The Returns of Smarter Spending on Food in Health Care

By Dr. Howard Abrams, Director, Openlab & Nourish: The Future of Food in Health Care

Dr. Abrams is the Director of OpenLab, a service design and innovation shop based at Toronto General Hospital, part of the University Health Network. OpenLab is a trans-disciplinary space where patients, care-givers, designers, engineers, social scientists and clinicians come together to find creative solutions to transform the way health care is delivered and experienced. In addition, Dr. Abrams is practicing consultant in Internal Medicine at UHN, Sinai Health System, and Women's College Hospital.

Andre Picard recently proposed in the Globe and Mail: “if we want a healthier Canada, we should spend less on healthcare.” This may, at first, seem counterintuitive, but it has been long recognized that the social determinants of health are at least, if not more, important in the health of a population. This is where food intersects with public health in a pivotal way. If we look at the evidence, we know that food insecurity and poor housing are two major risk factors for chronic disease and adverse health outcomes. Patients we serve don’t show up out of thin air, but come out of a community environment rich with factors that impact their health —the food that they can access and eat is one of them. More and more, institutions are being asked to shift their focus (and public dollars) upstream towards population health. Rather than just improving the efficiency of providing formal health care, how do we look at reducing the demand for expensive health care through better diets? And how do we enlist the formal health care sector in supporting this goal?

“If we say that healthy eating is one of the cornerstones of healthy living, then where can physicians and other care providers reinforce this within our health systems? ”

We have excellent evidence-based research on good nutrition. Studies of the Seventh-day Adventists and Mediterranean diets show that plant-based diets with less meat and fish decrease cardiovascular risk and lead to longer and healthier lives. However, promoting healthy diets is still an uphill battle. Highly processed junk foods are readily available practically everywhere we go - from supermarkets to hospital food courts - and are deliberately engineered to make our bodies believe that we are consuming a nutrient-dense food. If we say that healthy eating is one of the cornerstones of healthy living, then where can physicians and other care providers reinforce this within our health systems? Can healthcare institutions gain credibility in advocating for healthy diets when we still serve french fries and sugary drinks in hospital food courts?

Working to bring food into a more central place in health care faces a barrier in the management paradigm of: “if you can’t measure it, you can’t manage it.” In complex adaptive systems where outcomes accrue over long time periods, it is difficult to measure the independent contribution of healthy eating, which means it’s difficult for institutions to be convinced they should invest in it. How do we measure the exact benefits of an exact number of dollars spent to supply a specific kind of food over the length of a patient’s stay? Over a year? A lifetime? Healthcare institutions work with limited budgets to deliver services for needs now, and have difficulty justifying putting money up front to generate potential savings down the line.

“What are the lost opportunities when we do not invest in healthy sustainable food as a core part of a patient’s health and well-being, or as a pathway towards distributive justice and food security?”

Henry Mintzberg, professor of management at McGill University, takes another view arguing that just because some things are hard to measure does not mean they are not of value. It just means you have to manage them differently. As opposed to seeing only the financial costs, we need to also consider the opportunity costs. What are the lost opportunities when we do not invest in healthy sustainable food as a core part of a patient’s health and well-being, or as a pathway towards distributive justice and food security?

Thinking about the opportunities around food can also bring a more systemic perspective from health care providers to see the linkages between patient, population and planetary health. Concern is growing about how climate change might reduce equitable access to safe and healthy food -- and the downstream effects on the health system it could have. Advocacy led by healthcare around thoughtful eating choices can intersect with more systemic environmental change around sustainable and just food systems.

Encouraging the benefits of thoughtful and healthy food choices can be a low-cost intervention that contributes to long-term systemic change. We are already seeing innovative projects within the system. Through Openlab, a health innovation lab at University Health Network (UHN), we have a project called Urban Farm where we are working with Toronto Rehab, Lyndhurst Centre, to bring urban farming to a hospital setting. This will provide both local, healthy food, and be part of the rehab program for patients.

If the ultimate goal is a healthy, flourishing population, we have to ask how we can we enlist the formal healthcare system to support a thriving food system. To inform next steps, Openlab collaborated on an infographic featuring 16 different opportunities for health care institutions in Canada to leverage food as a way to improve patient, organization and community outcomes. Developed by Nourish: The Future of Food in Health Care, a national systems change project led by the McConnell Foundation, it offers a menu of opportunities include retooling medical schools to include nutrition education and expanding antimicrobial stewardship programs to include responsible food purchasing. We should all consider how we can be supportive players in the healthy food ecosystem. The formal health care sector can be a leader, not a barrier, to this change.