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Office of Nutrition Research (ONR)

Office of AIDS Research (OAR)

National Heart, Lung, and Blood Institute (NHLBI)

National Institute on Aging (NIA)

Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)

National Institute of Dental and Craniofacial Research (NIDCR)

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

National Institute of Mental Health (NIMH)

National Institute on Minority Health and Health Disparities (NIMHD)

National Center for Complementary and Integrative Health (NCCIH)

National Cancer Institute (NCI)

Tribal Health Research Office (THRO)

Office of The Director, National Institutes of Health (OD)

Division of Program Coordination, Planning and Strategic Initiatives, Office of Disease Prevention (ODP)

Office of Dietary Supplements (ODS)

Office of Research on Women's Health (ORWH)

Administration for Community Living (ACL)

Centers for Disease Control and Prevention (CDC), Division of Nutrition, Physical Activity and Obesity (DNPAO)

Centers for Medicare & Medicaid Services, (CMS)

Office of the Assistant Secretary of Health (OASH)

Office of Disease Prevention and Health Promotion (ODPHP)

Health Resources and Services Administration (HRSA)

Indian Health Service (IHS)

U.S. Department of Veterans Affairs (VA)

United States Department of Agriculture (USDA)

Food and Drug Administration (FDA)

Agency for Healthcare Research and Quality (AHRQ)

Purpose

This Request for Information (RFI) invites input on research opportunities and best practices for Food is Medicine research programs. These programs are part of a whole-of-government approach to end hunger, improve nutrition and physical activity, and reduce diet-related diseases and disparities. Review of this entire RFI notice is encouraged to ensure a comprehensive response is prepared and to have a full understanding of how your response will be used.

Background

Poor nutrition is one of the leading contributing factors of death and disability in the U.S. Indeed, millions of Americans are affected by food insecurity and diet-related diseases, including heart disease, obesity, and type 2 diabetes. Besides the economic burden, the toll of hunger and these diseases disproportionately impact underserved communities, including NIH-designated populations that experience health disparities, people with disabilities, older adults, certain military families, and veterans. Better integrating nutrition into health using Food is Medicine initiatives is a key component of the Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health.

Food is Medicine is an umbrella term for a variety of activities and services that respond to the critical link between nutrition and health. It does not have a technical, widely agreed upon definition.[i] It has been referred to as having the following two components (1) the provision of food that supports health and (2) a nexus to the health care system.¹ The nexus to health care systems recognizes health care providers as a trusted source of information. Of people who report receiving dietary guidance from their health care provider, 78 percent of those that do receive such advice initiate dietary change. ^[ii] Food is Medicine is not intended to replace the use of medications or other treatments but may be able to reduce the doses needed or allow medications to work more effectively.

Food is Medicine services and activities include but are not limited to: (1) medically tailored meals (MTMs), (2) medically tailored and healthy food packages or groceries (3) nutritious food referrals or vouchers, (4) prescriptions for nutritious groceries or produce, and (5) culinary medicine and teaching kitchen programs.

Sustainable clinical-community partnerships may reinforce and act as an effective bridge between healthcare systems and patients to improve an individual’s dietary and lifestyle behaviors. Indeed, evidence is mounting that Food is Medicine approaches are associated with meaningful improvements in food security, health biomarkers (e.g., body mass index, cardiometabolic parameters, hemoglobin A1C), insurance costs, and health quality indicators (e.g., hospital readmissions for the same diagnosis).^{1,[iii],[iv],[v]}

Community-based food and meal programs are an innovation that enhances successful Food is Medicine models that support wider social determinants of health and hold much promise for positive nutritional health impacts. Several of these programs have linked with long-standing Federal nutrition education programs like the USDA administered Expanded Food and Nutrition Education Program (EFNEP) and the Supplemental Nutrition Assistance Program Education (SNAP-Ed) and are using Federally supported materials such as MyPlate and WIC Nutrition Education resources.

Recognizing that connecting eligible people to sustainable community-based Food is Medicine activities is a viable solution to address the social determinants of health, the US Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) is permitting substantial flexibility in programmatic design and authorized states to undertake transformative initiatives through Section 1115 of the Social Security Act. These demonstration waivers now allow states an avenue to develop and test whole-person care approaches in Medicaid. More than four states have obtained Medicaid waivers to provide services, including those that also address Food is Medicine, other nutrition services, and housing security.[vi] In addition, CMS finalized a rule that allows certain accountable care organizations to qualify for advanced payments that could be used to address food security through Food is Medicine programs for Medicare recipients in 2024.[vii]

As part of a whole-of-government approach to better integrating nutrition into health, there are considerable investments and interest in the intersection between food and health care systems exemplified through programs supported by the Centers for Disease Control and Prevention (CDC), Indian Health Service (IHS), the National Institutes of Health, the United States Department of Veteran’s Affairs (VA), and the United States Department of Agriculture (USDA). For example, between 2019 to 2022, the USDA administered Gus Schumacher Nutrition Incentive Program (GusNIP) provided $267 million in funding to 172 projects throughout the United States and its territories. In addition, the second year of GusNIP, participants redeemed more than $20 million in nutrition incentives and GusNIP participants reported increased fruit and vegetable intake and improvements in food security. More work is needed to understand how existing incentive programs, among other Food is Medicine activities can better improve nutrition and advance health equity. In addition, various healthcare organizations have been entering the Food is Medicine space, some in collaboration with the Cooperative Extension System via the USDA and CDC. As one example, Dining with Diabetes has been implemented in a variety of states and has included developing, implementing, and evaluating a referral process between healthcare systems and Cooperative Extension.

Through this RFI, the National Institutes of Health (NIH) and other federal departments and agencies are seeking input on research opportunities that will optimize, implement, and disseminate information on regionally and culturally appropriate as well as linguistically sensitive Food is Medicine activities. This information will be used by the federal government for research planning and strategies for implementing Food is Medicine activities to reduce food and nutrition insecurity, diet-related diseases and disparities, and disease related malnutrition.

This RFI invites participation from a broad range of interested parties, including but not limited to:

• Biomedical, behavioral, and social science researchers
• Community organizations and other not-for-profit organizations
• Cooperative Extension professionals, community health care workers, and other public health education professionals
• General public
• Indigenous food sovereignty organizations and advocacy groups
• Individuals with lived experience with hunger, food insecurity, or a chronic condition, including but not limited to older individuals
• Individuals who have received Food is Medicine services or are eligible to receive them but did not use or sustain the use of them
• Individuals or organizations with experience implementing or evaluating Food is Medicine programs
• Individuals working in agriculture, housing, transportation, grocery, restaurant, food manufacturing, educational, medical insurance, and communication sectors
• Individuals and organizations who have collaborated with other private and public sector organizations in the development, implementation, financing (including braiding funding sources), or evaluation of Food is Medicine services or activities.
• Managed care organizations and their associated actuarial partners
• Medical advocacy and outreach organizations
• Patient advocacy groups focused on medical conditions or disabilities that impact dietary intake
• Physicians, social workers, nurses, nurse practitioners, physician assistants, dentists, registered dietitians, nutritionists, diabetes or nutrition educators, pharmacists, occupational therapists, speech language pathologists, and other health care professionals
• Private health and medical insurers
• State, Tribal, US territories, and local governments
• Private- and public-school systems
• Students or staff of universities or colleges (e.g., affected by food insecurity), including Historically Black Colleges and Universities, Hispanic Serving Institutions, and other Minority Serving Institutions
• Tribal government or networks
• Individuals working in Federally Qualified Health Centers

Information Requested

RESEARCH

• What are considered high priority research gaps and opportunities for Food is Medicine?
• What barriers currently hinder the ability to evaluate the impact of Food is Medicine services on health outcomes, health care utilization, cost of care across the life course, nutrition-based disparities, and recipient experience?
• What short-term health care, quality of life or patient-centered outcomes (e.g., quality of care, disease-specific biometric measures, symptom and side effect management during treatment, engagement in preventive services such as primary care, mental health, behavioral health, and obstetrics/gynecology care, prenatal and postpartum outcomes in parent-child dyads, utilization, cost, etc.) can be most impacted by Food is Medicine services and for what populations (e.g., urban, rural, pregnancy, children, underrepresented, underserved populations with health disparities)?
• Are there technologies such as machine learning and AI that can be combined with electronic health records to better utilize healthcare administrative data for use in site-specific or health system Food is Medicine research?
• Are there any existing data sets, common data elements, or metrics that could be used for meta-analyses or systematic reviews that seek to assess research on Food is Medicine health and social outcomes?
• What environmental, cultural, social, and mental health aspects influence health, quality of life, or patient-centered outcomes of Food is Medicine?
• What are the cost/benefits and/or cost/effectiveness of a Food is Medicine approach relative to other health care strategies to improve long-term health, especially in populations who experience health disparities?
• What models exist or can be developed or adapted to test the cost/benefits and/or cost/effectiveness of Food is Medicine strategies for health?
• What type of analysis is needed to assess the relative merits and challenges of differing Food is Medicine strategies? In what context do the various strategies work best?
• What online grocery or online meal delivery systems have propriety data that could be shared to better address FIM Food is Medicine research gaps?

PROVISION OF SERVICES AND ACTIVITIES

• What strategies are needed for populations with varied functional capabilities (e.g., ability to open a package, chew); housing supports (e.g., access to refrigeration or cooking utensils); or transportation (e.g., ability to access or receive food delivery to a secure high rise or rural locations)?
• What are best practices and/or lessons learned for providing Food is Medicine services? (e.g., best practices in planning/designing programs; creating awareness and sustaining engagement- directly with intended recipients and indirectly with influencers ; fulfillment/delivery; evaluation; and the identification of individuals to be served by these programs, other implementation challenges and how those challenges were overcome, if applicable)?
• What are examples of needed staffing and resources (e.g., health care providers, social workers, information technology, electronic health record coding, IT systems, contractual vehicles, payment mechanisms, vendors/food retailers, CPT codes, etc.) for various types of Food is Medicine interventions across health systems and community-based organizations?
• What are examples of needed staffing (e.g., screening, refer/follow-up, and fulfillment) for various types of Food is Medicine interventions?
• How may Food is Medicine services be combined with other food assistance, nutrition and health education, and health care services (e.g., social services, meals on wheels, Community Health Workers, care transitions case management, etc.) to improve engagement and affect health outcomes?
• How may Food is Medicine services leverage ongoing nutrition education and existing nutrition assistance and access programs (e.g., WIC, SNAP, NSLP, VA Teaching Kitchens, etc.)?
• In what ways can Food is Medicine services be used to address nutrition disparities and unequal access to nutritional foods?

COMMUNITY OUTREACH AND ENGAGEMENT

• What are key strategies for community engagement and outreach, or obtaining local community input from those with lived experience or organizations that provide direct Food is Medicine or related services to persons with hunger and food insecurity, populations who experience health disparities, or other health-related social needs?
• How can health care organizations work effectively with community-based organizations and programs to adequately resource community-responsive approaches for Food is Medicine implementation and research?
• How might Food is Medicine programs integrate a culture is medicine approach that incorporates cultural foods and food practices (e.g., Indigenous gathering, hunting, and agricultural food practices)?
• What issues may arise in a community-living setting, high-rise building, food deserts, rural locations, or other unusual community living settings that may influence Food is Medicine research interventions?
• How may community issues influence interventions or changes within health care settings?
• How can we respectfully include knowledge to enhance Food is Medicine research, services, and activities for American Indian and Alaska Native food and Tribes?
• How do some Food is Medicine research interventions yield spillover benefits for the intervention community, such as supporting local agriculture?
• How may agricultural programs and health care organizations work effectively to center power within communities, and individuals in advancing Food is Medicine as a practice?

EDUCATION AND TRAINING

• What training is needed for health care providers (e.g., physicians, nurse practitioners, nurses, physician assistants, dentists, pharmacists, registered dietitian nutritionists, doulas, etc.), to successfully use and disseminate Food is Medicine information?
• What training is needed for community health workers, federally- and community-funded food and meal program staff (e.g., Older Americans Act Senior Nutrition program staff, 2-1-1, social service intake, referral and benefits counseling staff, food banks, etc.), and nutrition and health education staff to successfully operate in or advance the Food is Medicine space?
• What training is needed for Cooperative Extension professionals to successfully advance the Food is Medicine initiatives?
• What training/education is needed at individual, family, and community levels (including K-12, colleges, and universities) to increase knowledge of Food is Medicine throughout the lifecycle for all Americans to reduce diet-related diseases and disparities?

COVERAGE FOR SERVICES

• How can federal, healthcare, philanthropic, and other funders effectively collaborate to support implementation of these programs (we are interested in strategies for innovative financing arrangements such as value-based payment and braiding together of funding sources as well as better understanding of how services and service components are priced)?
• What dietary interventions or specialized diets are most frequently required by persons who receive Food is Medicine programs, or who might be anticipated to need Food is Medicine programs? How are individual needs accommodated, and which interventions are more or less likely to implement individualized meals, programs, or food items?
• Are there any data sets, common data elements, or metrics that could be interrogated through evidence scans and systematic reviews to help synthesize and disseminate research and increase connections between health plans (payers) that invest in Food is Medicine?
• What types of reimbursement strategies exist, and what approaches hold promise for nationwide scaling for Food is Medicine services within health care, state and local governments, and community-based entities?
• What are key milestones, data elements, continuous quality improvement (CQI) processes, or deliverables that could be tracked to measure implementation (acceptability, reach, fidelity, maintenance, cost) to ensure success of Food is Medicine programs?
• Are there any additional comments that you would like to share about Food is Medicine programs or research?
• What measures or outcomes do you use or should be considered to evaluate the success of Food is Medicine from the perspectives of funders, recipients, service providers, and the community?
• What are the optimal methods to evaluate the success of Food is Medicine programs including measures to determine return on investment (i.e., an ROI calculator [viii])?

ADDITIONAL COMMENTS

Are there any additional comments that you would like to share about Food is Medicine services and activities?

FOOTNOTES ----------------------------------------------------------------------------------------------------------

[i] https://www.aspeninstitute.org/programs/food-and-society-program/food-is-medicine-project/

[ii] https://foodinsight.org/wp-content/uploads/2018/05/2018-FHS-Report.pdf

[iii] https://www.nature.com/articles/s41591-022-02027-3

[iv] https://academic.oup.com/advances/article/12/5/1944/6274221?searchresult=1

[v] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2797397

[vi] https://www.hhs.gov/about/news/2022/11/01/hhs-approves-ar-medicaid-waiver-to-provide-medically-necessary-housing-nutrition-support-services.html?amp

[vii] https://public-inspection.federalregister.gov/2022-23873.pdf

[viii] https://www.commonwealthfund.org/roi-calculator

How to submit a response

Responses to this RFI must be uploaded using the online form at this URL: https://rfi.grants.nih.gov/?s=6418bcd5d23bfe80540f6582

Answer fields are available for each question. Text can either be directly typed into these fields, or cut and pasted from another electronic document. It is not necessary to address each question/item. Do not include any proprietary, classified, confidential, trade secrets, or sensitive information in your response.

Responses must be received by 11:59 pm (ET) on June 30, 2023

Providing a response to this RFI is voluntary. Responses will be reviewed and analyzed by federal government staff. No individual feedback will be provided to any responder. The Government will use the information submitted in response to this RFI at its discretion. The Government reserves the right to use any anonymized submitted information on public NIH websites, in reports, in summaries of the state of the science, in any possible resultant solicitation(s), grant(s), or cooperative agreement(s), or in the development of future funding opportunities.

This RFI is for information and planning purposes only and shall not be construed as a solicitation, intent to publish a grant, or cooperative agreement, or as an obligation on the part of the Federal Government, the NIH, or individual NIH institutes and centers to provide support for any ideas identified in response to it. The Government will not pay for the preparation of any information submitted for this RFI or for the Government’s use of such information. No basis for claims against the U.S. Government shall arise because of a response to this request for information or from the Government’s use of such information.

Inquiries

Please direct all inquiries to:

Christopher J. Lynch, Ph.D.
Pronouns: he/his
Office of Nutrition Research (ONR)
Division of Program Coordination, Planning and Strategic Initiatives (DPCPSI)
Telephone: 301-325-4232
Email: [email protected] (Please do not send RFI responses to this e-mail address)

For technical issues with this online form contact:
Michael Dorsey, Ph.D.
Pronouns: he/his
NIH, Office of Extramural Research
Email: [email protected]
(Please do not send RFI responses to this e-mail address)