Cancer. Heart disease. Mental health disorders. Cognitive impairment. Stroke. Diabetes.
Overconsumption of ultra-processed foods (UPFs) is increasingly linked to poor outcomes for these conditions and others according to top research institutions, yet explicit language limiting UPFs is rarely included in public health program waivers and generally considered an afterthought by health payers.
These foods are designed to lead to higher caloric intake and are stripped of nutritional value, but also are seen as addictive and cost-effective.
In January, the White House hosted its first Food is Medicine summit to promote its mission of reducing chronic disease. Food is medicine utilizes programs like medically tailored meals and fresh produce prescriptions to improve outcomes caused by healthy nutrition.
As food is medicine priorities catch on across the country through state Medicaid Section 1115 waivers and within private-public partnerships, are health insurers reckoning with data showing the dangers of UPFs?
Fierce Healthcare spoke with payers, tech startups, consultants, food as medicine directors, clinical experts and researchers to get a glimpse into how different stakeholders view UPFs today.
Though limiting UPFs aligns with the objectives of many food is medicine programs, rarely do the programs go as far to ensure UPFs are restricted.
“I’ve probably had, I don’t know, 5 million conversations with health plans,” quipped Josh Hix, CEO of Season Health, a food is medicine platform that sells to health plans in value-based partnerships. “Approximately zero times have the words ‘ultra-processed’ ever come up.”
“The payers certainly I think take a more simplistic view, which is they want to get healthy foods to their members,” said Michele Rager, vice president of clinical nutrition at Season Health. “They don’t necessarily think about all of the things that they might want to cut out.”
Ultra-processed foods 101
UPFs, as defined under the NOVA classification scoring system by researchers in Brazil, are items with many ingredients typically not found in a traditional kitchen, and contain suspect dyes, additives, sweeteners and emulsifiers.
They usually undergo many forms of processing to allow for unnaturally long preservation, easily packaged delivery and meals that are ready to eat.
Food becomes processed each time it is changed from its natural state as a whole food. Mixing, blending, chopping, cooking and freezing are all examples of processing. These simplistic methods of processing foods are a degree removed from the extreme methods used on ultra-processed foods.
“The more that you process food from its original form, the less nutrients it’s going to have,” said Erin Martin, founder and director of produce prescription program FreshRx Oklahoma and co-lead at the Oklahoma Food is Medicine Policy Coalition. “This is the worst way to be eating food.”
Kevin Hall is a senior investigator at the National Institutes of Health (NIH). He is one the country’s leading researchers on nutrition, body weight and now, UPFs, which constitute 60% of the average American’s diet.
His team gathers participants to stay at the NIH Clinical Center in Bethesda, Maryland to run complex dietary studies. Participants will stay for months at a time, where “every morsel” of food they eat, and don’t eat, is carefully created, distributed and analyzed to see how their bodies are affected.
For one study in 2019, a group was given a diet of 80% UPFs and the other was given only minimally processed foods. The group given minimally processed foods consumed 500 less calories per day, yet both groups reported an equal satisfaction with the meals provided.
The team is now focused on curbing overconsumption by trying to determine what precisely about UPFs cause overeating.
“Maybe we can reengineer these UPFs … so they don’t drive people to overconsume calories,” he posed. “Maybe there’s a little bit too much fear mongering around UPFs before we have a really good idea of what are the mechanisms potentially by which they are linked to these negative health consequences.”
Scientific evidence surrounding UPFs is currently being deliberated by the Dietary Guidelines Advisory Council within the Department of Agriculture. HHS declined to comment on this story until the committee completed its review. However, European countries have banned certain foods commonly found in American grocery stores, though California has begun to ban certain food additives.
“I think payers generally follow federal guidance and reimbursement in the healthcare world, and I don’t think it’s too different here,” said Chris Lew, principal at consulting firm Rock Health.
How payers approach food is medicine
Insurance companies have embraced a wide range of partnerships to further food is medicine objectives.
Cigna embraces the meal kit phenomenon with HelloFresh for its employer plans. Blue Cross Blue Shield of Tennessee joined forces with FarmboxRx to deliver produce, coupled with preventative health screenings and condition-specific education.
Grocery chain Albertsons tapped Soda Health to give Medicare Advantage (MA) members prepaid debit cards for fruits, whole grains, fish and poultry, and Alignment Healthcare has extended co-branded MA plans with Instacart to more than 1,300 members across California and Nevada, said Dawn Maroney, president of markets for Alignment Health.
Mom’s Meals is one of the country’s foremost providers of home-delivered meals. They work with more than 500 health plans, managed care organizations, accountable care organizations, agencies, states and government entities for people in Medicare and Medicaid. Their meals follow federal guidelines and specific requirements for nine chronic conditions, said Catherine Macpherson, chief nutrition officer, in a statement to Fierce Healthcare.
“Current dietary guidelines recommend nutrient dense foods but do not explicitly address ultra-processed foods,” she explained. “We do not use any additives or preservatives to maintain the freshness of our meals, which arrive refrigerated and can be stored in the fridge for two weeks.”
Healthcare costs decreased for AmeriHealth Caritas District of Columbia members that received Mom’s Meals’ medically tailored meals and nutrition education. Among those with chronic conditions, there was a $4 million reduction in cost and 65% fewer readmissions.
UnitedHealthcare has a value-based Type 2 diabetes solution for its members called Level2 for certain UHG employees and eligible employers with self-funded health plans. Members are provided a continuous glucose monitor and provided individualized nutrition plans by dietitians, said Dave Moen, executive director of clinical affairs.
In this program, 73% of members with a high hemoglobin A1C had a clinically meaningful improvement.
“Almost every large or small insurer is now thinking about food is medicine,” said Dariush Mozaffarian, director of the Tufts Food is Medicine Institute.
He said insurers are incentivized to address nutrition gaps because of a rising cost of care, recognition of disparities by race and geography and the soaring costs of GLP-1 drugs.
UPFs spotlight not as bright
But just because insurers and lawmakers are addressing food is medicine doesn’t mean UPFs are on their radar in the same way.
“There’s an opportunity for it to come up a lot more,” said Kyle Dardashti, founder and CEO of Heali, a mobile app comprised of a hyper-personalized food database, helping users understand exactly what foods they should avoid for their condition.
Heali, currently under contract with Blue Shield of California and Medicaid fee-for-service in California, can categorize and precisely label UPFs with the additives they contain. Dardashti sees an opportunity between the insurers and meal provider companies to ensure meal providers are meeting nutritional requirements.
With Heali, members with chronic kidney disease may need to lower phosphorus intake, while members on IBS, for example, might go on a low FODMAP diet. A recipe can be analyzed against an infinite permutation of dietary preferences, just one example of how technology could be used to inform better nutrition decisions.
“For us, we want to go deeper than just say, ‘OK, this is an UPF,” Dardashti said. “We can say, for people who want to get particular, which ingredients are emulsifiers, so they can avoid them.”
Another app, January AI, allows users to get a nutritional overview of the meal they’re about to eat by snapping a photo of the dish with their phone’s camera or by scanning a barcode. The app uses predictive AI to monitor blood sugar without a continuous glucose monitor.
CEO and founder Noosheen Hashemi said the app can help the 96 million people with prediabetes in the U.S. address early health troubles that eventually leads to other comorbidities.
While many of the solutions within food is medicine are geared toward individual conditions, Hashemi wishes insurers focused more on prevention.
“Insurance companies generally just wait until you get sick,” she said. “What you put in your mouth is more important than anything else … in terms of whether you’re going to have excessive blood sugar.”
Both Heali and January AI have hit the market for the average consumer in the last year.
Major food is medicine advocates, like Kaiser Permanente and Highmark Health, have varied approaches to UPFs. At Kaiser, UPFs are not yet part of the system’s food is medicine work.
“We’re putting a lot of emphasis in food is medicine,” said Sean Hashmi, a nephrologist and weight management leader at Kaiser Permanente. “There’s no best choice. It’s all about making food better.”
Highmark’s medically tailored food offerings are personalized through a registered dietitian that avoids UPFs when possible.
“But with that being said, when you look at the scale that we, the healthcare industry, need to hit, it’s unrealistic to not provide any type of processed foods just because of the supply chain and costs,” said Nebeyou Abebe, senior vice president of social determinants of health for Highmark.
Challenges to changing the landscape
Therein lies one of the many issues facing the no-UPF movement.
First, there’s no universal definition of UPFs. Differentiating a UPF product at the grocery store requires a judgment call based on common sense, a scan of the nutritional label and some knowledge in nutrition.
One area where food is medicine is making huge strides is in Section 1115 state Medicaid waivers, where states can put dollars toward food benefits interventions. There are 11 states using Medicaid waivers to implement food is medicine, and more states are expected to join them.
To put a requirement in a law or waiver, it needs to a have strong definition, said Erika Hanson, a clinical instructor for the Center for Health Law and Policy Innovation at Harvard Law School. Otherwise, the policy cannot lead to enforceable changes.
In the Childhood Diabetes Reduction Act of 2024 brought forward by Sen. Bernie Sanders, I-Vermont, the bill is a rare example of explicit regulation of UPFs. It would require warning labels on all UPFs to reduce the effects of advertising on children. That legislation has had no movement since its introduction in April.
It’s also difficult for many people to access food that isn’t processed. UPFs are ubiquitous, even at the healthiest grocery stores, while older or low income adults may lack the transportation needed to access higher quality food.
“We’ve created this perfect storm for people to just reach for the UPFs,” said FreshRx Oklahoma's Martin.
“I’d say the general offering in Medicare Advantage, and at SCAN in particular, is just access to food,” said Karen Schulte, president of SCAN Health Plan. “There’s so much food insecurity.”
Finally, is it even realistic to expect people across the country to revamp their diet when they are completely inundated by UPFs?
“For most people, extreme elimination is just not something they can follow, said Season Health's Hix.
“The reality is there’s no quick fix in nutrition,” added Omada Health Chief Medical Officer Carolyn Jasik, M.D. “You have to eat whole foods, in variety and just enough. It’s always been the case. All natural organic chicken nuggets—is that even possible in a frozen plastic bag?”
How to earn payers’ attention
To the segment of the population that is wary of the threats posed by UPFs, it’s easy to forget the strides that have been made in improving nutrition.
Reimbursable medically tailored meals are a good thing for members where processed foods are minimized, said Heali's Dardashti.
“The progress we’ve made in food is medicine is massive, and we should be applauding this progress in every way, shape and form,” he said.
Still, the system is imperfect. Many grocery cards that insurance plan members use are not effective because they’re used as a marketing gimmick to incentivize higher enrollment in MA. These cards do not always restrict what foods can be bought, experts told Fierce Healthcare.
MA members can also receive medically tailored meals for two weeks after getting discharged from the hospital, said Tufts Food is Medicine Institute's Mozaffarian, but many patients do not need meals for two weeks whiles others may need meals for a month.
At Tufts, the institute has developed the Food Compass, a replacement to the NOVA system that is designed to look at UPFs more holistically to include nutrients and UPF markets. Right now, the compass is just a research tool.
“I think one of the most convincing critiques of the NOVA scoring system … is that there’s lacking evidence to demonstrate that UPFs themselves are driving the poor health outcomes, rather than some confounders in those observational studies, like specific additives, glycemic load of the foods or the energy density of the foods,” said Lew with Rock Health.
Without more federal guidance, payers will be moved by studies showing real-world improvements in the member population—that could lead to an increase in star ratings—as a direct result of food interventions,” said Lauren Barca, vice president of quality for 86Borders, a company engaging health plans with their most vulnerable members.
One case study (PDF) with Healthrageous, a meal delivery company for MA plans, found that eligible Molina Healthcare members in California had significantly reduced emergency department and inpatient visits and costs. The average annual cost savings per member was $1,381.
“I think attention like that is what’s going to help move the needle,” said Barca. “Ultimately, I think it’s making sure that payers have some accountability in this, recognizing that if they put money into it, they will have a return on that investment.”
“If we can prove that there’s a business case, that’s how we scale through food is medicine,” said Abebe at Highmark Health. “That’s how we inevitably would limit the intake of UPFs, because there would be a shift in consumer demand for these types of foods.”