Food and Health Fact #200

To mark the 200^th edition of Food and Health Facts, we have switched to a slightly different presentation (a result of now using the Beehiiv platform). The Food and Health Facts website also has a new and improved look (thank you, Grayson Ullman) and is now easier to navigate – with an improved ability to search through past columns. Expect a few more tweaks in the weeks and months ahead.

If you’re new to Food and Health Facts, some information about me is here and my past writings here. And my recent review of a book about aging, published in the Wall Street Journal, can be accessed here.

Susan Bratton is the founder and CEO of Savor Health, a nutrition-focused digital health company. She recently received the C2 Award for Innovation in Oncology Care. This prestigious national award, which is sponsored by Astra Zeneca and Scientific American, recognizes, honors, and celebrates the innovative individuals and organizations dedicated to making a difference for those living with and affected by cancer.   

What is the focus of Savor Health?  

Savor Health is focused on democratizing access to the expertise of registered dietitians (“RDs”) in order to improve health outcomes, reduce healthcare costs, and generate the outcomes data necessary for nutrition intervention to be broadly adopted as standard of care in medicine.   

Diet-related chronic disease accounts for 90% of all healthcare spending and is concentrated among the 28% of Americans who have 3 or more chronic conditions.  Doctors aren’t trained in nutrition and, unfortunately, the medical resource that possesses a deep knowledge of nutrition science is an RD and they are in exceedingly short supply.

There is only 1 RD for every 3,000 Americans, a statistic that is much worse than it appears when we focus on the diet-related conditions such as kidney disease.  In cancer, there is only 1 oncology RD for every 5,800 Americans currently undergoing cancer treatment which explains why 80 percent of cancer patients seek but don’t receive the support of an RD. Food and nutrition advertising make it difficult for the untrained consumer to know “what to eat” for health. 

Savor Health solves this problem and bridges the gap in access to RD knowledge with a virtual Dietitian-on-Demand, Ina^®, who provides 24/7 “on demand” guidelines-based nutrition intervention via SMS text, including triage and escalation, when necessary.    

The AI-based knowledge Platform that powers Ina^® is supported by “Human in the Loop” credentialed RDs at all times, to ensure safety and accuracy and continually train and improve the interventions.   

Like an RD, the Platform applies the relevant nutrition science guidelines to each individual patient profile and then incorporates environmental and contextual information and intent to make the guidance understandable, actionable, and achievable to drive adherence.    

Our market leading results include 70 percent utilization, 91 percent satisfaction and 84 percent adherence, as well as a continuous and growing stream of insightful outcomes and other real world data.

Do you primarily serve individuals or institutions?  

Both.  Savor Health is a B2B2C model. We license our software to healthcare enterprises including payors (including self-insured employers) and pharma companies to support their members or patients taking their drugs in order to improve outcomes and reduce cost of care.

How did you get interested in these issues?   

My freshman year in college I took a class called “Biology of the Cancer Cell.” At the time, it covered research looking at red and processed meats as carcinogens in animal models. It was compelling enough for me to decide to become a vegetarian and focus on healthful eating. 

Fast forward to 2009. A friend was diagnosed and ultimately succumbed to a glioblastoma. Even at leading cancer center, my friend was told nutrition “doesn’t matter.” The cognitive dissonance this created led me to dive deep into the literature regarding the role that nutrition and nutrition intervention play in cancer care. 

The evidence was overwhelming and compelling, convincing me that nutrition is an effective lever but that due to a significant shortage of RDs, 80 percent of cancer patients were not getting the nutrition support they needed and desired.

The evidence of the impact of nutrition intervention included not only strengthening immunity and maintaining a healthy weight to optimize outcomes but also as a lever to manage and mitigate symptoms resulting in the ability to remain on the treatment regimen to optimize survival and to keep patients out of the ER and hospital.  

With that, I jumped off the high dive, quit my job, and started Meals to Heal, the first provider of home delivered medically tailored meals (“MTM”) for the cancer patient. Six years in the MTM business informed my decision to rebrand to Savor Health and pivot to a software solution providing the nutrition knowledge cancer patients desired to take back control and have agency in their treatment journey, licensing this expert knowledge to health plans and pharma companies and to Food Is Medicine businesses like MTM and MTG (grocery).

Can you talk about your Dietition on Demand?  

Ina^® was developed by a team of oncology-credentialed RDs, MDs (medical and radiation oncology), RNs, and LCSWs [Licensed Certified Social Workers]. They, along with our technology development team, created a proprietary expert system (the “Platform”) that combines patient data, a database of over 100,000 expertly curated nutrition interventions, and a rules engine to match each patient with the most clinically and contextually appropriate nutrition intervention for them at a point in time. It is dynamically updated as the patient’s condition and other factors change and evolve. 

Ina^® provides 24/7 “on demand” personalized query response, ongoing personalized “push” guidance, and “last mile” meal and grocery delivery support through partnerships with companies like Instacart and Performance Kitchen, among others.  

Launched in November 2019, the Platform and Ina^® have supported thousands of cancer patients and is continually learning and expanding our knowledge with every new unique patient. Having launched and refined in the highly complex disease of cancer for proof of concept, Savor Health has now expanded to diabetes, kidney disease and heart disease to address the large number of Americans with these conditions, often in combination with the others.

What’s the role of food in preventing and treating cancer?

Nutrition and food are effective in cancer treatment to optimize the immune health of the patient through the proper nutrients and calories, while also preventing malnutrition and weight loss – two conditions that are highly correlated with mortality. 

Nutrition is also an effective lever to manage and mitigate symptoms of cancer and cancer treatment, enabling patients to remain on the treatment their oncologist believes will result in the best outcome, prevent costly and often preventable ER visits, inpatient admissions, and other events.

What’s the profile of the meals you recommend?   

That depends on a number of factors including the patient’s diagnosis, underlying comorbidities, medications, BMI and other clinical variables, as well preferences, food allergies, and required calories. In order to make our meals and menu plans easy to follow, we start with ensuring the appropriate guidelines for the patient are adhered to. We then focus on the contextual information and intent

What were you doing professionally before starting Savor Health?   

I was a healthcare services investment banker advising hospital, payor, nursing home, health tech and other businesses on a range of strategic and financial transactions including raising capital and M&A.

Can you talk about the health care and health insurance industries vis-à-vis chronic disease and the obstacles they create to realizing better health?   

The healthcare system is reactive rather than proactive, short-term focused due to high member turnover in both commercial and governmental health plans, and highly sensitive to cost. There is little focus on prevention or on addressing root cause. It is procedure and pill-centric.

As a result, healthcare spending as a share of GDP has increased from 5 percent in 1960 to 20 percent today, with no sign of slowing. Past attempts to control costs such as utilization management, narrow networks, formulary-based drug management etc have reached their maximum utility because they are not addressing root cause. 

That is bad news and good news. The good news is that, today, there is a much greater openness to nutrition intervention and food is medicine because these historical approaches no longer work very well. Reimbursement of MTM and MTG is a huge step in the right direction – when we were in the MTM business there was no reimbursement! Greater reimbursement of RDs is essential to change as is bringing the RD “inside the tent” as part of rounding and whole-patient care.

Are there other ways in which the U.S. health care system creates obstacles to Americans realizing better health?  

One of the biggest barriers is lack of access to data – healthcare data is siloed, incomplete and no one is playing “nice in the sandbox” and willingly sharing it. It is considered an asset to fearlessly guard.  Without access to complete data, no provider can truly understand the patient because, for example, they may not know that the patient was just in the ER or hospital across town. Or they don’t have the complete list of medications prescribed by all of the patient’s physicians.

You’ve worked with Bayer. What has been the nature of that work?

Our work with Bayer was in providing Ina^® as a companion patient support tool to patients on two of their oncology rugs. The goal was to improve adherence and compliance and generate real-world data. We worked closely with the brand teams in developing a distribution plan and communications to drive patients to Ina^® and with legal, medical, and regulatory teams for final approval and launch.

What are your thoughts on the pros and cons of Ozempic and other weight-loss drugs?   

I think the GLP-1 drugs can be game changers for certain patients, but not for all. Today, I am seeing them as the “be all end all” for anyone who is overweight, which is far too broad a population, both because of cost to the system but also medical necessity. 

There should be very strict medical criteria to prescribe them, such as someone with a BMI of 40 or above, the presence of multiple diet-related co-morbidities and a high risk of mortality in the next 6-12 months.  

While I am not a physician, we should prioritize those whose health, and possibly life, are at high risk as a result of being significantly overweight – and not simply those who want to “lose a few pounds,” which I have witnessed with a few friends who suffered some pretty bad side effects. These side effects are not insignificant and often persist after the person stops taking the drug. This is another reason to initially prioritize access to only those in dire need until we have more longer term side effect data.  

The other issue is the type of weight loss that is occurring – loss of muscle and not fat – which means these people may be thinner but not necessarily healthier. Combined with the fact that most people gain the weight back, nutrition education and support should be mandatory in order to ensure that, while taking the drug, patients will have the “right” kind of weight loss and develop healthy eating habits and knowledge so that when off the drug they will be more likely to keep the weight off. 

Post market, Phase IV trials and other real world data from “off label” prescribing will be beneficial in the GLP-1 category as we will be able to better understand and refine, beyond the initial “on label” indications, the optimal profile for these drugs and what modifications to prescribing or other interventions should be paired with certain indications.  

We know that they are truly life-saving for those who are morbidly obese, but what and how should we think about use in those who “want to lose a few pounds”?  Should some receive them “for life” and others as a kickstart to weight loss, paired with nutrition and lifestyle education and support? Given the cost and side effect profile, I would expect to see a tightening of clinical criteria for reimbursable use along a continuum of clinical need, as well as addition of other interventions such as those in the “lifestyle" category.

What are your thoughts on medically-tailored meals?

As mentioned before, we were in the MTM business and, through that experience have developed some perspectives on the “what” and the “when.” 

First, this is an incredibly difficult business and my hat is off to anyone in the MTM business. It is a manufacturing business with unique and vexing constraints. Because of these constraints, variety is very difficult to achieve and, as a result, people get tired of the same meals every week or every few weeks – even if they are meals that fit within the “eating style” of the person. 

Layer on to that the fact that America is a highly diverse place with myriad ethic and cultural eating styles and preferences which further strains the ability of the MTM provider to meet the needs of a diverse population.  

As a result, I think MTMs should be for a few specific, well-defined use cases – the current post-discharge benefit of two weeks is one.  Our experience is that with enough meals “in rotation,” you don’t have the issue of users tiring of the meals and they can achieve the intended outcome within that limited time frame as well as a positive ROI. 

Both for short term, post-discharge use as well as longer term, to meet the needs of an ethnically diverse population, a broad MTM benefit will require the payor to partner with multiple vendors in order to provide the greatest variety and prevent users tiring of the same meals and to cover a broader range of eating styles. 

Because the cost of MTM is high relative to groceries, the system can’t afford to pay for everyone to receive them, which suggests that we should have very strict criteria for the conditions upon which they are a covered benefit, the duration (err on the side of shorter versus longer), and, the addition of “wrap around” nutrition education and guidance to drive adherence (eat the meals) and rapidly wean people off of them through a “step-down” to groceries and then to full empowerment. 

Without this education and guidance “wrap around,” the cost will be higher than necessary, which will limit the number of people who receive the MTM benefit. The goal would be to optimize for the right intervention at the right time in the right setting and to support and empower patients to a lower cost, greater agency setting. I’d also like to see more truly local solutions being offered to tap into the local food providers within each community to best meet the needs (and tastes) of the residents of these communities.

What are the big health-related lesson lessons you’ve learned while running Savor Health? 

The biggest lesson I have learned is that people really DO want to eat better. They just don’t know what to eat for them, food labels are hard to understand, and CPG [consumer and packaged goods] marketing is confusing (if not misleading), and it’s hard to afford healthy food.

Also, the healthcare system is paternalistic and thinks from its own point of view, rather than that of patients, which fails to address, often even acknowledge, the diversity among us. We don’t make it easy. Ther are also ethnic and cultural preferences but also literacy, language, socioeconomic status, environmental and other contextual barriers and enablers. 

So we’re set up to fail. But I don’t think about it as failing to change behavior as it is recognizing and solving for these external contextual and environmental factors. 

We need to change the environment or at least recognize, acknowledge, and address the environmental barriers and tap into the environmental enablers that exist rather than blame it on the common (mis)conception that people just aren’t willing to change their behavior. 

The other lesson that I have learned is that nutrition and food are held to a different standard. I can’t tell you how many people have said, “well, how do you know they will eat what you tell them to?” No one ever says to a drug company, “well, even though your clinical trial had great results, we know that over 50% don’t take their drugs or don’t’ take that as prescribed so we won’t make it available to the patients.”