“This Program has Given Me the Proper Nutrition that I Deserve”: Participant Perspective on a Medically Tailored Meal Intervention

Introduction

Diet-related disease, including type 2 diabetes mellitus, coronary heart disease, congestive heart failure, hypertension, and many other clinical conditions, are leading causes of morbidity and mortality in the U.S.^1-3Diet-related disease results from barriers to healthy eating, including food insecurity, unhealthful food environments, and lack of time and capacity to prepare healthful meals.^4,5 Food is Medicine interventions seek to prevent and/or treat diet-related disease through the provision of nutrition resources.^6,7 One type of Food is Medicine intervention, medically tailored meals, has received growing attention. ¹ Medically tailored meals (MTM) entail the home delivery of ready-to-consume meals, prepared under the supervision of a registered dietitian nutritionist to be appropriate for the combination of comorbidities an individual faces. ¹ Studies have found that medically tailored meals improve diet quality and health outcomes, and are associated with reductions in acute healthcare utilization, such as emergency department visits, and healthcare spending.^7-12 This has led to growing interest in expanding medically tailored meals as clinical management interventions.

With their promise for improving health, understanding how best to design MTM interventions is an important question. However, there is a lack of data on two key implementation questions for MTM programs. The first question is one of dose—should the meals be targeted to a focal individual alone, or for the entire household? Because food is often shared in households, providing meals for only a focal individual could result in ‘underdosing’ the nutrition resources provided. However, providing meals to additional household members increases program cost, and because MTM are tailored to a specific individual’s needs, they may not accord with other household members’ preferences. Further, because MTM represents a substantial proportion of the focal individual’s food needs, household budget space can be ‘freed up’, allowing more to be spent on other members’ food.^9,13

The second question relates to delivery. Many organizations providing MTM employ delivery drivers who regularly visit a particular individual. While not as intensive a connection as a daily home visiting program, such as Meals on Wheels,^14-16 a weekly connection with a friendly face may still be a beneficial social connection that could reduce loneliness and improve mental health. On the other hand, advances in commercial logistics mean that MTM can now be delivered cost effectively by commercial logistics firms. This can enable organizations to expand their reach into areas they could not previously serve, but potentially with the downside of reducing this social connection.

The Food as Medicine for Families (FAME-F) randomized clinical trial was conducted to answer these questions. FAME-F was planned as a mixed methods study. A prior manuscript has reported quantitative results, ¹⁷ and this manuscript presents qualitative findings.

Methods

Results

Participants

Twenty-five participants completed interviews; all were included in analysis (Table 1). Of these participants, 72% were women; 60% identified their race as White, 20% as Black, 4% as Asian, and 16% as “other” or unknown; and 12% identified their ethnicity as Latino or Hispanic. Participants’ ages ranged from 33 to 78 years (mean: 56 years, SD: 11 years). Participants were evenly dispersed across possible treatment allocations: delivered household (24%), delivered individual (28%), shipped household (24%), and shipped individual (24%).

OPEN IN VIEWER

Table 1.

Demographics Characteristics (n=25)

Characteristic	N or mean	% or SD
Age (Range: 33—78 years)	56	11
Race
White	15	60%
Black	5	20%
Other	4	16%
Asian	1	4%
Ethnicity
Hispanic or Latino	3	12%
Non-Hispanic or Latino	22	88%
Gender
Woman	18	72%
Man	7	28%
Intervention Dose
Delivered Household	6	24%
Delivered Individual	7	28%
Shipped Household	6	24%
Shipped Individual	6	24%

Discussion

In this qualitative evaluation of the experience of participants in a randomized trial that provides MTM, participants were overall enthusiastic about the intervention. Participants reported positive impacts on health, although satisfaction with the meals varied by taste preferences. Participants did not clearly see benefits to the ‘feed the family’ approach, nor did they perceive clear benefits for the ‘dedicated driver’ approach.

The findings of this study are consistent with and expand those of prior MTM studies. Most notably, these results are consistent with the quantitative results of the FAME-F study, which showed little difference in diet quality between the ‘feed the family’ and ‘feed the individual’ arm, and little difference in mental health outcomes between the ‘dedicated driver’ and ‘commercial shipper’ arms. Further, these results are consistent with prior qualitative work on MTM interventions.^9,29-31 In particular, these results lend further support for the idea that MTM improves health through overcoming barriers to healthy eating, and that MTM interventions are feasible and acceptable for participants. ¹ Overall, this supports the testing of MTM interventions in larger-scale trials. ⁷

The findings of this study have important implications. One particularly important implication relates to whether to provide meals for the focal individual or all members of the household. For instance, there are ongoing implementations of medically tailored meal interventions that provide meals for children and other dependents in the household, along with a focal individual. ³² Arguments in support of feeding all household members typically focus in two places—first the impact on the focal individual, and second, the impact on others in the household. Regarding the focal individual, the argument is that, because food is shared in households, the focal individual would share meals with other household members, resulting in ‘underdosing’ of the intervention. Regarding others in the household, the argument is that since barriers to healthy eating like food insecurity are shared, others in the household may also benefit from an MTM intervention that overcomes those barriers. This study suggests that, at least for MTM, providing meals for the focal individual alone does not seem to lead to ‘underdosing’. This is likely because sharing is less common than anticipated, owing to the medical tailoring of the meals which makes them less suitable for other household members. We note that this may differ for other food is medicine interventions, such as food subsidies or provision of unprepared grocery items. Another reason is that by providing a substantial proportion of the focal individual’s food needs, household budget space is freed to support the household budget more broadly, so all household members may still benefit indirectly. Regarding the potential impacts of MTM on other household members, it may make more sense to address this by enrolling other household members separately in an MTM intervention, rather than providing meals for the entire household. This would allow tailoring for the specific individual, and is more in-keeping with the intention of MTM as a specific clinical management program, rather than a population-level nutrition intervention such as SNAP (the Supplemental Nutrition Assistance Program). Although not examined in this study (which sought to pilot specific MTM design features in preparation for larger-scale interventions), incorporating strategies for sustainable healthy eating after the end of the intervention is an important part of intervention design. Another related issue that could be explored in more detail in future studies is coordination among multiple nutrition interventions that different household members may be enrolled in, and what the impacts of combining more than one nutrition intervention within a household may be.

Regarding the delivery approach (that is, whether to use a dedicated driver or a commercial shipper), it is notable that, at least in the sample interviewed, there were not clear differences between the studied approaches from the participant’s perspective. Therefore, the decision of which to use might be made on the basis of other considerations, such as cost, feasibility, reach, or convenience. It is also important to note that the experience of different delivery approaches could vary based on whether an individual lives alone or with others. We do reiterate however that this study did not evaluate a home visiting program. Such programs, which provide meals and structured daily in-home visits, are more intensive forms of social connection intervention than studied here. The benefits of those programs have been well established in prior work.^14-16

The results of this study should be understood in light of several limitations. This was a small study and while saturation was reached in our sample, there may be other experiences with MTM interventions not captured here. Demographically, the sample was largely White women. Perspectives may vary across gender, ethnic, and cultural groups. Another limitation is that this was a short-term study, and experiences could vary with longer participation. However, these limitations are balanced by key strengths—in particular triangulation with quantitative findings.

Conclusion

MTM are promising interventions that can help people improve health by overcoming barriers to healthy eating, The results of this help inform important questions in MTM intervention design. In particular, the results provide reassurance that providing MTM for a focal individual alone can still lead to meaningful dietary improvements, and that using whichever delivery approach is best suited, from a logistical standpoint, is unlikely to have major implications for participant experience.

Supplemental Material