Food is Medicine Advocate Urges Evidence-Based Solutions Amid SNAP Cutbacks

Margaret Flinter (00:00)
Recorded on location at Aspen Ideas Health in Aspen, Colorado.

Mark Masselli (00:12)
Our guest is a nationally recognized expert on food insecurity and health outcomes. She focuses on programs
and policies that make a difference in people's lives.

Dr. Hilary Seligman (00:22)
The bottom line of all of this is that food insecurity rates are going to rise. And when food insecurity rates rise,
we see decreases in the population's health. We see people becoming sicker. We see the healthcare system
having to bear the cost of increased chronic illness.

Margaret (00:43)
Dr. Hilary Seligman is Professor of Medicine, epidemiology, and biostatistics at the University of California
San Francisco.

Dr. Seligman (00:51)
WIC has proven that it can effectively support better health outcomes for mother and baby, and it has proven
that it can be scaled. It's in every county in the United States. And so I call WIC the Original Food as Medicine
Program.

Margaret (1:09)
This is Conversations on Healthcare.

Mark (01:22)
Well, Dr. Seligman, welcome to Conversations on Healthcare.

Dr. Seligman (01:25)
Thank You. I'm so happy to be here.

Mark (01:26)
And we have an expert on snap. And, you know, this is an important time, I think for our listeners to understand
what's happening, both in the House and the Senate version. I think it's one of the most pro, profound cuts, to the
SNAP program, about 30%. I'm wondering, what's the lay of the land look like for you? What's the implications
for people, across the country who might lose their benefits?

Dr. Seligman (01:54)
There's two things going on from a federal perspective that I think are really important to understand. One is
proposals to drastically cut SNAP benefits, both the dollar value that people receive every month, as well as
who can enroll. And the other is efforts to restrict what foods people can buy with their SNAP benefits, which
also is gonna have a profound impact, on people as well. And so, I think we are looking at a generational
change. SNAP is one of the largest anti-poverty programs in the United States. It is also enormously effective at
supporting people's health. And so this is gonna be a problem for years going forward as people lose access.
How, How many people are on the SNAP program? About 45 million people. But what it's important to
recognize in this federal landscape is that SNAP is what the economists call countercyclical. When the economy
is good, people don't need SNAP benefits as much, and naturally snap enrollment falls. And when the economy
is poor and people lose jobs and unemployment rises, snap benefits rise. And the important part of that is that
when people receive money for food through snap, that money gets spent immediately in local economic
communities. The USDA estimates that every dollar SNAP benefits generates a dollar and 80 cents of local
economic activity. So this is also a way that historically we've been able to keep our local economies moving.

Margaret (03:31)
Right. And not a surprise that when people lose their jobs, they're reliance on, on food stamps go up. You know,
I wanna, also, ask for your thoughts on what has also happened, which is the billion dollars in cuts to food banks
around the country. Maybe they're not as visible, to everybody. We certainly saw during the COVID, when we
were doing mass vaccines, how important those food banks were to helping people. But what's been the impact
of the cuts to the food banks, which are kind of a partner program, if you will, to food stamps?

Dr. Seligman (04:00)

Thank you so much for asking that. Because food banks are a vital part of the hunger safety net in the us. And
historically, when SNAP benefits would be cut, the food banks were sort of the system of last resort. That's
where people would go when they had no other options to fall back on. But we're seeing a simultaneous effort to
reduce SNAP benefits and to massively cut funding to food.

Margaret (04:27)
A Billion dollars.

Dr. Seligman (04:28)
A billion dollars. And so I think really the bottom line of all of this is that food insecurity rates are going to rise.
Yes. And when food insecurity rates rise, we see decreases in the population's health. Right. We see people
becoming sicker. We see the healthcare system having to bear the costs of increased chronic illness and even
more acute illness. This is gonna be a problem moving forward.

Margaret (04:57)
And we see this across the age spectrum. We know our elderly rely on food banks, our babies and children and
everybody in the middle.

Dr. Seligman (05:03)
Exactly.

Mark (05:04)
You, You were talking earlier about when the economy gets better, there are fewer people on it. That's the
argument that the administration seems to be using, that the economy's better. We don't need a lot of it. What's
the pushback on that?

Dr. Seligman (05:16)
Yeah, I think that's true. People do need less of this program when the economy is better. And that happens
naturally. People lose their eligibility for SNAP benefits because they have a job, because they make more,
more incomes and they, and they disenroll from the program. The average duration of utilization of SNAP
benefits is very brief, right. On the order of months, people need SNAP benefits to help get them through an
acutely difficult period, and then they come off when they have a job. And so that's really part of the, of the
challenge here. What the, what the administration though is arguing is that we need to kick people off the
program, people who otherwise would be eligible. And the important part of that is that across the population,
most people actually can't work because they're children. They're older adults past retirement age, or they are
disabled. And so really these people are going to have to rely on SNAP benefits. And if they lose eligibility for
SNAP benefits, there aren't, there isn't a huge safety net, especially because of the food bank defunding.

Margaret (06:27)
And, and you know, it seems, so much of this is very logical in things that are complex to understand sometimes
in policy are very clear around food, right? If we have inflation, food costs more people can't buy it. They lose
their food stamps; they really can't buy it. They eat less healthy food. We see them in the healthcare system with
unhealthier status. Tell us about EAT San Francisco. I think this is an initiative that you've established to really
try and put healthy food in the hands of people who need it. We'd love to hear more about that.

Dr. Seligman (06:56)
Great. ESF is a, what we call a produce prescription program. There are lots of efforts across the United States
to try to better link the healthcare system with community access to food. You know, when I was a primary care
physician practicing at San Francisco General, and I had a patient who was sick, I could write a prescription for
an antibiotic and it would get sent to the pharmacy in the back of the grocery store and they could pick up that
antibiotic. No, no question asked. No questions asked. But if I want to help my patients get access to healthy
food, I can't fax a prescription to the front of the grocery store so they can get some produce. That's a systems
problem that we can change. And there's a whole movement of medically tailored meals and medically tailored
groceries and produce prescriptions that are trying to create that system to link healthcare and healthy food so
that healthcare providers could write the prescription people need, not only to prevent chronic illness, but to
treat it. ESF is one of many produce prescription programs in the United States. We are really proud of the way
we can reduce food insecurity, we can support better dietary intake, and we can help people to manage their
chronic illnesses.

Mark (08:10)

You know, one of the hats that we wear is that we're a federally qualified health center. And we go back to our
founder, Dr. Jack Geiger, who early in his career started to prescribe, food as a prescription, for the problems
that they were facing, which was obviously hunger. I'm wondering though, about the current administration,
because we hear them using the phrase food is medicine. We also hear them saying, should people be able to
have, soda pop, as part of that? Where are the seams of opportunity to work together with them, if any?

Dr. Seligman (08:45)
Well, I think in this particular space, a lot is unknown, but there are a lot of potential opportunities. This
administration has done a, a really deep dive into chronic disease. There is a desire to help make the population
of the US healthier again. And there is an interest in supporting better dietary intake. And the challenge I think
for us is to move those, is to amplify those efforts in a way that is based in science, that is based in evidence and
will support everybody in the US equally. That really is the opportunity that we have. And whichever partners at
the federal level, state level, and local level can help us reach that mission, we would be really happy to partner
with.

Mark (09:32)
Where's the focus of that attention? Is the Department of Agriculture, is it HHS, is it CMS or is it all of them?

Dr. Seligman (09:37)
Well, part of the challenge is that it's all of them. U-S-D-A-F-D-A has a big role as well in regulating foods and
front of package labels, et cetera. and CMS does a lot of the work around access to healthy foods through health
insurance. So it is across many different federal, federal agencies. And that's part of what makes working in
food policy so challenging but interesting.

Margaret (10:01)
You know, I, came into my career in public health and nursing when WIC was just arriving on the scene. And I
thought, what a brilliant idea. I was in a rural, underserved, low-income area, and WIC has had to evolve over
the years. Right. There are some criticisms, maybe about too many high caloric things, but served its purpose.
You've done some research that seems to really need to be brought forward about the health outcomes
specifically of fruits and vegetables in the general population. I think also in maternal infant health as well. Tell
us about some of your research findings and how that's driving your agenda forward.

Dr. Seligman (10:37)
Well, let's just start with talking about WIC for a minute. The first question that I always get asked about food as
medicine programs, produce prescriptions, medically tailored meals, medically tailored groceries, is, is it
effective? And the second question is, okay, but can it be scaled? And I will tell you, WIC has already proven
this. WIC has proven that it can effectively support better health outcomes for mother and baby. And that it has
proven that it can be scaled. It's in every county in the United States. And so I call WIC the original food is
Medicine program. That's great. And I think they need to lean into that. And so a lot of our work has supported
really decades of evidence suggesting that WIC supports better health. And it also has sought to explore what
could we achieve if we bumped up those benefits? Could we further support households and families in getting
the food that they need to their children so that they can develop healthy palates, develop patterns of eating for
the, in their childhood that will support chronic disease prevention for the rest of their lives. We know that 42%
of Americans are obese now that cardiovascular disease is rising, that diabetes rates are rising and diabetes is
occurring even in children now and adolescents. But if we can support healthier dietary intake in programs like
WIC, we can really make a difference.

Mark (12:11)
You know, I want to ask the question about food policy. And I wanna understand what's the network look like
that you work with? You're a national expert on it, but I also think people who listening would be interested in
how did you come to this career and what's the pathway that others might take to get into this really important
work? 'cause it has such an impact on the health and wellbeing of all citizens.

Dr. Seligman (12:34)
Well, I'm trained as a primary care physician, and I started my career working as a physician, at San Francisco
General Hospital. And I actually was inspired by a patient with prediabetes who, told me in the course of our
conversation that every day, for lunch, he ate a piece of spam between two cinnamon rolls. And the reason for
that was that it kept him full for the rest of the day. And he wasn't sure that he would have the money for dinner.
Yep. And so it was possible that that was the only meal he would be able to eat that day. And so as a primary
care physician, I, I sat there and I asked myself, I know I can get him medications. I know that I can prescribe

him a drug that will help prevent progression of his prediabetes to diabetes, but what this person actually means
needs is healthy food. And that was the problem that drove me to start this line of inquiry. And so I always tell
people, find that thing that just doesn't feel right to you. Right. And try to figure out how you can make a
difference there.

Margaret (13:42)
And you know, back maybe a little bit disproportionate, I'll speak to the FQHCs, seeing FQHCs as part of the, a
link in the chain or the primary care centers at UCSF, perhaps where you might actually distribute food, where
you might actually hold those once a week. It's like the diaper bank. There's the food bank. There's these
essential things that are not million-dollar ticket items. Right. They're very fundamental, but they make a big
difference. What's your, engagement with the healthcare system in San Francisco, maybe beyond, U-C-F-S-S?
Are you working with the network of community clinics, migrant farm workers, FQHCs? Tell us about that
network.

Dr. Seligman (14:21)
We work with who, whichever health systems are interested in having our support in developing food as
medicine types of programming within their health system. And I want to emphasize that this is a little bit of a
Band-Aid. And I'm really happy that we started with snap because snap if SNAP were available to everybody in
this country who needed it, and we were effectively using that as a lever to support people's healthy diets, we
wouldn't Need to, of course, the emergencies. We wouldn't need to be doing this through healthcare. And we
wouldn't need to be supporting people through food banks. And so I have been a real champion of supporting
this work through healthcare because otherwise there people are falling through the cracks. But ultimately the
best answer to food insecurity and the health impacts of food insecurity is going to lie in a better hunger safety
net and a hunger safety net that works for everybody in the us.

Mark (15:24)
That's Great. Great point. You know, we're at the Aspen Ideas Health gathering, and we're hearing from a lot of
different people, one of the groups that we heard from were farmers. and the impact, and maybe talk about, you
talked earlier about the dollar having a, a force multiplier effect, in terms of the economy. But what about,
farmers and the impact that this might have on them?

Dr. Seligman (15:45)
Such an important question. So first of all, there are a number of additional programs that are threatened to be
defunded in the current environment. And some of those are funding programs that move crop directly from
farmers, especially small and mid-size farmers to schools and two food banks. This is particularly challenging in
this moment because this defunding is happening at a moment when many of the farmers at this very festival
have told us they've already put crop into the ground. Right. Right. And so how are they going to harvest the
crop without the funding that they had, that they had been promised? So I do think that we're going to have a
shake up to the system that's gonna be very, very challenging for our small and medium sized farmers as well.
One of the things that these food-as-medicine programs that move healthy food into healthcare have also done
really well is to develop links or systems that connect farmers directly to healthcare organizations through
produce boxes. Right. And these have also been a really important strategy for moving healthy food, particularly
to people with diabetes or people with heart failure who can really use access to that.

Mark (17:01)
And it provides the farmer a steady source of income as well…

Dr. Seligman (17:03)
Steady source of income.

Mark (17:03)
…which is very important. 'cause they're lean, lean years, where the weather is not as nice as it is here in Aspen,
but, and they face difficulty.

Dr. Seligman (17:12)
Exactly.

Margaret (17:13)
Well, you've taken such a, a broad view of it. We also, remember another, long ago colleague, mayor Kurt Tony
up in Somerville, Massachusetts, identifying that the cafeteria workers, the school lunch people were a key pivot

point in delivering, cooking and delivering the healthy food to kids, or making healthy meals available and
trying to take that continuum all the way through, which is so important. But I wanted to ask you, as a primary
care internist, here, we have heard so much about GLP1’s here at this conference and obesity and I think two
different issues, hunger and obesity, two different issues. We need to sort of look at them differently. but what's
your take on the GLP1’s as a potential to really improve health, through reducing obesity when so many other
things have failed for so many people?

Dr. Seligman (18:01)
Really important tool in the toolbox GLP1’s, but they're not gonna solve all of our problems. And in particular,
you know, nine in 10 people in the United States exceed recommended sodium intake. Most Americans, eight
outta 10 don't meet dietary guidance for fruits and vegetables. GLP1’s can't be our only, tool. We have to be
able to change our food system in a way that healthy foods are available to everybody who wants to consume
them. The generational shift in obesity rates that has happened over the last 40 to 50 years is not primarily a
problem of genes. Our genes have not changed. But our food environment has changed dramatically. And so we
have to be working on the environment at the same time as we're working on the medications.

Mark (18:56)
So what, what do you think about the Secretary Kennedy's, focus in on some of the food, industry being bad
actors here? I'm not sure red dyes are the only thing that there may, but certainly sugar in in the food. Where,
where, what do you see the food indices responsibility and how would you address that? Is that doesn't seem
with this administration is gonna happen through regulation, is it gonna happen through public persuasion, or
how do you see it?

Dr. Seligman (19:25)
I don't know how the changes in the food industry are going to happen. I will say that lessons we learned from
tobacco were that it took intervention or activity on many, many different fronts. Right. There was regulation,
there were changes in cultural norms. There were changes in the media. There were changes in policies in
restaurants and bars and local communities. And we are going to need that same type of multi-level approach in
the context of food. It is also going to take some powerful leverage to reign in the food industry. And we're just,
we just have to do that. There is not going to be a way to solve this problem if we don't change the way the food
industry is acting in this space.

Mark (20:19)
Well, Margaret, I remember Mayor Bloomberg was able to get smoking out of, restaurants, out of restaurants
that was big, but was not able to get, the larger sized Cokes, sodas and sodas out as well. So much more
powerful. And, and that was an impressive lift, but not able to do it all the way.

Margaret (20:38)
But those partnerships are key. And I know you're the deputy scientific lead for the American Heart
Association. If I get this whole title right, let's see. Healthcare by Food. That's right. I wrote it Down Initiative.
It's another arm to exercise research, through and certainly a national presence that can help deliver that
message. Tell us about your work with them and some of the research that you have going on.

Dr. Seligman (21:01)
So the goal of that initiative through the American Heart Association is to create a system where health insurers,
private, public, both of them reliably fund healthy food as a strategy towards improving health. They, they fund
or pay for medication, they should fund or pay for, healthy food as well. What these insurers tell us that they
need in order to make those changes among some other things, is they need research. That tells us who should
be covered for how long, using what kind of strategy. Is it medically tailored meals? Is it a produce prescription?
Is it medically tailored groceries? What does it look like and, and what outcomes should we expect? And the,
the, goal of this initiative is to try to answer those questions and to try to create a system that would functionally
allow reimbursement to happen just as seamlessly as sending a prescription to the pharmacy. That we could
seamlessly deliver healthy food to patients when they needed it. And that would be reimbursed by healthcare.

Mark (22:15)
You know, I wanna also, identify another hat that you wear. You're also the, direct and nutrition and obesity
policy, research and evaluation network with CDC. Maybe talk to us a little bit about their work.

Dr. Seligman (22:28)
So CDC has a really important role in bringing together and supporting state and local health departments in
doing the policy and systems and environmental level work that creates, as we like to say, in public health,
making the healthy choice, the easy choice. And this encompasses a range of things like what kinds of foods are
being offered in your work cafeteria, what kinds of breastfeeding support is there, what kinds of produce
prescription programs are available in your community. And so what I do as the director of NOPREN is try to
bring together academic researchers and state and lo local public health department implementers and other
implementers to try to catalyze that work. As you, as you alluded to just a minute ago, Bloomberg was able to
make some changes in tobacco that weren't possible with food. Food is complex. It's hard to make these
changes. And the only hopes we have of doing it is through partnerships with communities. And that takes
support, or it takes, it takes a lot of people helping to build that infrastructure. And that's the goal of NOPREN.

Margaret (23:43)
Well, Hilary, I know you're in an academic medical center as well as deep, into your community, but I would
imagine you are precepting teaching, supporting research at every level of the pipeline of the healthcare
workforce. What do you see in the generation coming up? Is this a passion for them? Is there a recognition that,
gosh, we can't just rely on drugs to fix these things that are systemic, political, social, and very tangible things
like food that people need? Tell us about your teaching/educational work.

Dr. Seligman (214:12)
So first of all, I will say when I was coming up through this work, and leaning towards doing more research and
policy, the goal was to train people to do exceptional research and policy. And that is not a goal of this
generation. It is a sub goal. The goal is to have an impact in the community. And I love that generational
change. This generation is motivated, they are passionate, but they don't wanna learn to do research for
research’s sake. They want to learn to do research so they can make a difference. And so that's really what we
try to do. We try to respond to that drive. I direct the National Clinician Scholars Program where that really is
our mission. I do that at UCSF, is to, is to support people in becoming change makers. And that means
understanding how to do research and to use data. But also understanding how policy works And how to be an
effective leader within a really complex ecosystem.

Mark (25:17)
You know, food insecurity has been with us since the beginning of time. Any new technologies that you see on
the horizon that you're encouraged by?

Dr. Seligman (25:26)
You know, I'm gonna have to say no to that question for this reason:

Mark (25:32)
I was gonna ask if AI was one of those technologies, because we've gotta get AI, if we got GLP in one, we gotta
get AI in into this conversation.

Dr. Seligman (25:39)
Well, this is the thing. Fundamentally, nutrition is really simple and we have a problem in public health
sometimes. And with our communication and making things really complicated, fundamentally, it's simple and
we need to keep it simple because that's the most important message. Eat more few fruits and vegetables, eat
more lean protein, plant protein. If you can do it and eat more whole grains. If you can do that, you will be in
good shape.

Mark (26:10)
Can I, can I add to that?

Dr. Seligman (26:11)
Yes.

Mark (26:11)
On plant protein, having some, being someone who's, been a vegetarian for, decades and decades, unless you
start early with plant protein, the mouth taste is just not something I've seen with older people being able to, to
succeed and making that transition. So doing this at a younger age is really critical. That doesn't mean old
people can't change. We can.

Dr. Seligman (26:36)
Absolutely. And that comes back to the WIC point, which is it's just establishing healthy pals really early in life.
Right. And you mentioned school meals. You know, school meals are the healthiest meal most children get all
day long. And so these efforts to provide healthy meals and access to plant proteins through the National School
Lunch Program are really important because that's how kids are starting to build their pallets.

Mark (27:03)
I would think, just on the delivery system of food though, there's something around understanding that science,
getting local food grown closer to where people are is really important. So are there people who are sort of
charting that out of, if food is medicine, it's gotta be somewhat grown in my neighborhood? That may be hard if
I'm in New York City. it may be hard to distribute if I'm in a frontier, region, of, of the country. So who, who's
thinking about that distribution network so that we can start growing more locally.

Margaret (27:40)
And that experience for kids.

Dr. Seligman (27:41)
Yes.

Margaret (27:42)
What does this taste like, look like? It's exciting For kids, right?

Dr. Seligman (27:44)
Yes. Well, what you're calling attention to is a, is a systems approach to this work. It looks at the entire food
system and looks at it from the perspective of health as well as things like climate change and sustainability.
And that also brings into this work another federal agency that we didn't mention before, which is EPA has a lot
of interest in this area, right. And again, it is calling attention to the complexity of this work that we have, this
big complicated system, but also that food for people is not just what do you have access to today? Food is
really about people's identity. People's joy, people's experience and social relationships with other people, how
they connect with their ancestors. Food means so much to people. And so being able to weave people's
individual experience with food all the way up to these climate change, this is the fundamental problem. And
this is, I think, where we need to do better in this field.

Margaret (28:50)
What a great summary statement for the show. Dr. Hilary Seligman, thank you for joining us, for conversations
on healthcare coming to you at the Aspen Ideas Health. Thank you to our audience for joining us. And
remember, follow us on Facebook or X, YouTube, and please, we always love to hear from you and share your
comments. Thank you again, Hilary, for joining us.

(29:15)
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