Episode Transcript:

Dr. Frank Maddux
So we're here today talking about health care outcomes. And one of the things that you and I've talked about in our 39 years of marriage has been the impact of social determinants of healthcare outcomes and why the environment people live in and the circumstances they live in impact how well they do, whether they are dialysis patients, or CKD patients, or just our colleagues. So can you just talk a little bit about your perspective on social determinants of health care outcomes and how they impact the things we were trained in regarding physiology and traditional health care outcomes?

Dr. Dugan Maddux
I think because we have been involved in taking care of people with chronic disease, I mean, chronic kidney disease, end stage renal disease, we've definitely gotten to know people and seeing how much their environment impacts their outcomes, how well they do, how they feel. And so I think that understanding that there are some things that people can't change that are determinants of health, their genetics and the kind of healthcare they have access to. But there are lots of things, and in fact, some studies have shown that the majority of things that seem to impact a lot of outcomes have to do with things that are part of your environment, where you live, do you live in a safe neighborhood? Do you have stable housing? Do you have access to nutritious and healthy food? Do you have access to health care? Can you get to the healthcare that's available to you and that all of those things impact health outcomes, how well people do and we definitely see it in CKD. And that there are things that can be changed, unlike your genetics, which you can't change. So I think it can really change the way people feel and how they do.

Dr. Frank Maddux
Your feeling is that environment where people are making choices on their own, in their own environment or creating priorities of what's important actually has impact on the traditional healthcare outcomes that we have.

Dr. Dugan Maddux
Yes, people's behavior and the choices they make. But sometimes people can't make different choices because they don't have stable housing or they don't have the access to nutritious food. So even though we'd like for them, and we can talk about what they should do with their diet, they just aren't able to do that. And that definitely impacts their outcomes.

Dr. Frank Maddux
So we've identified some years ago, five themes for our dialysis population that we thought were important components of social determinants, not necessarily the only ones. And they included food security, stable housing, community, kinetics, you know, the ability to move and stay active in life, and engagement. And today, I thought we might actually concentrate a little on food security or food insecurity, can you sort of describe what that is? And sort of the details of what we learned and how we learned about that?

Dr. Dugan Maddux
Yeah, so food insecurity just in general is well recognized. And it's the inability for a person to have access to enough nutritious food to live a healthy and active life. And so we see that, I think we've seen that a lot during the coronavirus pandemic, that people, many people in the United States live on that sort of edge of being able to really have enough food for themselves and their family all the time. And so many people do rely on not only food sources to help them have enough food like food pantries, but also some people and particularly as we're talking about people who are chronically ill rely on somebody to help them get access to their food or help them prepare their food. So all of those things can lead to food insecurity. And when we look globally, food insecurity issues globally, and most of what you see there is sort of undernutrition, people have don't have access to enough calories and so they have poor nutrition. What we see in more developed countries than we see in the United States is we almost have over nutrition, we have access to foods that are calorie dense, that are high fat, high sugar, so people have access to food, but it leads to some chronic conditions that we see: obesity, high blood pressure, cardiovascular disease, and chronic kidney disease, because we have a problem with food insecurity leading to over nutrition.

Dr. Frank Maddux
So when we think about nutrition in our population of patients, we’re thinking about nutritional competence, this concept of nutritional resilience, how well can they tolerate an acute illness and maintain nutrition? What's the relationship between food security and access to food and CKD outcomes and the things that actually drive the physiologic behaviors we see?

Dr. Dugan Maddux
Yeah, so in CKD, there have been studies that have shown that if you have access to good nutritious food, that you are a decreased risk for developing chronic kidney disease because the diseases that cause kidney problems, diabetes, high blood pressure, cardiovascular disease, are more common if you're not eating healthy food. And then also studies have well shown that if you have chronic kidney disease and you don't have access or don't include in your overall behaviors, eating nutritious foods, fruits and vegetables, low fat foods, if you're eating more processed foods and lots of red meat, then you're more likely to progress to end stage renal disease. So there are physiologic things about the kidney, and your overall vasculature that if you're not eating these healthy diets that are rich in fruits and vegetables, that you're at more risk to have a poor outcome. And in particular in kidney disease, we see that a lot of these processed foods have a lot of dietary acid in them. And that is a real problem for late stage CKD and poor outcomes. So the fruits and vegetables are more nutritious in a variety of ways, particularly in CKD.

Dr. Frank Maddux
Two questions before we talk about food as a medicine. Is this just a U.S. problem? Or is this also a problem in the larger environment? The global environment?

Dr. Dugan Maddux
I'm think culturally there's a lot of difference in the way people approach food and have access to food in different developed countries. So I think there are larger or smaller issues related to food and health in other countries. And again, I think in the United States, what we see is that people have to find food resources where they can. And we see a lot of access to food that's very affordable, but not very nutritious. And so that's created some of the chronic health problems we have here.

Dr. Frank Maddux
We've studied nutrition through many studies of patients with kidney disease over the past the MDRD study and other studies, and they were really around these physiologic measurements that albumin and other things are, are sort of critical indicators of nutritional status. Tell me about the studies and what's been what's been looked at with regard to these types of foods and the quality of the food that people are actually eating. I know that there's some advocates for plant based protein and other such things. Can you just give us a little insight into that?

Dr. Dugan Maddux
Yeah, well, MDRD and some of the early kidney studies looked at lowering protein and whether that stuff slowed progression to end stage renal disease and we know physiologically that diets are really high in proteins stress the kidney, they create some hyperfiltration and, and create some kidney injury. So MDRD didn't show, in particular that lowering protein changed the outcomes, but they think in part because everybody was doing better with their diet during the time that they were part of the MDRD study. But I think since then some larger population studies in Haynes and some other studies have shown that plant based diets are associated with better outcomes and CKD and other diseases. So there's been some good data in recent years, particularly around CKD that that the food you eat matters, and there was some worry about plant based foods because some things that are plant based are higher and phosphorus, but that particular type of phosphorus does not cause the trouble that we see with bone and mineral metabolism, diseases and CKD. So, we now in the renal community for CKD and in our end stage renal disease, dietary counseling are recognizing the great value of having more fruits and vegetables of all kinds and having a well balanced nutritious diet and that works very well in CKD and end stage renal disease

Dr. Frank Maddux
So in our annual medical report you and David Waters did a chapter on food security and Food Is Medicine and that initiative, can you describe what the Food Is Medicine Initiative is, and what you learned in the interactions with Community Servings.

Dr. Dugan Maddux
Yeah, Community Servings is a Boston based nonprofit and they've been around for over 20 years feeding people who have chronic health problems. And they are today feeding a lot of people who have chronic diseases including CKD, diabetes, those kinds of things. The food is medicine concept is around using food and nutritious food to actually change health outcomes. That is a treatment much like our pharmaceutical treatments are, like our medicines are. So the idea being that if you can improve someone's diet, you can actually slow down the progression of whatever chronic disease they had that has diet related issues to it, and CKD is one of those. So they have done studies to show that in their diabetic population if they can provide these medically tailored meals, meaning meals that are prescribed for an individual, they're designed to address the individual's chronic health conditions. So they're very specifically tailored to meet their needs for diabetes, high blood pressure, chronic kidney disease, that if you are using those kind of dietary interventions, you see lower hemoglobin A1C, better diabetic control, fewer ER visits, fewer hospitalizations, better quality of life. And I think some of these Food Is Medicine, food security interventions, change people's stress about where am I going to get food, how am I going to feed my family and changing that stress also has physiologic impact as well, that helps improve someone's health.

Dr. Frank Maddux
How widely available are medically tailored meals? And frankly, I can only imagine they're more expensive. So a lot of this issue is a financial issue, and how do people actually gain access to the right foods that they should be eating? Or are these higher quality foods you're describing?

Dr. Dugan Maddux 
Yeah, and let me just say too that there's sort of a pyramid of food, you know, where there's the food insecurity and you just want to help people have access to enough food. So they're this like SNAP, the Supplemental Nutrition Assistance Program, and then their food pantries that have food for people. And then you can come up the pyramid from that to get more specific about how you help people with food. So there are population based food assistance like in schools, we want to make sure that we're providing nutritious food in schools, and there's produce prescription kinds of support where you get a voucher to go to a farmers market where you're more likely to be able to get some fresh fruits and vegetables, and then medically tailored food where it is specific for the chronic condition but it's not a pre prepared meal. It's access to some unprepared foods that are better for you like the fresh food farmacy where you can go and get the right foods for you. And then medically tailored meals are specifically designed for an individual and they come pre prepared and are delivered to the home for like a week's worth of meals over a longer period of time. So the medically tailored meal is a very specific intervention, although they found that they have to feed the family as well as the person who really get the benefit from that. But the community servings and the larger more national presence of the Food Is Medicine coalition where there are these nonprofit's around the country that do these medically tailored meal interventions have done research to show that even though they cost more money, I mean, the higher up the pyramid you get, the more expensive the intervention is that for these complex conditions and people who have a lot of health care needs, if you can reduce their hospitalization, reduce their ER visits, that's better for them, it's better for their health outcomes, but it also lowers the healthcare cost and so the offset of the expense to the healthcare system that you get with these meals pays for them and so people like Community Serving organizations within the food as medicine coalition have done enough research now that they have payers that are interested in using this as a way to reduce their healthcare costs.

Dr. Frank Maddux
So I have this very visual image of fresh food farmacy. Describe that a little bit more what is the fresh food farmacy?

Dr. Dugan Maddux 
So Geisinger has been, you know, well known for this fresh food farmacy and I think there are others around the country that do this as well, but the idea is that your health care provider who sees you knows your chronic medical conditions and they can write a prescription for you to go to the pharmacy that is a warehouse of fresh food and that with that you can go and have a weekly box or bag of food that is appropriate for your chronic medical condition. It also allows people to get engaged with people or helping them learn about food, learn about their health. For example, at Geisinger when I last talked to them and read about them, their fresh food farmacy is run by nutritionists and they have people there that can do some coaching, they can do foot checks, they can help make sure that you have some other wraparound services to just also having access to healthy food.

Dr. Frank Maddux
So what's the relationship between community sustained agriculture and the fresh food farmacy or the food security issue? It seems like these local farms might play a big role in this.

Dr. Dugan Maddux
Yeah. And I think especially during this pandemic time where we've seen that there's food and there's, there's a disconnect to getting that to the right people, and lots of food is local. And so having these community agricultural entities that want to connect to people who need the food, and they do that often through these nonprofit kind of organizations, I think there will be a lot more work on making sure that we can get the food to people in a local way. And that is an issue as we're looking at our nationwide chronic kidney disease care, dialysis care. How do we help people get food in their local environment will be a challenge.

Dr. Frank Maddux
Where would you rate this amongst the various things that are environmental and socially determined impact is food high on that list is low on that list. It's been impressive during the pandemic, how important the access to food has been for many people that were displaced from the economic impact of the pandemic.

Dr. Dugan Maddux
Yeah, so Kaiser and some others have, you know, begun to just make assessments of what their population, their patient population needs from a social services. And that's an important point that we some one of the reasons we don't really know the ranking for some of these things is we're not doing probably as much assessment of social determinants of health as we should. And there are some good tools out there to begin to do that now. But among the top three would be housing, and food, and then transportation comes in there as well. So I think food would clearly go into the top three and again, it's food, access to nutritious food and its access to food, for your family. Both of those things I think are really important. And when we look at CKD, we see that there are data that show that poorer neighborhoods have more CKD risk, more CKD and poorer outcomes. And so we definitely see that there are neighborhoods where people don't have access to nutritious food. And that's also an issue that needs to be addressed as well that we need to make sure that we're creating good access for everybody.

Dr. Frank Maddux
So in our Fresenius Medical Care world, any bright spots on what you see some people have tried or have begun working on to at least recognize some of the issues and potentially even address some capabilities we might have as an organization?

Dr. Dugan Maddux
Yes. So there are some very practical things happening today already. So there's a part of our group in the south region started an effort called Food First, where the nutrition counseling just really started with, do you have enough food before we start talking about potassium and salt and all those other things? Do you have access to enough food? And how can we get you enough nutritious food? That's really a first step and that has spread around through the dietary counseling and interventions to think around the country at FKC. And so I think that's a really important first step. And we definitely get a lot of local requests, like we see that we can do our patients need this with regard to food, is this something that we can help them with? How can we, you know, in a compliant way, be involved in helping connect local resources like food pantries with people who need food in our dialysis facilities? We also have been supporting some research efforts. So there's some research around Mom's Meals and delivering those and see if we can impact volume overload. And intradialytic weight gain through some direct intervention with food like Mom's Meals, which is sort of a medically appropriate meal delivery service.

Dr. Frank Maddux
Can you tell the story of I think it's Winnie.

Dr. Dugan Maddux
She is a dialysis patient. And she recognized that particularly during this pandemic, that there were people in the renal community connected on social media, who needed food. And so she had an idea to start a GoFundMe project around buying boxes of nutritious food for people who had renal disease. So she set up a GoFundMe and then reached out through Peter to some of us to say, “Well, what should be in the box and is this feasible,” and so some of our dietitians helped to say well, these would be appropriate things to put in a box. And so she started accepting applications that were pretty simple, you know, that people filled out and then she would arrange for them to receive $100 worth of nutritious renal appropriate food in a box. And she's gotten great feedback. Her goal was to raise $10,000. She's over shot her goal, she did very well with that and so she's on social media, you can see how the response that people have to just getting this hundred dollars worth of food at a time where they really need that extra help. So it's been very successful and just fascinating to see her be able to support this effort.

Dr. Frank Maddux
So, I recall this Medical Office Live event where Dr. Cosette Jamison spoke about how she was engaging patients iwith regards to cooking and food.  Can you describe a little bit what you recall of that interaction?

Dr. Dugan Maddux
Cosette Jamison, who's a nephrologist, and medical director in the Washington, DC area, and she recognized she's very interested in social determinants of health in general and in food in particular. So I think she and her dietician set up a kitchen and they are doing cooking classes every month. And it is not only the food, but it's talking about the joy of food, and that food creates relationships. And so I think the other thing about social determinants of health is, and we've seen this in the Camden coalition work where they’ve worked on housing interventions and things like that is you create this authentic relationship with people, that we are here to help you, we're not just worried about your potassium, but we are here to help you live a good life. And so with your chronic condition. And so part of doing that is looking at things that bring people joy and relationship and food is definitely one of those.

Dr. Frank Maddux
So as we end if you might give us your sense of what the vision or aspiration of how food insecurity might be addressed within our organization, or how the food is medicine, sort of concepts and project might actually have an impact, what would you see in the future?

Dr. Dugan Maddux
So a couple of things. One is I think, definitely we need to see food come into the mainstream healthcare delivery system. So right now food sort of sits, you know, Food Is Medicine or food pantries sort of sit out here and social services and they're not really part of our mainstream health delivery. And so I think we definitely want to see that we are tightly connected and partnered with these food organizations that can provide medically tailored food, prescription produce food or medically tailored meals for depending on what people need. So hopefully we will see the continued evolution of bringing these groups into more of our mainstream so that if I write a prescription for food, it's similar to writing a prescription for an ACE inhibitor or something like that. Also, we've started doing this, we have now of food insecurity question as part of the social worker evaluation. So we need to know how many patients and who needs help with food, we want to ask those questions so that we can then be very active in helping to solve that problem, not sort of stumble upon that need, you know, somewhere along the line. And the hope would be that if we help people with some of these basic things, they can then attend to some of the other things that they now you know, just are too stressed, or can't attend to today so that overall, they'll have better health outcomes related to that. So that's my hope that we get to be much more mainstream, and what we think about and work on every day.

Dr. Frank Maddux
Great. Any final thoughts or message to our Dialogues audience?

Dr. Dugan Maddux
Just that these things like housing and food are really important. And they are a very basic way to say, what can we help you with today and to start a relationship that if people need help with housing or food, we've got to help them address that before we can expect that they can think or worry about some of the other things we want them to do as part of their healthcare that are very complicated. So I'm hopeful that people will realize that these are basic things but they can make a very big difference.

Dr. Frank Maddux
Thanks for being on the show today.

Dr. Dugan Maddux
It's my pleasure. Thank you for having me.