Better Food, Better Health: Thinking Outside the Box

November 17, 2025

Maggie L. Shaw
Crystal Clark, MD, MPH

Commentary

Video

For the conclusion to this 4-part video series, tune in to learn the lessons each organization will carry forward from this pilot program experience.

For the past month, the “Better Food, Better Health” video series has documented UPMC Health Plan’s pilot program designed to tackle persistent chronic disease challenges. The pilot aimed to use "food as medicine" to stabilize or improve health trajectories for UPMC Community HealthChoices members in southeastern Philadelphia suffering from high blood pressure, diabetes, and heart failure.

The program revealed that having insurance and theoretical access to care were insufficient to ensure member wellness, as chronic conditions continued to drive frequent hospital admissions. To address the underlying social determinants of health, UPMC designed a multifaceted intervention based on removing social and logistical barriers. The program partnered with community-based organizations: MANNA provided medical nutrition therapy, delivering complete, medically tailored meals and monthly counseling from registered dietitians, and Philabundance supplied essential access to fresh produce.

Better Food, Better Health Video Series

Part 1: Better Food, Better Health: Redefining Chronic Disease Care Through Nutrition

Part 2: Better Food, Better Health: Empowering Members by Confronting Health Care Barriers

Part 3: Better Food, Better Health: Creating a Blueprint for Success

The team encountered significant challenges. Enrollment was difficult, requiring staff to contact over 400 potential participants to secure a cohort of 167, often struggling to reach transient individuals who frequently changed phone numbers. Another unexpected barrier was members’ difficulty in embracing self-monitoring. Although participants were given tools like glucometers and blood pressure machines, many did not understand or prioritize using them, requiring intense effort to integrate monitoring into their overall improvement strategy. There was also a demonstrable need for highly personalized, out-of-the-box support and in-person engagement to build trust.

The project lasted 18 months, longer than typical nutrition interventions, with everyone recognizing that it takes time for participants to become comfortable with technology and monitoring. Traditional clinical metrics, like reductions in hemoglobin A1C or emergency care visits, failed to capture the program's full impact. The team had to redefine success, prioritizing qualitative feedback and subjective improvements.

The ultimate achievement was the creation of a systemic "playbook"—a blueprint for other organizations seeking to tackle complex, human-centered health challenges by addressing the foundational realities of participants' lives. Full spectrum nutrition services, supported by a partnership requiring patience and flexibility, proved essential.

Concluding this 4-episode series with The American Journal of Managed Care®, the team speaks to the lessons they learned, emphasizing that success requires patience, clarity, and collaboration.

Editor's note: Since this interview, Amba Kasongo has become program director of the Delaware Valley Chapter of the Alzheimer’s Association.