To Treat Chronic Ailments, Fix Diet First

Oct 23, 2019 by

The New York Times


For many patients, the right food may be the best medicine.


Mr. Buhl is a journalist who reports on health issues, the environment and economics.

A volunteer cutting kale for a Medi-Cal meal program in 2017.
Credit Ramin Rahimian for The New York Times

On the kitchen counter in her Leimert Park apartment in Los Angeles, Diane Henry lays out her meals for the week. They’re frozen, in equal-size containers: Florentine tart, noodles with carrots, oven-fried chicken with brown rice and carrots, and Moroccan chicken. She didn’t choose the menu, but she does get a few options. Generally she’s happy with the selections.

With strict nutrition guidelines allowing only two grams of sodium per day, some meals require seasoning. If Ms. Henry wants more flavor, she will use salsa, lemon or turmeric. Though she says the meals are tasty, she is tempted to cheat. “I really want mac and cheese and soul food and pastrami,” she says.

But Ms. Henry, 54, wants even more to live without fluid surrounding her lungs, a key part of her condition, congestive heart failure. The program she signed up for is designed to help her and approximately 1,000 other clients avoid ending up in hospital, as she did last November.

Last year, California’s version of Medicaid, Medi-Cal, introduced a three-year pilot study that’s already showing what experts in the health care field have seen anecdotally — that tailored nutrition can improve health and lower medical costs for chronically ill patients. The pilot includes specially formulated meals and in-home visits for patients like Ms. Henry who suffer from her type of heart disease, which has caused some of the highest rates of hospital readmissions.

Project Angel Food, one of six California nonprofits participating in the pilot, delivers Ms. Henry’s meals. In addition to providing lunch and dinner, and a nutritional guide for every meal, nutritionists show clients how to portion her meals — and when they’re ready to transition off the program, how to shop for food and cook for themselves.

Nayeli Perales, a registered dietitian with Project Angel Food, has four sessions with each client over 12 weeks. After determining her client’s dietary habits, Ms. Perales will explain the new restrictions and follow up to track progress. After clients have transitioned out of the program, Ms. Perales will make a follow-up visit to help clients make their own meals and shop for healthy food that meets their dietary restrictions. “After the program, they still will be making their own meals and will be eating out,” Ms. Perales said. “It is an overall lifestyle change.”

Most of the restrictions eliminate saturated fats and emphasize whole grains, in addition to limiting sodium and fluids. (In congestive heart failure, the body can no longer maintain an appropriate balance between sodium and water.) For lower-income patients who may often rely on canned or prepared foods, this can feel overwhelming, especially if they don’t have the means to start shopping for healthy fresh food and cooking it from scratch.

Medi-Cal patients were chosen for the pilot because in general they frequently use the health care system. Data from 2017 shows that of California Medicaid’s patients with congestive heart failure who are discharged from hospital, a third return in less than a month. Published estimates of average hospital stays for those with the condition range between five to six days, with cost estimates between $10,000 and $15,000 per stay. But self-reported statistics showed a mere 6.2 percent readmission rate after 30 days for the 404 participants enrolled in the Medi-Cal pilot, as of Sept. 30.

Because of high utilization rates associated with congestive heart failure, it was one of the conditions of most interest to the federal Centers for Medicare & Medicaid Services in their Hospital Readmissions Reduction Program, under the Affordable Care Act. That program incrementally reduced hospital payments for frequent readmissions.

As many of the issues that prompt heavy use of health care assistance are social and structural, like low health literacy, social isolation, and lack of access to healthy food options, the Medicare and Medicaid program often hit hospitals in poorer neighborhoods and rural hospitals the hardest. The decreased reimbursement leads to a downward spiral for hospitals and patients. Some provocative research on that subject, published last year, suggested that the federal centers’ program might actually have increased mortality from heart failure.

Another body of research, however, is showing that medically tailored meals can go a long way toward reversing that downward health spiral. A retrospective cohort study headed by Seth Berkowitz, M.D. at the University of North Carolina Chapel Hill School of Medicine, and published in April concluded: “Participation in a medically tailored meals program appears to be associated with fewer hospital and skilled nursing admissions and less overall medical spending.”

Tanvir Hussain, a clinical cardiologist and board member of Project Angel Food, said he is impressed by the preliminary results of the Medi-Cal study. If the numbers hold up and Medi-Cal chooses to add medically tailored meals in its coverage, he said, it could be a game changer for the lower-income populations he serves in southern Los Angeles.

“Maximal compliance with drug therapy doesn’t keep congestive heart failure patients out of the hospital without dietary adherence,” Dr. Hussain said. So providing medically tailored meals “is a potentially easy win all around,” he said. “Sick or elderly patients can stay home and remain independent, while reduced hospital admissions dramatically reduces health care costs and overall burden on the system.”

In Pennsylvania, Medicare payers are using medically tailored meals as part of treatment, based on a small 2013 study led by a Philadelphia nonprofit, Manna, that showed patients who received three medically tailored meals per day had shorter stays at hospital and far lower rates of hospitalization overall, compared to a control group. Now four companies that administer Medicaid in southeastern Pennsylvania have contracted with Manna to deliver specially tailored meals for selected patients with diabetes, cancer, renal disease, cancer and high-risk pregnancy, as well as congestive heart failure.

AmeriHealth Caritas’s southeastern Pennsylvania health plan began a medically tailored meals pilot in August 2016; starting with 472 members who went through the program, it had delivered 175,601 meals to a total of 553 members as of Sept. 30.

Care management has been at the center of that program. “Patients on the program must be simultaneously engaged in care management, so food is a small part of all pieces that fit together for members’ health,” said Joanne McFall, market president for AmeriHealth Caritas’s southeastern Pennsylvania health plan.

A study of 179 of the initial participants, from August 2016 to January 2018, showed a reduction of nearly 25 percent in overall medical costs, a 31 percent decrease in inpatient visits and a 20 percent decrease in emergency room visits.

Manna also serves patients with Aetna Better Health of Pennsylvania, a Medicare contractor. Their meals program began in October 2016 with 30 members, and has slowly grown over time. They too have seen a 30 percent reduction in patient hospitalization, according to Dr. Bernard Lewin, the organization’s chief medical officer.

Dr. Lewin said that medically tailored meals represent a “shift in thinking from a problem-based medical delivery system to a holistic, wellness-focused preventive maintenance.”

Providing free meals to sick people at home could be politically contentious in many states unless officials in charge of payments see significant cost savings. But supporters say the savings from reducing frequent hospital admissions could be just as substantial, or even better, than any drug or device for heart failure.

While medical cost reductions are a significant benefit, Dr. Lewin said, he’s most concerned with the quality of people’s lives. “Someone who has congestive heart failure has a limited ability to do any work, and I mean walking up a flight of stairs. By addressing dietary elements to address that condition, they’re now able to get out of the house, but that improvement doesn’t show up on any spreadsheet.”

Ms. Henry said that since she joined the Medi-Cal pilot in December, she’s lost some weight and has more energy, though she admits some days are better than others.

“What I want to do is be able to take a long walk, go dancing,” she said. “And wear my heels! I’m 54 and I still have a lot of life left.”

Larry Buhl is a multimedia journalist based in Los Angeles.

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An earlier version of this article misstated the federal program that Medi-Cal is a version of. It is Medicaid, not Medicare.

The article also misstated the amount of sodium allowed under strict daily nutrition guidelines. It is two grams, not two milligrams.

The surname of a dietitian in the article was misstated in some instances. She is Nayeli Perales, not Pareles.

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