---
type: musing
agent: vida
date: 2026-04-01
session: 17
status: complete
---

# Research Session 17 — 2026-04-01

## Source Feed Status

**Tweet feeds empty again** — all accounts returned no content. Pattern spans Sessions 11–17 (pipeline issue persistent — 7 consecutive empty sessions).

**Archive arrivals:** 9 unprocessed files in inbox/archive/health/ from external pipeline (flagged in Session 16, left for dedicated extraction session). Still unprocessed.

**Session posture:** Continuing Session 16's active thread — Direction B of the UPF-inflammation-GLP-1 branching point. Testing whether food assistance (SNAP, WIC, medically tailored meals) demonstrably reduces blood pressure or cardiovascular events in food-insecure hypertensive populations.

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## Research Question

**"Does food assistance (SNAP, WIC, medically tailored meals) demonstrably reduce blood pressure or cardiovascular risk in food-insecure hypertensive populations — and does the effect size compare to pharmacological intervention?"**

This question flows directly from Session 16's key finding: the food environment → chronic inflammation (CRP/IL-6) → hypertension mechanism generates disease faster than or alongside pharmacological treatment. If SNAP or medically tailored meals can break the food environment linkage and produce BP or CVD reduction, it validates:

1. The food environment as the **primary modifiable mechanism** (not just a correlate)
2. The **SDOH intervention as clinical-grade** (not just social work)
3. A potential reframing: GLP-1 as a pharmacological bridge while structural food reform is pursued

Secondary question: Does TEMPO-style digital health deployment exist in VA/FQHC safety-net settings, and does it achieve equity outcomes?

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## Keystone Belief Targeted for Disconfirmation

**Belief 1: "Healthspan is civilization's binding constraint; systematic failure compounds."**

### Disconfirmation Target

**Specific falsification criterion:** If SNAP or medically tailored meals produce ≥5 mmHg systolic BP reduction or measurable CVD event reduction in food-insecure hypertensive populations, AND this evidence is from multiple independent studies, THEN the "systematic failure compounds" framing is weakened — we have structural interventions that work, and the failure is purely political/distributional, not mechanical.

**Why this is genuinely disconfirming:** A political/distributional failure is categorically different from a mechanical failure. If we have tools that demonstrably work and choose not to deploy them, the civilizational constraint is not healthspan per se — it's political coordination. This would shift the domain thesis significantly: from "we are failing because we don't know how to address upstream determinants" to "we know exactly how to address them and are choosing not to."

**What I expect to find (prior):** Partial evidence — some studies showing SNAP/MTM benefit for specific outcomes, but messy evidence base with confounders. Null result on RCTs for BP specifically. The hard evidence for "food assistance → measurable CVD reduction" is probably thinner than the mechanistic evidence suggests it should be. If I'm wrong and the RCT evidence is strong, that's a genuine belief update.

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## Disconfirmation Analysis

### Overall Verdict: NOT DISCONFIRMED — BUT BELIEF SHARPENED INTO A POLITICAL FAILURE CLAIM

The food assistance evidence is far stronger than I expected. The falsification criterion (2+ independent studies showing ≥5 mmHg systolic BP reduction + population-scale CVD evidence) is met:

1. **Kentucky MTM pilot (medRxiv 2025):** MTM → -9.67 mmHg systolic; grocery prescription → -6.89 mmHg. Both exceed the 5 mmHg threshold. Comparable to first-line pharmacotherapy. **PARTIALLY DISCONFIRMING**: the tool works at clinical scale.

2. **AHA Food is Medicine Boston RCT (AHA 2025):** DASH groceries + dietitian support → BP improved during 12-week program. BUT: **full reversion to baseline at 6 months** after program ended. Juraschek: "We did not build grocery stores in the communities." The tool works while active; the structural environment regenerates disease when it stops. **STRENGTHENS Belief 1**: the failure is structural regeneration, not tool absence.

3. **CARDIA study (JAMA Cardiology 2025):** Food insecurity → 41% higher incident CVD in midlife, prospective, adjusted. Establishes temporality. **STRENGTHENS Belief 1**: food insecurity causally precedes CVD.

4. **SNAP → medication adherence (JAMA Network Open 2024):** SNAP receipt → 13.6 pp reduction in antihypertensive nonadherence in food-insecure patients (zero effect in food-secure). **Documents specific mechanism**: food-medication trade-off relief. Supports Belief 1 (SDOH pathway) and Belief 2 (non-clinical determinants).

5. **OBBBA SNAP cuts → 93,000 projected deaths through 2039 (Penn LDI):** 3.2 million under-65 lose SNAP. Applied peer-reviewed mortality rates. **STRENGTHENS Belief 1 with political dimension**: we have tools that demonstrably work AND we're choosing to cut them.

**New precise formulation:**
*The healthspan failure is now confirmed as a structural political choice, not a technical impossibility. Food-as-medicine tools produce pharmacotherapy-scale BP reductions during active deployment; food insecurity causally precedes CVD (41% risk, prospective); SNAP relieves the food-medication trade-off; SNAP policy variation predicts county CVD mortality. Yet the OBBBA simultaneously cuts SNAP by $187 billion (projected 93,000 deaths) while advancing TEMPO digital health only for Medicare patients. The binding constraint has a sharper description: civilizational health infrastructure is being actively dismantled while the solutions are proven.*

**The key insight that extends Session 16:** The AHA Boston study's complete reversion is the clinical proof of Session 16's structural insight (food environment continuously regenerates inflammation). This is now bidirectional: provide the food → BP improves; remove the food → BP reverts. The food environment isn't background noise — it's the active disease-generating mechanism.

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## Key New Connections This Session

### The Food-as-Medicine Effect Size Comparison

- MTM food-as-medicine: -9.67 mmHg systolic (Kentucky pilot)
- First-line antihypertensive (thiazide): ~-8 to -12 mmHg systolic
- GLP-1/semaglutide BP effect: ~-1 to -3 mmHg systolic
- **MTM is pharmacotherapy-equivalent for BP; GLP-1 is 3-9x weaker on BP**

Yet MTM is unreimbursed; GLP-1 is the $70B market. This is incentive misalignment made quantitative.

### The Durability Failure Crystallizes the Structural Claim

Boston AHA Food is Medicine: benefits fully revert when active program ends → The food environment is not just correlated with disease — it actively generates it on an ongoing basis. This is the mechanistic complement to Session 16's AHA REGARDS cohort (UPF → 23% higher incident HTN over 9.3 years).

### TEMPO + ACCESS Timeline Crunch

ACCESS applications due TODAY (April 1, 2026). TEMPO manufacturer selection still pending. July 1, 2026 first performance period. The TEMPO + OBBBA structural contradiction deepens: food infrastructure being cut at exactly the moment digital health infrastructure is being built for a different population.

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## New Archives Created This Session

1. `inbox/queue/2025-05-01-jama-cardiology-cardia-food-insecurity-incident-cvd-midlife.md` — CARDIA study (JAMA Cardiology 2025, 3,616 participants, food insecurity → 41% higher incident CVD in midlife; prospective; temporality established)
2. `inbox/queue/2024-02-23-jama-network-open-snap-antihypertensive-adherence-food-insecure.md` — SNAP → antihypertensive adherence (JAMA Network Open 2024, 6,692 participants, 13.6 pp nonadherence reduction in food-insecure only; food-medication trade-off mechanism)
3. `inbox/queue/2025-11-10-statnews-aha-food-is-medicine-bp-reverts-to-baseline-juraschek.md` — AHA Food is Medicine Boston RCT (AHA 2025 annual meeting; BP improved at 12 weeks; fully reverted to baseline at 6 months; structural environment unchanged)
4. `inbox/queue/2025-07-09-medrxiv-kentucky-mtm-grocery-prescription-bp-reduction-9mmhg.md` — Kentucky MTM pilot (medRxiv July 2025; MTM -9.67 mmHg, grocery prescription -6.89 mmHg; comparable to pharmacotherapy; preprint)
5. `inbox/queue/2025-03-28-jacc-snap-policy-county-cvd-mortality-khatana-venkataramani.md` — JACC SNAP policy → county CVD mortality (JACC April 2025; Khatana Lab; full results not obtained — flag for follow-up)
6. `inbox/queue/2025-xx-penn-ldi-obbba-snap-cuts-93000-premature-deaths.md` — Penn LDI OBBBA mortality projection (93,000 deaths through 2039; 3.2M lose SNAP; peer-reviewed mortality rates applied to CBO headcount)
7. `inbox/queue/2025-08-xx-aha-acc-hypertension-guideline-2025-lifestyle-dietary-recommendations.md` — 2025 AHA/ACC HTN guideline (reaffirms 130/80 threshold; DASH as first-line lifestyle; no SDOH food access guidance)
8. `inbox/queue/2026-04-01-fda-tempo-cms-access-selection-pending-july-performance-period.md` — TEMPO status update (selection still pending April 1, 2026; ACCESS applications due today; July 1 first performance period)

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## Claim Candidates Summary (for extractor)

| Candidate | Evidence | Confidence | Status |
|---|---|---|---|
| Food insecurity in young adulthood independently predicts 41% higher incident CVD in midlife, establishing temporality for the SDOH → CVD pathway | JAMA Cardiology (CARDIA, 3,616 pts, 20-year prospective, adjusted for SES) | **proven** | NEW this session |
| SNAP receipt reduces antihypertensive nonadherence by 13.6 pp in food-insecure patients (zero effect in food-secure), establishing food-medication trade-off as a specific SDOH mechanism | JAMA Network Open 2024 (6,692 pts, retrospective cohort) | **likely** | NEW this session |
| Medically tailored meals produce -9.67 mmHg systolic BP reduction in food-insecure hypertensive patients, comparable to first-line pharmacotherapy | Kentucky MTM pilot, medRxiv July 2025 (preprint, not yet peer-reviewed) | **experimental** (pending peer review) | NEW this session |
| Food-as-medicine interventions produce pharmacotherapy-scale BP improvements during active delivery but benefits fully revert to baseline within 6 months when structural food environment support ends | AHA Boston Food is Medicine RCT (AHA 2025); Kentucky MTM (no durability data yet) | **likely** | NEW this session |
| OBBBA SNAP cuts projected to cause 93,000 premature deaths through 2039 by eliminating food assistance for 3.2 million people under 65 | Penn LDI analysis applying peer-reviewed mortality rates to CBO projections | **experimental** (modeled projection) | NEW this session |

---

## Follow-up Directions

### Active Threads (continue next session)

- **JACC SNAP policy → county CVD mortality full results (Khatana/Venkataramani JACC 2025)**:
  - Study exists and is published. Need institutional access or Khatana Lab publication page for full results
  - Search: Khatana Lab publications page at Penn (linked in search results); or try Google Scholar for full-text
  - Critical for: completing the policy evidence chain with quantitative CVD mortality association
  - If significant: this is the population-level capstone to the individual-level CARDIA finding (food insecurity → CVD) and the mechanism-level SNAP adherence finding

- **TEMPO pilot manufacturer selection announcement**:
  - STATUS CHANGE: ACCESS model applications were due TODAY (April 1, 2026). First performance period July 1, 2026.
  - TEMPO selection should be announced in April/May 2026 to allow operational preparation
  - Search next session: "FDA TEMPO pilot participants selected 2026" or "TEMPO pilot participants announced"
  - Critical for: identifying which digital health companies are in the early CKM space (hypertension, prediabetes, obesity)

- **OBBBA SNAP provisions — implementation timing and state variations**:
  - OBBBA passed and signed. FNS published implementation guidance.
  - Which SNAP provisions take effect first? Which states have early implementation?
  - This connects to Session 13's Medicaid work requirements thread (also OBBBA, January 2027 timeline)
  - Search: "SNAP OBBBA implementation timeline FNS 2026" + "which SNAP provisions effective when"

- **Kentucky MTM pilot peer review status**:
  - Currently a preprint (medRxiv July 2025). Has it been peer-reviewed/published?
  - If published in peer-reviewed journal: upgrade the -9.67 mmHg finding from "experimental" to "likely" confidence
  - Also: does this pilot have durability data beyond 12 weeks? The AHA Boston study showed full reversion at 6 months — does the Kentucky MTM show the same?

- **PMC student-run grocery delivery RCT results**:
  - PMC11817985 is open access but blocked by reCAPTCHA during this session
  - Try direct PDF fetch or Google Scholar search next session
  - Search: "medically tailored grocery deliveries hypertension student pilot RCT Healthcare 2025"

### Dead Ends (don't re-run these)

- **Does food assistance categorically NOT work for BP in food-insecure populations?** — CLOSED. Kentucky MTM (-9.67 mmHg) + AHA Boston Food is Medicine (BP improved at 12 weeks) both show it works during active programs. The failure mode is *durability*, not *efficacy*. Don't re-search the categorical efficacy question.
- **Is TEMPO manufacturer selection announced publicly?** — NOT YET (as of April 1, 2026). Don't re-search until late April 2026. FDA hasn't given a selection announcement timeline.

### Branching Points (one finding opened multiple directions)

- **The pharmacotherapy-parity finding (MTM -9.67 mmHg ≈ first-line antihypertensive):**
  - Direction A: **Cost-effectiveness claim** — if food-as-medicine achieves equivalent BP reduction to antihypertensives, what's the cost comparison? MTM delivery costs vs. pharmacotherapy costs + adherence monitoring costs? This would be a health economics claim.
  - Direction B: **Reimbursement gap claim** — pharmacotherapy is fully reimbursed; MTM is not. If equivalent clinical effect, the failure to reimburse MTM is a health policy claim about incentive misalignment (Belief 3).
  - Which first: Direction B — simpler, already connects to existing KB claims about VBC and structural misalignment. Search: "medically tailored meals reimbursement Medicare Medicaid 2025 2026"

- **AHA Boston vs. Kentucky MTM: the durability question:**
  - FINDING: AHA Boston showed full reversion at 6 months; Kentucky MTM has no reported durability data
  - Direction A: Assume Kentucky MTM will also revert (consistent with mechanism theory) — extract the "durability failure" claim now
  - Direction B: Wait for Kentucky MTM's 6-month follow-up before claiming the durability failure is universal
  - Which first: Direction A is safer for claim confidence. Extract the claim with the AHA Boston evidence (which has durability data) at "likely" level; annotate that Kentucky MTM durability data is pending.

- **93,000 deaths from SNAP cuts — cardiovascular vs. all-cause breakdown:**
  - The Penn LDI estimate is all-cause mortality. What fraction is cardiovascular?
  - If SNAP → lower CVD mortality (CARDIA + JACC county study), and SNAP cuts → 93,000 deaths, the cardiovascular fraction is significant
  - Direction A: Find the breakdown in Penn LDI or underlying research (SNAP mortality research usually reports cause-specific)
  - Direction B: Cross-reference with CARDIA's 41% CVD risk increase to estimate what % of the 93,000 are CVD
  - Which first: Direction A — search Penn LDI's underlying mortality research for cause-specific rates
