a16z Podcast - On Food As Medicine (A Holiday Snack)

Episode Date: November 26, 2020

What happens if we treat food as a medicine in the healthcare system: How, where, and who (pays)? What role can technology play in increasing access, distribution, and more? General partner Julie Yoo talks with the founder and former medical director of Geisinger Fresh Food Farmacy, Dr. Andrea Feinberg, and with the co-founder of food delivery start up Plated in this "holiday" cross-promo of our show Bio Eats World. 

Hi, everyone. I'm sharing our most recent episode of BioEats World here today as a bit of a holiday snack since it covers the topic of food as medicine. Be sure to check out other episodes and subscribe to BioEats World wherever you get your podcasts. Hi, I'm Lauren. And I'm Hannah, and this is BioEats World, where we talk about all the ways our ability to engineer biology and re-engineer health care is transforming the future. This episode is our Thanksgiving special. here, Hannah and I are thankful to all of our listeners and hope that you were able to celebrate and stay healthy in the midst of this global pandemic. And since this is Thanksgiving, we are, of course, talking about food. We all know that eating healthy is better for us, and that following that advice is harder than it sounds. And yet the reality is that when it comes to not just preventing sickness, but helping sick people get better, and potentially saving the health care

system billions in treating chronic disease, food is one of the most powerful medical treatments we have. In this conversation, A16Z general partner Julie Yu talks with Dr. Andrea Feinberg, previously the founder and medical director of Geisinger Fresh Food Pharmacy, and Josh Hicks, entrepreneur and co-founder of the food delivery startup plated, all about what food as a medicine might look like. Whether personal taste and variety matters, how technology might not just help access but shift our snacking tendencies towards health and the enormous opportunity to impact chronic disease through addressing food insecurity. Happy Thanksgiving, everyone. Here's to using every tool we have to keep ourselves and our loved ones healthy so that we can celebrate with them

next year. I'll kick things off by giving a little shout out to the OG Hippocrates. In 400 BC, he was attributed with us, quote, let thy food be thy medicine and medicine be thy food. You know, food actually has a lot of the properties that one would wish of medicines, right? So whether it's safety, whether it's efficacy, whether it's access and affordability, and I think most importantly, this notion of compliance, right? The fact that we literally have to eat to survive. That's such an integral part of our life that we can think about how that leverages into the way that we deliver care. The food is medicine and this whole nutrition area is maybe unique among healthcare in the sense that the crossover to the consumer world is very strong.

wrong. It's a consumer product, right? I mean, unlike other interventions, other pharma or drugs or surgical procedures or what have you, this is a thing that whether it's helping you or hurting you, everyone who is so fortunate is doing two or three or more times per day. I ran a meal kit business, which focused on delivery. And that was in some ways my real introduction to this world of food is medicine because we had a bunch of customers that were almost accidentally getting healthy by signing up for the service. When I think about the whole constellation, of factors that can increase somebody's health, food is the greatest level we probably have in our armamentarian, whether they're providing healthy, medically tailored meals,

medically tailored food or voucher type programs. But using those kinds of programs in different settings have repeatedly demonstrated significant physiologic benefits, financial savings, improved health outcomes. Something that I think has always been a huge impediment to scalable solutions in this area is distribution. The delivery component of food is oftentimes the cost barrier to making this accessible to broad swaths of the population. What are the fundamental barriers and unlocks that you see for being able to scale these kinds of services? For a lot of Americans, curbside grocery pickup has become a new and very favorite way of getting food for a lot of reasons. You're ordering online instead of going into the store. The delivery

piece is important, but also this idea that you're sort of choice set, right? Food content, food ordering, food metadata, if you will, is actually data. We all, to a degree, live in our own food media bubbles. And I think that shift is more powerful than, you know, might be at first obvious, because you've changed the food environment for that person. And you've changed what's in the digital checkout aisle. If it's Snickers bars there, the person might buy the Snickers bars. and as long as you're not doing it three times a day, it's like having a drink. Every once in a while, it's probably okay. But if you can change that for the most vulnerable, for the sickest people,

so that they don't see the candy bar at checkout. I think there's a lot of compelling academic evidence and real-world stories around how that can be really helpful for people. Yeah, and you guys just touch on a couple of concepts that really weren't possible until now, right? So the notion of being able to do delivery at-scale cost-effectively systems for doing curbside pickups or the online and the offline world, One could argue that we as consumers only learned how to do e-commerce in the last decade. And so now we have an understanding of how we can incorporate that into our diets.

What other big tectonic shifts like that have you guys seen or do you think need to happen in order for food is medicine to become more of just a day-to-day consumer-oriented thing? Are there any key barriers that are hindering our ability to bring this to the masses? We need to have accessible systems that are broadly where the consumer can order and their payments can be processed through paid by the insurer per se. So that whole system has to work where it becomes possible if you're on WIC that you can or you have SNAP benefits that you can purchase the healthy food that we want you to purchase. This is often the case integrating those pieces is the remaining challenge and it's a big one.

I would also note on a more somber topic and I think it's relatively well proven out. that metabolic dysfunction and or a lot of conditions that come from poor nutrition have made people multiples more vulnerable to COVID. It's oftentimes driven by food insecurity, oftentimes driven by poor choices. Neither of those are necessarily easy to fix, but I do think we have fairly straightforward ways to fix them. And so I think there's a big opportunity there. As we all know, in health care reimbursement is the tail that wags the dog in many cases. One of the major forces that we've all seen in healthcare is the broadening recognition of social determinants on par with what we consider traditional healthcare delivery. So where would you guys say

we are in the maturity curve of payment systems being put into place that are able to subsidize these kinds of programs in a way that's scalable? Food insecurity is a huge driver of health care cost. The more food and secure a person is the greater their health care costs, will be. So if you have mild food insecurity, households, health care annual costs rise by about 15%. If you have moderate food insecurity, health care costs increase by 30%. And if you have severe food insecurity, a health care cost for the household can rise upwards of 70%. So we're currently spending $3.5 trillion on health care. A chunk of it is due to our poorly addressing unmet social needs.

When you start rewarding health systems for taking care of the healthy and keeping people out of harm's way is when we will start having more and more health systems investing in the social determinants of health. Eating healthier makes you healthier, even if you start out sick. And it's far cheaper than mostly other interventions, and it improves the patient's quality of life. So it feels like a maybe rare sort of win-win-win.

And I guess like a lot of things in health care, it's also unevenly distributed. I mean, I was talking to the CEO of a baby food company recently. You told me that greater than 50%, the majority of babies today are on WIC. The women, infant, and children federal benefit and getting some kind of food benefit through that, which is just staggering. It may not be labeled as food as medicine, but a food benefit for a majority of children being born today is really just eye-opening. I think one of the challenges with food is that we as modern humans crave variety in food. As a mom of a toddler, I went through the phase of being able to feed my son just one thing for the entire first year of his life, which is fascinating to me, right? And then the way that we introduce

variety into their life is really socially driven, right? Because I as mom had to organize my baby's life around mine that I went for what's convenient and what's easy to produce. Do you consider that like a primary requirement of any viable food system is providing adult humans with variety to make it pleasurable to eat? Or is there actually a more viable endstay? where we all are just drinking soilant and mono foods that are far more easier to produce, far easier to distribute, don't require as much overhead for us as individuals to consume, but take out a lot of the pleasure of eating. In healthcare, when a patient goes to see a clinician, and they receive three prescriptions,

in general, they only take about one of those three prescriptions. So there's a lot of personal choice involved with taking medications, and there's a lot of personal choice with what you eat. Julie, if someone said to you, X, Y, and Z is better for your baby, no question, you're going to do what's better for your baby. So if it's easy and affordable and within your time, lifestyle. So much comes down to the personal choice and helping a person understand what are the best choices they can make for themselves.

I think the variety is really essential, Julie, but there's only so much trade-off you can make against things like cost and sort of ease, right? And everybody's making different trade-offs at different points in their day. And it's different person-to-person in household-to-household, making it easier for people because we delivered it to you, and making it probably cheaper and easier and lowering some of the access. You've got to attack all of these problems. If it's a lot of variety, but it's out of reach from an economic perspective, it's obviously not solving the problem. What's also interesting is that, you know, the governing body in our country for food and drug is literally, you know, the FDA, right?

How do we assess our willingness to reimburse for food, almost in the same way that we would reimburse for drugs? What do you think needs to happen to create the evidence, the clinical quality base of data to justify reimbursement at that level? You know, we hold preventive measures at a higher standard than we need to. I can send you 20 articles or 50 articles on food is medicine working commercially. At every level, whether it's a voucher program, medically tailored meals or medically tailored food, it works. It's been demonstrated time and time again. And in a variety of diseases in overall well-being, in regards to metabolic disorders, in regards to cancer, in regards to AIDS.

Currently in the United States, about 86% of our health care spend is on chronic disease. And linking a food intervention with complex patients that are costly is a very inexpensive way to approach chronic disease. When you give people good nutritious food, not surprisingly, they get healthier, they do better, they access health care systems at a lower cost and number. So the evidence is good to talk about, but we have evidence already. If you look at observational studies of providing food to people, Medicaid, Medicare, dual eligible patients, and they get healthier, they have reduced ER visits, hospitalizations, then even if it's not a randomized control trial, you can deduce that this is a positive intervention in a patient's life. Providing food is not that expensive when you consider, let's just take diabetes for a moment, diabetes medications can cost, hundreds of dollars a month. And food costs for a food and secure individual could cost $50 a month. So while I was at Geising, our patients who had diabetes out of control,

so a very diet responsive condition, we provided them with healthy food, education, and social support. And what we saw was dramatic improvements clinically with hemoglobin A1Cs, which is a marker of diabetes control. We saw about 60 plus percent decrease in health care costs. And for our very sick patients, we cut their costs by two-thirds. If we want to focus on getting people healthier, we wouldn't only spend 3% of our health care spend on prevention. And we wouldn't have this high, high level of evidence needed to demonstrate things that actually lay people, health care providers and scientists all agree works. And it's maybe funny, but obvious to say eating a Mediterranean diet seems pretty safe. We believe that it works, and we think we have

a pathway, maybe a long one, but a pathway to reimbursement. Andrea, maybe, as the resident provider here, how you think about the provider side of it, I always get told this stat of the average medical degree has one hour of nutritional education in it, and that's part of the reason why food is medicine is not well incorporated. So those clinicians, myself included, that went through medical school years back. We had no real nutritional education. Currently now, they're building in culinary programs and food as medicine programs into the curriculum. The fact is that if the clinician believes that something will work, then we have a greater likelihood of patients at least thinking about it. And that's why it's very important for us

at Geisinger to have. The food that we prescribed was prescribed by the clinician, literally as a medication. So very important. I had a lot of clinicians say to me, how did you know your program would work. I'm like, I'm so sorry. I don't understand. Have you not read like the first paragraph of diabetes approach is the lifestyle diet and exercise? I think they feel that patients won't really change their lifestyles. Hence, they should just push medications. But we need to figure out ways to motivate patients, educate patients, and help patients do for themselves. Yeah. And we're coming on Upon Thanksgiving here, so much of what I love about American society is that that is a rallying cry to food banks and other programs delivering food to families who can't celebrate Thanksgiving otherwise. As people are so centrally thinking about food as part of this national holiday, I'm curious, have you guys seen examples at the intersection of consumer and provider where you can use sort of these social and cultural opportunities to onboard people into food-oriented experiences that then have longevity?

Your food environment really does drive what you eat. It has to be sustainable, right? I've talked to dietitians in the past who will relay that they use with their clients this idea that are you going to never eat birthday cake again? You probably will. We should build a lifestyle change for you that is sustainable and that works and that has the right weekly average. Outside of perhaps the most acutely ill patients, there is room for an indulgent meal here and there. Sort of the dose response idea for food, how often can you have a piece of pumpkin pie or whatever it is? I mean, clearly for a healthy person, there is some frequency at which it doesn't seem to be a problem, I think. And if there's a spike in there, because you have a slightly richer day-night meal,

it's okay. When I think about Thanksgiving, currently we have upwards of 50 million people now in the United States that are food insecure due to COVID. So this is a great time when people are visiting their food pantries to provide healthier options. And the food banks know this. There's a growing understanding that they want to provide food as medicine as well, whether it's Thanksgiving or any other cultural holiday. Whenever a clinician or a dietician or anyone who's trying to help people choose food wisely, absolutely need to consider the person's preferences where they are culturally. We need to accept that people are going to do what feels good to them. But we should help them kind of get out of that food bubble and move them towards the health

food bubble because the food that we're eating, if it's making us sick, we need to do something different. So a lot of what we've discussed so far has to do with how can we either change the behavior of consumers or bring food to people in their day-to-day living. How can you incorporate nutrition just invisibly into the way that public health operates? I think perhaps one of the biggest innovations in preventative health is the fact that, you know, we've prevented millions of kids from getting cavities every year by simply just putting fluoride into our water, right? And we don't even think about that on a day-to-day basis.

And yet that's a huge reason that we've been able to significantly change the course of disease in dentistry. Is it too far off to believe that we could one day have Lipitor in the water or other such medical interventions that are just embedded into our utilities, you know, in such a way that we don't have to think about them. We don't have to cause humans to change behavior in any such way. Payment is sort of taken care of. Can we imagine versions of that happening in our lifetime? So fluoride in the water is not a given. In California, it's a given. But when you go into rural America, when I was living in Pennsylvania, there are communities that did not have fluoride in their water and they lost their teeth. And you think how can that happen in this day and age,

but it does. This all comes down to public health. When we have to, as a nation, decide, that we have a responsibility, a bare minimum responsibility that people should have access to affordable, healthy food. And that's a pipe dream probably. But I think that we could put farmers to work, we could put restaurateurs to work, we could put entrepreneurs to create a food ecosystem where that food is available for all. There should be a bare minimum, healthy, nutritious food that's available for all children, for all adults, for all seniors. And it should be well integrated and the sicker you are, the more important it is to have that. I don't think it's a pipe dream and I don't actually think that it needs to be or is that far off. I don't think it's about

changing people's behavior because I actually think that's a, in a lot of ways, a fool's air. And I think it's about helping people to make the changes they actually want to make. And I actually think that the amount of people and how much change they want to make is underestimated. I think most people have at least a broad understanding that their food affects their health. It's the ease of use and the access and the cost that really the sort of axes of that decision that have to get improved so that people, once they've decided they want to make a change, whatever that change might be, it's easy for them. Because I think to some degree, we all do the easy thing.

It's not like the tools that Silicon Valley has built over the past few decades have made people want to communicate more. We do it because it's easier. And I think that idea of sort of friction and sometimes the kind of surprising and magical things that happen when friction comes down can be applied in the service of enablement here as well. Yeah. And perhaps the real answer is that it's a combination of both. You know, we have examples like vitamin D enriched milk, right? And it's not just about the vitamin D. It's also how do you get the milk to the people? And so perhaps it's a hybrid that will ultimately be the right solution here. Thanks so much for joining us on BioEats World.

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