Episode 3: Food is Medicine with Dr. Dugan Maddux
Dr. Dugan Maddux, Vice President of Kidney Disease Initiatives for Fresenius Medical Care North America, joins Field Notes to discuss the consequences of food insecurity for people living with serious chronic conditions and the importance of medically tailored meals in treating kidney disease.

Brad Puffer: Welcome everyone to this episode of Field Notes. I'm Brad Puffer on the medical office communications team at Fresenius Medical Care, North America, and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day.

Today, we turn to a topic that has never been more important, as we face an ongoing pandemic, food. A poor diet can lead to a host of serious issues like hypertension, obesity, heart disease, diabetes, all leading to kidney disease. And some new studies, show a steep rise in food insecurity the past several months across all populations due to a spike in unemployment.

We actually conducted a recent survey that showed 60% of people living with chronic kidney disease or kidney failure, experience food insecurity. That's far more than the general population. And another 43%, say they either skip meals or reduce their meal size.

For those people living with chronic conditions, like kidney failure, food can really be medicine for the body. It's not just food itself, but the right foods that really matter. Joining us today to talk about this important issue is Dr. Dugan Maddux, Vice President of Kidney Disease Initiatives here at Fresenius Medical Care, North America. Dr. Maddux authored a chapter of our annual medical report last year called Food to Treat and Prevent Chronic Kidney Disease. Dr. Maddux, welcome to Field Notes.

Dr. Dugan Maddux: Thank you, Brad. I'm glad to be here.

Brad Puffer: I know this issue of both food insecurity and food as medicine is really important to you. Why are you so passionate about this?

Dr. Dugan Maddux: So over the past few years, I have been passionate about social determinants of health in general. And food and security in particular, as it's become pretty clear to me how this really impacts patient outcomes. When I first started practicing nephrology, I could definitely see that a lot of the patients that I was caring for, often needed medication samples or forms filled out for social security or they were struggling with getting their prescriptions. And we often had local food drives and food pantries to try to help patients make ends meet.

So I think I knew that this was a problem all along. But then as I stepped into this corporate role at Fresenius about 10 years ago, it really gave me an opportunity to see around the country, what a big issue this is and to talk to people, and to see that social determinants of health can really have an impact on a lot of our vulnerable patients, who have complex medical conditions.

So in addition to that, the last five to eight years, a lot of research has shown that social determinants of health directly impact health outcomes, especially, for people with chronic health conditions like chronic kidney disease. So for example, people who are unhoused have difficulty adhering to their medications or coming to all of their appointments. People who have food insecurity have to make often difficult choices between buying food or buying their medicines. People who don't have transportation have difficulty getting to procedures and appointments.

So, we see poor health outcomes just through research for people who are at risk for chronic diseases or have worse outcomes from those diseases, when they have issues that impact their social determinants of health, their medication, their food, and security.

Brad Puffer: Yeah. And I can imagine that the social determinants of health are all exacerbated right now for so many people due to the loss of jobs, facing what we're all facing with this pandemic. And especially, when we talk about food. Why is this food insecurity, food as medicine issue, so important right now?

Dr. Dugan Maddux: Right. I mean, you just have to turn on the news to see the food lines. And I think just during this time, where so many people are out of work, that very thin margin that a lot of people have for affording food for themselves and their family is just gone. And so we have a lot more families with food insecurity.

And this is a particular issue for our very vulnerable population, people who are elderly, people who are chronically ill, who often depend on other people to bring food in or prepare food for them or who may rely on a shelter to help provide food. And during the time of this COVID pandemic, a lot of those resources are gone. They're unable to be available for people. so many people have lost that support that they need, and may include food insecurity a very big issue during this time.

Brad Puffer: I want to step back just a bit, and help us understand the difference between food insecurity and this concept of food as medicine, because we've been talking about both. How would you define the two?

Dr. Dugan Maddux: Yeah, I think that's really important to make a distinction between those two. So food insecurity has a very specific definition from the US Department of Agriculture. And it is, the lack of consistent access to enough food for an active, healthy life.

And there are other definitions that are similar to that that we see in the research literature, meaning that food insecurity is a limited or uncertain ability to actually acquire nutritionally adequate and safe foods in a socially acceptable way. So food insecurity is about people and families, who do not have enough money or resources or ability to buy the food they need or get the food they need.

And part of food insecurity in the United States is lack of access to nutritious food. And this is a particular issue in neighborhoods and areas that are socio economically challenged. So the food that may be accessible and affordable in that neighborhood, may be poor quality food that is really not good for your health.

Food is medicine is a bit different from just food insecurity. Food is medicine is a phrase that recognizes that nutrition and chronic diseases are linked together. So people who are at risk for chronic diseases like diabetes, high blood pressure or cardiovascular disease or kidney disease or who already have one or more of those diseases, they can be healthier if they have access to proper nutritious food. And in this case, food is actually a treatment for these chronic conditions or prevention for these chronic conditions.

Brad Puffer: And so when we talk about medically tailored meals, that's what we're talking about, food is medicine, meaning, meals that are designed to help people with specific conditions.

Dr. Dugan Maddux: Exactly. They are specifically for people with complex medical conditions. The goal being to change the outcomes for the people who had those conditions, to make their health outcomes better.

Brad Puffer: And what have we learned about medically tailored meals, can they really make this impact? Do we have evidence?

Dr. Dugan Maddux: Yes. So evidence is really important, and I think it's important just about diet and nutrition in general. So a lot of people will know that studies have been done over the last 20, 30 years around the Mediterranean diet for heart health, around the dash diet, which is the dietary approaches to stop hypertension, which actually showed in randomized controlled trials, that it improved kidney disease outcomes, heart outcomes, and lowered blood pressure.

And these are diets that are generally nutritious. They're rich in fruits and vegetables and whole grains, they limit sugary sweets and sugary beverages. So that's really important. And in that same tradition of science randomized controlled trials, some CKD studies have recently shown that diets that are high in fiber, rich in fruits and vegetables, low in salt and acids can slow the progression of chronic kidney disease, and decrease the risk of developing chronic kidney disease.

And in addition, similar randomized control trials have shown that medically tailored meals that are pre designed to provide the best diet to support good health for people with chronic diseases, like diabetes and kidney disease, can change the outcome. So for diabetes, for example, medically tailored meals designed for a diabetic individual can lower the hemoglobin A1C and improve diabetic control.

And in general, providing medically tailored meals for people with complex medical conditions, reduces the emergency room visits, reduces hospitalizations, reduces admissions to skilled nursing facilities. So all of this is really important and good for patients. But it's also important in that, it lowers health care costs And so that is attractive and important to the payers.

Brad Puffer: Well, it seems like a no brainer, but at the same time, it's probably a lot easier to get reimbursement for a pharmaceutical than it is for a food delivery or medically tailored meal. There's so many organizations like food pantries helping feed people, but not as many really helping with these specific medical needs. What do you think the challenges are to make this concept more widespread?

Dr. Dugan Maddux: Well, I think, part of it is exactly what you say, that people don't really aren't thinking about food as a medical intervention. And so this research will hopefully change people's understanding about the impact of these medically tailored meals and medically tailored food programs. So not all of them are pre prepared meals, some of them are about having just the food in your home that is medically appropriate.

But the medically tailored meal programs are pretty expensive, they require a lot of personalized care, they require a lot of nutrition and dietician expertise. So there is a lot more professional involvement in developing the proper nutritional meal and diet for an individual person.

And in addition, the medically tailored meal, providers have to be in contact and share data with the prescribers, who would be the doctors, and the physician extenders who are evaluating patients and making diagnoses and documenting these chronic conditions. They also need the technology to be connected to the insurance companies, and the payers who are going to pay for these medical interventions. So this is a lot more work and expense at organization for medically tailored meal providers. And a lot of these are nonprofit entities, so these are big steps in organizational development.

Brad Puffer: Got it. And it is great to hear that there are some insurance companies that are stepping to the plate to reimburse for these medically tailored meals. I know we're invested in seeing this group, this idea grow further and made a significant donation to the food as medicine coalition. Tell us about that effort and why we're supporting that organization, what we hope to see accomplished with its growth.

Dr. Dugan Maddux: Yeah. So the food is medicine coalition is a national group, which is really important and it's a coalition of programs that provide medically tailored meals. And we have followed them for quite a while, we're very aware of the research around this group and these outcomes. So we have been very interested in the improvement. they have for people particularly, with chronic kidney disease and end stage kidney disease.

So these groups are not only involved in delivering medically tailored meals and medically appropriate meals, they are committed to sharing the best practices for those organizations of medically tailored meal delivery with other groups to try to improve the access to medically tailored meals around the country. They are committed to public policy discussions to help people learn about the importance of medically tailored meals are committed to resources around providing research and evidence based interventions around medically tailored meals.

So as a corporation, we certainly agree that people with chronic illnesses should not have to manage worrying about or doing without healthy food, while they are also having to live with and manage complex medical conditions. And we believe that, healthy and nutritious food, food that's particularly tailored to an individual's needs when they have complex medical conditions is part of providing superior care for people and patients. So I think altogether, we're very much aligned with this national food as medicine coalition.

Brad Puffer: And from what I understand, other countries have had some success with this, right? In different health care systems, in providing medically tailored meals for these chronic conditions.

Dr. Dugan Maddux: Yes. I think there is good documentation of the impact of this in other countries as well. And in particular, in the United States, we have a real division between our social services and our health care services. And I think medically tailored meals is a beginning to see that these things are intertwined. That social determinants, impact health care outcomes.

Brad Puffer: When we talk about the food and medicine coalition, what are some of the specific challenges they have faced recently during this pandemic? And do you think that the pandemic has actually put an even bigger spotlight on this issue?

Dr. Dugan Maddux: Yes. So just in the last couple of weeks, I listened to a webinar from the food is medicine coalition members, and they talked about all the changes they're seeing, particularly, during this COVID-19 pandemic. So they all seen that their usual work force is volunteers, they're all of them nonprofits and they just had a tremendous change in their workforce during this time, because all their volunteers can't come into their kitchens and their pantries. And yet, they still had to deliver their services a meal. So they've changed from a volunteer workforce to an employee workforce.

They've also had to change to a lot more technology to automate food production, and to allow a lot of employees to work from home, like their dieticians and nutritionists, without actually coming into the facility. And all this is happening at a time, where more people need food. So the medically tailored meal providers are receiving more referrals than ever before, they are feeding more people. And in addition, they and a lot of communities are helping to provide additional services for the over burdened food pantries, who need some additional support with providing food.

So even community servings the food is medicine provider here in Boston noted that their meal production is up by about 50% during this pandemic. So where before they were providing about 10,000 meals per week, they're now providing almost 15,000 meals per week.

Brad Puffer: Wow. That's a big increase. Well, let's talk about the future beyond COVID-19 as this issue is certainly not going away. What do you think, really needs to change to make sure more people can get these medically tailored foods, especially to treat kidney disease?

Dr. Dugan Maddux: It's pretty clear that the food is medicine interventions, need to become part of our mainstream health care delivery system. That people should be screened for food insecurity and the need for food intervention, and that payers and insurances should participate in providing this service for their beneficiaries. And that means, Medicare Medicaid need to get on board with the benefits of this intervention.

We should expect that if we're providing food as medicine interventions, we should track and measure them as part of our quality outcomes in health care. That we should think about healthy food and make it available, just like we would think about prescription medications for people.

Brad Puffer: Well, how are we working to try to better identify these issues for our patients. At Fresenius Kidney Care for example, how can we really make a difference?

Dr. Dugan Maddux: I think one of the big steps is what we're doing today. I mean talking about it, having conversations about it, increasing awareness about food insecurity as an issue, efforts to engage our providers, our physicians in thinking about this issue more often. And in addition, we've recently added a screening tool for social workers for all the patients who are coming into FKC to be screened for food insecurity. We're using the hunger vital sign questions that will identify patients who have food insecurity issues, and there are clinical pathways to try to address that and improve that for patients.

So we'll have an idea of the scope of this issue for our patients and begin to develop good partnerships and interventions to support treatments and interventions for food and security.

Brad Puffer: I imagine those partnerships are key to that. we've talked about the coalition but these organizations are spread out across the country, so making sure that we can connect those organizations with our social workers, our dieticians and making those connections is going to be critical.

Dr. Dugan Maddux: Yes. I think that's going to be part of the work we need to do is to identify all the resources and create very clear ways that we can connect those partners with people and patients who need those services.

Brad Puffer: Well, it's been a pleasure speaking with you Dr. Maddux. Thank you so much for taking the time.

Dr. Dugan Maddux: It's been my pleasure Brad, thank you.

Brad Puffer: And to our audience, we hope you will come back and join us, as we discuss more important issues in the weeks ahead. A reminder that you can access our annual medical report in other feature articles on our website at fmcna.com. And you will find our field notes series on our website, as well as, on the Apple Store and Google Play. Until next time. I'm Brad Puffer. You've been listening to Field Notes by Fresenius Medical Care. Take care everyone and stay safe.