Food For Thought: A Vision For Generative ‘Food Is Medicine’

For centuries, many cultures around the world have used food as medicine. This approach has been documented in ancient Egypt,¹ Greece, and China,² as well as in Indigenous populations in North America.³ The belief in food as medicine remains strong among many cultures today; however, it is less prevalent in the United States, where many families face obstacles to eating healthy food, including busy schedules; food prices; lack of accessible and affordable healthy options; and the prevalence of heavily marketed, ultraprocessed food.^4,5

Food Is Medicine has increasingly been implemented in the US as a health intervention prescribed by health care providers to address diet-related conditions and food insecurity.⁶ Gaining traction in the early 2000s and accelerating in recent years, the concept has evolved into a broader movement as a result of the growing evidence and recognition among health care providers and the public that nutrition plays a critical role in preventing and managing chronic illness.⁷ Momentum for Food Is Medicine is fueled by the proliferation of value-based payment models in health care and growing interest among hospitals, health systems, and payers in upstream interventions to prevent and treat high-cost, diet-related health conditions such as diabetes and heart disease.^8,9

Across the US, Food Is Medicine programs look different depending on local resources, geography, funding, partners, cultural context, and preferences. A scan of Food Is Medicine programs in North Carolina that we commissioned in 2022 identified six categories of food and nutrition support provided in Food Is Medicine interventions: a food box containing a combination of fresh and shelf-stable items; a produce-only food box; a fresh food box that includes minimally processed items; a shelf-stable food box; a medically tailored food box; and medically tailored meals.¹⁰ Our continued engagement with Food Is Medicine providers in North Carolina identified two additional food and nutrition supports that are used in interventions: vouchers that can be used at farmers markets, and prepaid debit cards that can be redeemed at grocery stores.¹¹

Community-based organizations (CBOs), which are nonprofit organizations that address needs in their communities, are critical providers of Food Is Medicine solutions throughout the country. CBOs partner with hospitals, health systems, health insurers, free clinics, community health centers, and Community Care Hubs or Network Leads, as they are called in North Carolina, to deliver food to patients to support the management and prevention of conditions such as diabetes, high blood pressure, high-risk pregnancies, and nutrition insecurity. Food may be delivered directly to homes or accessed at community pick-up sites such as clinics and health centers.

In this article, we review the history of the Food Is Medicine movement, discuss the extractive nature of many Food Is Medicine models in the US, and present our vision for a generative model of Food Is Medicine centered on CBOs and local food systems. The information presented is based on our review of the literature, our 2022 scan of Food Is Medicine programs in North Carolina, and our involvement with Food Is Medicine programs across the state during the past seven years.

Momentum In The Movement

During the past two decades, there has been increasing recognition of the inextricable link between food and health among health care providers, public health entities, and the American public. A growing body of evidence has demonstrated that Food Is Medicine increases fruit and vegetable consumption, improves health outcomes, and reduces household food insecurity.⁶ In 2022, the Biden-Harris administration released the National Strategy on Hunger, Nutrition, and Health, in conjunction with its historic White House conference on the topic.¹² In 2024, the Department of Health and Human Services convened its first Food Is Medicine Summit, which brought together stakeholders at the intersection of food, nutrition, and health.¹³ Across the country, large, national conferences continue to focus on Food Is Medicine.^14,15

Public and private funding for Food Is Medicine is growing. Pursuant to a Medicaid Section 1115 waiver approved in 2018, North Carolina’s Medicaid program pays for a variety of Food Is Medicine interventions based on their potential to improve health outcomes and lower health care costs. Among these interventions are nutrition supports, including food and nutrition case management, group nutrition classes, and interventions as part of the National Diabetes Prevention Program;¹⁶ fruit and vegetable prescriptions; healthy food boxes; and medically tailored meals.^17,18 Twelve additional states have Medicaid Section 1115 waivers that allow coverage of the direct provision of food, and three are awaiting approval.¹⁹ After its Food Is Medicine pilot program found that the intervention was associated with reduced food insecurity, improved health outcomes, and reduced medical costs,²⁰ Blue Cross and Blue Shield of North Carolina adopted Food Is Medicine in many of its commercial insurance products.

Since 2020, state and local governments have been getting involved in Food Is Medicine beyond the Medicaid payment pathway. The North Carolina General Assembly and Mecklenburg County have invested $18.5 million and $1 million, respectively, in Eat Well, a produce prescription program of the Durham, North Carolina, CBO Reinvestment Partners. The program provides participants identified by their various health partners with monthly prepaid debit cards to purchase fruits and vegetables at certain retail locations. An evaluation of Eat Well found that in addition to improving food security, it increased fruit and vegetable purchases by 95 percent from October 2019 to April 2020.²¹ Another evaluation of the program from June 2021 through 2022 found that participants with comorbidity characterized as “none to mild” had a 34 percent reduction in the odds of emergency department use not associated with hospital admission in the six months after program enrollment.²²

Philanthropy is playing an important role in the Food Is Medicine movement. In 2024, the Rockefeller Foundation increased its investment in Food Is Medicine solutions to $100 million.²³ National foundations including the Kresge Foundation and the Walmart Foundation, state-based foundations including the Sunflower Foundation (in Kansas) and the NY Health Foundation, and local grant makers such as the Hellman Foundation and the Stupski Foundation have also made investments.^24–29 Since 2021, the Blue Cross and Blue Shield of North Carolina Foundation has invested more than $6 million in ten community-based Food Is Medicine programs to incentivize sourcing from local farmers and build capacity through increased staffing and purchases of food and technology.³⁰

The Role Of Community-Based Organizations

The success of Food Is Medicine in North Carolina would not have been possible without CBOs.

The success of Food Is Medicine in North Carolina would not have been possible without CBOs, many of which are the driving force for these programs in their communities. CBOs have played a major role in developing Food Is Medicine partnerships with health care organizations, securing funding, designing programs, and procuring and delivering food.

Community-based Food Is Medicine programs offer much more than food. For example, in western North Carolina, the community-based nonprofit Hunger and Health Coalition (HHC) partners with UNC Health Appalachian, an integrated health system, to screen all patients for food insecurity.³¹ HHC has become the primary produce purchaser from Full Moon Farm, a small, woman-owned farm in the area, thereby helping keep the farm operational. In 2024, HHC purchased one-third of the farm’s produce for its Food Is Medicine and emergency food programs, and this year it plans to cover all of the farm’s overhead costs. In this model, HHC provides a sustainable income for farmers and a dependable market for their crops.

Given their strong community roots, CBOs are uniquely positioned to provide services in a way that preserves clients’ dignity through deeply relational interactions. CBOs’ relationships with community residents have the added benefit of mitigating isolation and loneliness among clients. These relationships help identify other challenges that clients face, and they increase clients’ connections to additional social services. For example, in Gaston County, North Carolina, through a collaboration between the Highland Neighborhood Association’s Really Amazing Meals with Soul (RAMS) Kitchen, a community-based grab-and-go restaurant, and Kintegra Health, a federally qualified health center, the restaurant provides healthy meals to neighborhood residents at no or low cost.³¹ It seeks residents’ input on menus, offers taste tests when introducing new food items, shares recipes, and provides education on the “why” behind portion sizes. RAMS Kitchen sources food from a community garden maintained by a local service program for low-income youth. Because restaurant staff are employees of the health center, they are paid a living wage with benefits. Delivery drivers for the restaurant are community members who often know the people they serve and check in on residents’ well-being in addition to providing food. For one ninety-five-year-old patron, the delivery driver, who was the only person checking in with them regularly, was able to identify the client’s care needs, which were then communicated to family members living out of state.

The Extractive Nature Of Food Is Medicine

Despite myriad benefits of CBO engagement in Food Is Medicine, CBOs are at risk of being replaced by the increasing number of for-profit vendors participating in these programs. For-profit ventures can more easily partner with health care organizations and meet contracting and compliance requirements such as security and information technology infrastructure, cyber insurance, and the capacity to deliver food across large or sparsely populated geographic areas.

Despite being a driver of Food Is Medicine and offering many benefits to their communities, CBOs often do not receive the financial or other support needed to sustain and scale up their operations. Too many Food Is Medicine initiatives extract resources from CBOs without replenishing them.

Being a Food Is Medicine supplier requires an operating model and an infrastructure that are completely different from those of most CBOs. To manage Food Is Medicine referrals, track services, and provide food aligned with clients’ needs and preferences, CBOs may need to acquire new technology and hire staff with specialized expertise, such as dietitians. Sourcing the food needed to fulfill referrals may require new procurement pathways and additional storage space. In many cases, CBOs involved in Food Is Medicine have to manage complex contracting and billing requirements.

Despite the resources and capacity building needed to scale up and sustain Food Is Medicine interventions, the payment that CBOs receive through Food Is Medicine programs often is insufficient to cover their operating costs. Although direct-to-consumer delivery is highly valued by Food Is Medicine clients, the cost is often underestimated by funders and payers, particularly in remote or mountainous areas where travel is slow and difficult, requiring significantly more resources for delivery. Some CBOs also accept referrals from health care providers and serve their patients at no charge, thus requiring expenditure of valuable volunteer and donated resources and risking crowd-out of the clients who are most in need. Some funders and program partners place costly data collection requirements on CBOs, such as requirements to collect clients’ biometric data. To set fair payment rates for CBOs’ services in Food Is Medicine initiatives, full accounting for the cost of their contributions is critical. Evaluation and data collection requirements should be appropriately scaled to allow CBOs to do what they do best: serve community needs.

Extractive Food Is Medicine practices could ultimately threaten CBOs’ involvement and even long-term sustainability.

Because CBOs often fully or partially self-fund participation in Food Is Medicine efforts through grants they secure, extractive Food Is Medicine practices could ultimately threaten CBOs’ involvement and even long-term sustainability. This could lead to weakening the social safety net and gaps in services, and it could ultimately contribute to increased health disparities, especially in rural communities, where resources are already limited.

A Generative Approach To Food Is Medicine

In contrast to extractive systems that pull value from a system without restoring it, generative approaches add value. We envision a generative Food Is Medicine system that recognizes and values the vital roles of all involved and enables each to do what they do best. Partnerships between health care organizations and CBOs are equitable, or at least mutually beneficial. Programs are codesigned, and data are shared between health care and CBO partners to enable process improvements. Requirements for contracting, data collection, and reporting are aligned with CBOs’ capacity. Payment to CBOs covers the full cost of providing Food Is Medicine services, including support for building infrastructure, collaborating with community partners, meeting community demand for healthy food, and disaster preparedness planning to minimize potential weather-related service disruptions.

In a generative approach, CBOs have the capacity and infrastructure to fulfill referrals from health care partners and meet community demand for healthy food. CBOs have sufficient resources to provide wrap-around services to support clients’ efforts to maintain a healthy diet, such as cooking classes focused on healthy options, farm tours to foster and deepen connections with local producers, sharing of culturally appropriate recipes, and peer support groups. A pilot program being conducted by the Appalachian Sustainable Agriculture Project, with funding from several sources and based in Asheville, North Carolina, exemplifies this approach.³¹ In a generative system, Food Is Medicine increases CBOs’ resources instead of consuming them and, in turn, strengthens the social safety net for the entire community.

Generative Food Is Medicine programs value and prioritize distribution of locally grown, healthy food.

Generative Food Is Medicine programs value and prioritize distribution of locally grown, healthy food, thereby supporting community health and contributing to the local economy. Locally grown food tastes better to clients and is healthier than food sourced from producers across the country because it travels shorter distances and is often grown with more sustainable agricultural practices and minimal use of pesticides. Local farmers are compensated at fair market prices and are engaged in Food Is Medicine initiatives to help determine what food to grow to meet client needs, and in what quantities. A generative approach to Food Is Medicine provides a reliable market for local farm products that helps support the sustainability of local farms. For example, in rural western North Carolina, TRACTOR Food and Farms, a nonprofit food hub engaged in Food Is Medicine efforts with several health care providers, sells locally grown produce directly to residents, in addition to providing food for community-supported agriculture boxes.³² Through this initiative, Food Is Medicine generates approximately half of the income for seventy local farmers.

In a generative approach, the food provided to clients is based not only on what they need but also on what they prefer. For example, in developing its menus, RAMS Kitchen prioritizes foods that reflect the cultures and traditions of diverse clients in the community. This approach enhances the accessibility and appeal of healthy food, thereby fostering connections with clients. In a generative model of Food Is Medicine, the transportation limitations of both CBOs and clients are considered when determining where food will be delivered, with the goal of providing home delivery when possible. Client touchpoints with program representatives prioritize meaningful engagement, empathy, and trust, so that clients feel connected to the source of their food.

With diet-related health conditions proliferating and health disparities continuing to widen in the US, there is too much at stake not to leverage the full potential of the Food Is Medicine movement. The eagerness for rapid scaling must be balanced with opportunities to take a generative approach. A generative approach includes the following three essential elements.

Integrating And Supporting CBOs

To build the foundation for generative Food Is Medicine initiatives, Food Is Medicine interventions should be centered on CBOs and local food systems. In a generative model, funders and health care partners provide CBOs with start-up and ongoing resources to build the capacity and infrastructure needed to support and sustain their participation. For example, Blue Cross and Blue Shield of North Carolina requires its national Food Is Medicine vendor to work with local CBOs for delivery and food sourcing, based on locally available food and community preferences. This vendor pays a registered dietitian to plan menus and conduct nutrition analyses and provides CBOs with information technology support to reduce the burden of data entry and reporting.

Prioritizing Locally Grown Food

Whenever possible, Food Is Medicine programs should source food from small and medium-size farms in their communities. To this end, Food Is Medicine initiatives may need to invest in local farms and food hubs to make locally grown food easily accessible.

Building Infrastructure

In most parts of the country, the infrastructure to deliver Food Is Medicine does not exist. To build this infrastructure, funders could work with local stakeholders to identify changes needed to enable CBOs and local farms to collaborate with vendors, health systems, and payers on development and implementation. To reduce the burden on CBOs and local food producers, centralizing functions such as program administration and contracting with health care organizations and other partner entities should be considered. Options could include regional nonprofit Food Is Medicine networks, national Food Is Medicine vendors that work with local food providers, or a combination of the two.

Recommendations For Policy And Practice

Although Food Is Medicine initiatives vary depending on local capacity, culture, and priorities, they should include several core elements. First, payers and health systems offering Food Is Medicine should develop partnerships with local CBOs or require their vendors to prioritize CBOs and local farms as partners. New or existing Food Is Medicine vendors not already partnering with CBOs or prioritizing local food should consider opportunities to adjust their models to maximize impact in the communities they serve.

Philanthropic organizations are uniquely positioned to advance generative approaches to Food Is Medicine. They should expand efforts to support promising models, provide basic infrastructure and capacity funding, catalyze mutually beneficial health care–CBO partnerships, and foster the multisector stakeholder collaborations needed to implement generative models.

Further assessment is needed to determine the payment rates that would enable CBOs to offer Food Is Medicine programs without compromising their ability to serve uninsured and underinsured populations. Additional research should be conducted to quantify the community benefits that can be achieved through generative Food Is Medicine models.

The Food is Medicine Coalition medically tailored meal intervention accreditation criteria and requirements³³ and the Fidelity, Equity, Dignity (FED) Principle³⁴ developed by Wholesome Wave and DAISA Enterprises provide frameworks that can be useful in the design and delivery of Food Is Medicine programs.

Conclusion

Too many Food Is Medicine programs extract resources from the CBOs that are essential to their success. Changes in policy and practice are needed to achieve a generative model that operates through mutually supportive partnerships among CBOs, payers, health systems, and vendors.

ACKNOWLEDGMENTS

The authors thank the many community-based organizations working in Food Is Medicine across North Carolina for informing their perspectives, including the Appalachian Sustainable Agriculture Project, Green Rural Redevelopment Organization, Conetoe Family Life Center, Highland Neighborhood Association’s RAMS Kitchen, Feast Down East, Hunger and Health Coalition, Nourish Up, Reinvestment Partners, and TRACTOR Food and Farms. Any views or opinions expressed in this article are solely those of the authors, and no endorsement of these views or opinions by others is expressed or implied. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. To access the authors’ disclosures, click on the Details tab of the article online.

NOTES

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