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WASHINGTON -- The U.S. needs a "whole-of-government" approach to addressing diet-related diseases, Sen. Cory Booker (D-N.J.) said Wednesday at a on food as medicine.

"Currently in the United States, half our population is pre-diabetic [or] has type 2 diabetes," said Booker, who is chairman of the Senate Agriculture, Nutrition, and Forestry Subcommittee on Food and Nutrition, Specialty Crops, Organics, and Research. "That is something that isn't exclusively affecting older people ... one-quarter of our teenagers today are pre-diabetic or have type 2 diabetes. Much of that can be attributed to the alarming fact that ultra-processed foods now compose two-thirds of the calories in the diets of our children and teens."

A System Based on Wellness

Booker, a vegan who for 2 months last summer, noted that in September, "the White House released a bold blueprint to end hunger, improve nutrition, and reduce the epidemic of diet-related diseases. A key component of the is a call to continue researching and scaling up 'food as medicine' programs, such as funding pilot programs to integrate medically tailored meals and nutrition counseling into our Medicare and Medicaid programs."

Booker added that incentivizing farmers to grow fruits and vegetables at the same level as the federal government supports commodity crop production "is a top priority for me in the Farm Bill."

Sen. Mike Braun (R-Ind.), the subcommittee's ranking member, recalled that when he was running his family's truck parts distribution company, "we built a system based upon wellness and avoiding the healthcare system and making my employees engage in their own well-being." For example, employees were offered a free biometric screening, "and if you didn't get it, you're going to get penalized because you weren't doing the right thing."

The wellness program is still going strong today, he added. "Employees have not had a [health insurance] premium increase in 15 years and they go into their deductible less now than they did then, because they've become healthcare consumers. In a nutshell, that's what we need to do more broadly across the country."

But many people -- especially lower-income people or those living in "food deserts" with no access to healthy foods -- have trouble accessing healthy meals and fresh fruits and vegetables, witnesses said. "For 20 years I served as a part-time primary care doctor and hospitalist at the Philadelphia Veterans Affairs Medical Center," said Kevin Volpp, MD, PhD, founding director of the University of Pennsylvania's Center for Health Incentives and Behavioral Economics. "Many of my patients struggled with chronic diseases, such as congestive heart failure and diabetes, which were exacerbated by their challenges finding affordable, healthy foods."

Clinical Trial Shortcomings

"Evidence indicates that incorporating food as medicine programs into healthcare can be associated with improvements in outcomes," said Volpp, who is also a member of the advocacy coordinating committee at the American Heart Association (AHA). "For example, medically tailored meals are associated with fewer hospital and skilled nursing facility admissions, fewer emergency room visits, and healthcare cost reductions."

However, he said, when it comes to proving the value of food as medicine, "only a small number of randomized controlled trials have been done, and they've typically been small and thus unable to provide definitive answers. Food as medicine interventions have not generally incorporated freedom of choice and input from patients, reducing potential rates of engagement."

"To unlock the full potential of food as medicine, we must systematically answer important questions regarding intensity, duration, and delivery of food as medicine interventions; the role of patient preferences and choices; the incorporation of educational behavioral strategies or coaching; the comparative effectiveness of ways to change behaviors and habits; and cost-effectiveness," Volpp added, noting that the AHA and the Rockefeller Foundation have committed a total of $250 million to build a National Food as Medicine Research Initiative. The organizations plan to launch the initiative next spring.

John Bulger, DO, MBA, chief medical officer of insurance operations and strategic partnerships at Geisinger Health Plan in Danville, Pennsylvania, discussed the success of the health plan's Fresh Food Farmacy project, which provides each of the program's 1,600 participants with enough healthy food for 10 meals for themselves and their families each week; participants also receive clinical interventions from care managers, dietitians, and diabetic education consultants. The result? Participants' average HbA1c level dropped by half, and hospital emergency department visits dropped by 30%, he said.

Bulger cited an example of a 55-year-old, 181-lb. widowed grandmother named Rita who was the program's first patient. "Her [blood] sugar was about three times what it should be ... and her cholesterol was twice what it should be. After going through the program, she actually had normal blood sugar -- she dropped her blood sugar by two-thirds. She lost 50 lb. to [reach] 135 lb. and dropped her bad cholesterol from being twice what it should be, to being about half the high end of normal."

Geisinger is now expanding the program to include additional diseases like kidney disease and heart failure, he said.

Role of Meat and Dairy Products

Sen. Roger Marshall, MD (R-Kansas), noted that he was working with Sen. Kirsten Gillibrand (D-N.Y.) "on getting milk back into the [school] lunch focus -- specifically whole milk. We're going to have a generation of women that have osteoporosis and osteopenia in their 40s rather than their 50s because they're not drinking milk at school."

He also expressed concern that the Agriculture Department's Food and Nutrition Service "recently provided recommendations for WIC [the Women, Infants, and Children program] that included additional non-dairy substitutes for moms and children ... I think this is contrary to the recommendations of increased options of dairy products in the Dietary Guidelines for Americans. And then I'm concerned about 'Meatless Mondays' and the impact of less protein in people's diets as well." He asked the witnesses whether they thought meat and dairy were important sources of protein and calcium.

"It's a complicated question to answer," said Volpp, adding that, for example, some meats are healthier than others. "Saturated fat is obviously a problem for people with heart disease. And the same thing with dairy -- I think there are healthier alternatives in some cases, but it is very important to have enough protein in the diet. So we need to figure out holistically how do you accomplish that, given the full range of food options."

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