., Tamimi, R. M., Willett, W. C., & Eliassen, A. H. (2019). Fruit and vegetable consumption and breast cancer incidence: Repeated measures over 30 years of follow-up. International journal of cancer, 142(7), 1310-1319, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6440478/
26. See Eating Fruits and Vegetables Lowers Kidney Failure Risk, https://www.cdc.gov/kidneydisease/publications-resources/fruits-vegetables-lowers-kidney-failure-risk.html
27. See Diet and 20-year chronic obstructive pulmonary disease mortality in middle-aged men from three European countries, https://www.nature.com/articles/1601370
28. See Fruit and vegetable consumption and risk of depression: accumulative evidence from an updated systematic review and meta-analysis of epidemiological studies, https://pubmed.ncbi.nlm.nih.gov/29759102/#:~:text=Meta%2Dregression%20of%20included%20observational,95%2C%200%C2%B799).
29. Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials? Phil. Eth. Human. Medicine (2008), https://peh-med.biomedcentral.com/articles/10.1186/1747-5341-3-14
30. Carter, P., Gray, L. J., Troughton, J., Khunti, K., & Davies, M. J. (2010). Fruit and vegetable intake and the incidence of type 2 diabetes mellitus: systematic review and meta-analysis. BMJ, 341, c4229, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924474/
31. Cooper, A. J., Forouhi, N. G., Ye, Z., Buijsse, B., Arriola, L., Balkau, B., ... & Franks, P. W. (2012). Fruit and vegetable intake and type 2 diabetes: EPIC-InterAct prospective study and meta-analysis. European journal of clinical nutrition, 66(10), 1082-1092, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3652306/
32. See Note 25, Supra.
33. See Relationships between Mediterranean diet and risk of hepatic fibrosis in patients with non-alcoholic fatty liver disease, Front. Nutr. (2023), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9992532/
34. Evaluation of Cardiovascular Risk Factors in HIV/AIDS Patients, Online Journal of Cardiology Research & Reports (2019), https://irispublishers.com/ojcrr/fulltext/evaluation-of-cardiovascular-risk-factors-in-hiv-aids-patients-attending-the-tiko-central-clinic.ID.000538.php
35. See Note 25, Supra.
36. See Note 25, Supra.
37. Appel, L. J., Moore, T. J., Obarzanek, E., Vollmer, W. M., Svetkey, L. P., Sacks, F. M., ... & Karanja, N. (1997). A clinical trial of the effects of dietary patterns on blood pressure. New England Journal of Medicine, 336(16), 1117-1124, https://www.nejm.org/doi/10.1056/NEJM199704173361601?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov
38. Chen, Y. M., Ho, S. C., & Lam, S. S. (2006). Greater fruit and vegetable intake is associated with increased bone mass among post-menopausal Chinese women, British Journal of Nutrition (2007), https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/greater-fruit-and-vegetable-intake-is-associated-with-increased-bone-mass-among-postmenopausal-chinese-women/563FB0E64C34F0A5CA58C43C2894039F
39. See Note 25, supra.
40. See Food Insecurity Among Working Age Veterans, https://www.ers.usda.gov/webdocs/publications/101269/err-829.pdf?v=6133.1 at iii.
