Food is medicine: How US policy is shifting toward nutrition for better health

In this new year, millions of Americans will make resolutions about healthier eating. In 2019, could U.S. government leaders further resolve to improve healthier eating as well, joining public health experts in seeing that food is medicine?

In 2018, Congress initiated a series of actions that represent a shift away from placing the full responsibility – and blame – on individual people to make their own healthier choices. These actions also show a growing recognition that many stakeholders – including the government – are accountable for a healthier, more equitable food system. This shift in thinking reflects an understanding that government can and should play a role in improving the diet of Americans.

As faculty members at Tufts University, our expertise spans clinical medicine, nutrition science, public health, policy analyses, Congress, federal agencies and government programs. It’s clear to us that the time is right for meaningful policy action to leverage food as medicine.

Why healthier eating is a national priority

Poor diet is among the greatest health and societal challenges of our time, causing death and disability, soaring health care spending, budget challenges for governments and private business, diminished military readiness and population disparities.

Medicare and Medicaid, the government programs that pay for medical care for people over age 65, low-income families, and the disabled, now consume US$1 in $4 in the federal budget. In addition, nearly $1 in $5^[2] in the entire U.S. economy is spent on health care, creating massive threats to the health of the national economy.

Diet-related diseases are major contributors to these expenses. For example, the annual medical and economic costs of heart disease and stroke are estimated at $316 billion^[3]; of diabetes, $327 billion^[4]; and of all obesity-related conditions, $1.42 trillion^[5]. These costs create enormous economic challenges for federal and state governments as well as for private American businesses, families, and individuals through rising health care premiums, out-pocket-costs, missed work and lower productivity.

Diet-related health burdens and costs also influence military readiness. Two-thirds of active duty military forces are overweight or obese, while 71 percent of young Americans are unable to join the military^[6] for one or more reasons, with obesity as the leading medical disqualifier.

The overall U.S. food system – including farming and imports, supermarkets and retail, restaurants and cafeterias, and food manufacturers – also reflects and contributes to profound disparities, especially among children. Minorities and the poor often have the worst diets^[7], causing a vicious cycle of poor health^[8], lower school performance, lost productivity, increased health costs and poverty.

Hungry for good food

As policymakers increasingly recognize the depth and breadth of these effects, they are beginning to act. In January 2018, House lawmakers created a bipartisan “Food is Medicine” working group^[9], dedicated to innovations in nutrition policy to improve health and reduce diet-related health costs. Simply the existence of a group in Congress focused on “Food is Medicine,” which hosted multiple briefings for congressional staff on key legislation to integrate nutrition into federal policy, is an advance.

On June 7, 2018, Congress instructed the U.S. Government Accountability Office to perform a comprehensive assessment and accounting^[10] of all federal policies related to food, chronic diseases and health care costs. The GAO is the government “watchdog,” providing independent audits of agencies and policies. The GAO has been asked to investigate six specific questions^[11] across diverse federal agencies and programs, including the evidence linking diet to chronic diseases, the corresponding national and federal health care costs, and the current strategies and missed opportunities to reduce these risks and costs. A series of GAO reports on food policy will likely come out in 2019 and 2020. The launch of this investigation represents a federal milestone for its scope and recognition of the opportunities in food policy.

The 2018 Farm Bill^[12], signed into law on Dec. 20, 2018, included several important provisions for healthier eating, especially in the Supplemental Nutrition Assistance Program (SNAP), which supports about one in seven Americans. This included expansion of the fruit and vegetable subsidy program to $250 million, a new $25 million Produce Prescription Program and strengthening of SNAP-Education, a $400 million/year nutrition education program. Several of these advances were recommended by the 2018 Bipartisan Policy Center report on healthier SNAP^[13], chaired by former Senate Majority Leader Bill Frist, M.D., and USDA Secretaries Ann Veneman and Dan Glickman.

While there were advances in the Farm Bill, a proposed amendment to include pilot testing for medically tailored meals^[14] was rejected. Medically tailored meals are ready-to-eat, personalized meals provided at home to low-income patients with complex medical illnesses like cancer, HIV, diabetes or heart failure. Several recent studies^[15] show that providing medically tailored meals to patients is associated with reduced hospitalizations, emergency room visits and overall health care spending. While this is a missed opportunity in the Farm Bill, the state of California is currently testing the effects of medically tailored meals on health outcomes and costs in a $6 million Medicaid intervention^[16] across six counties, which will provide new evidence for possible future national expansion.

Your produce is ready

Among the Farm Bill changes, we believe that the new Produce Prescription Program holds special promise. Already offered by some nonprofit and private insurance programs^[18], this new federal program will allow doctors to prescribe not just medications but also subsidized purchases of fruits and vegetables. While the $25 million represents a small relative investment, this direct federal commitment to evaluate produce prescriptions in health care has the potential to provide evidence to support future expansion throughout Medicaid and Medicare.

Together, these congressional activities in 2018 represent an evolution toward incorporating and addressing nutrition, diet-related diseases and their health care costs in federal policy. These actions build upon mounting public awareness of the central role of food in well-being; the accelerating consumer demand for, and corresponding industry shifts toward, healthier foods; and the growing recognition that individual consumers cannot be solely responsible for the current challenges in the food system.

Recommended policy actions

The recent congressional actions toward viewing food as medicine coincide with new scientific evidence on how specific government policies^[19] can improve nutrition and well-being, reduce health care costs and reduce disparities.

We believe that meaningful progress on these national challenges will require far more substantive policy changes that can make healthier eating the easy, accessible, less expensive option. Based on recent reviews^[20] of the science as well as our new research^[21], particularly promising federal government strategies for consideration include:

• Strengthening of nutrition standards^[22] in schools^[23], after school, early childhood education programs and child feeding programs, as well as in cafeterias at federal worksites and other federal facilities, such as prisons and Veterans Affairs hospitals.

• Federal incentives to incorporate nutrition into corporate worksite wellness programs, such as personalized, interactive technology platforms, gameification and economic incentives^[24] already available in private insurance and corporate programs.

• A federal excise tax^[25] on sugar-sweetened beverages^[26] and junk food, especially if tax revenues are used to subsidize healthier foods^[27], making the latter’s prices both more affordable and closer to their true societal value.

• Integrating nutrition into health care^[28], including in the electronic health record, medical education and licensing standards, fruit and vegetable prescriptions, medically tailored meals, provider quality and reimbursement guidelines, and risk-sharing arrangements that incentivize providers to improve the health of their communities.

• Leveraging the $70 billion per year SNAP program for better nutrition for low-income families^[29], for example through further strengthening of SNAP-Education^[30], increased subsidies for fruits and vegetables^[31] and a combined food incentive/disincentive program^[32] to nudge people toward healthier choices.

• U.S. Food and Drug Administration labeling standards and limits^[33] for additives such as salt, trans fat and added sugar; marketing standards to protect children; and evidence-based health claims for products that can help achieve better health.

• Increased federal research funding, including a new National Institute of Nutrition at the National Institutes of Health; as well as economic incentives for transparent public-private partnerships for health-focused food innovation and entrepreneurship.

Policy change is often not linear. Based on the significant impacts of nutrition on disease, health care, the economy, military readiness, disparities and the environment, federal actions in 2018 laid the foundation for nonpartisan federal leadership to create meaningful and lasting solutions.

References

1. ^{^} beats1/Shutterstock.com (www.shutterstock.com)
2. ^{^} $1 in $5 (www.cms.gov)
3. ^{^} $316 billion (www.ahajournals.org)
4. ^{^} $327 billion (www.ahajournals.org)
5. ^{^} $1.42 trillion (assets1b.milkeninstitute.org)
6. ^{^} unable to join the military (www.strongnation.org)
7. ^{^} worst diets (jamanetwork.com)
8. ^{^} poor health (now.tufts.edu)
9. ^{^} “Food is Medicine” working group (www.foodnavigator-usa.com)
10. ^{^} comprehensive assessment and accounting (timryan.house.gov)
11. ^{^} six specific questions (timryan.house.gov)
12. ^{^} 2018 Farm Bill (docs.house.gov)
13. ^{^} 2018 Bipartisan Policy Center report on healthier SNAP (bipartisanpolicy.org)
14. ^{^} medically tailored meals (www.fimcoalition.org)
15. ^{^} Several recent studies (www.fimcoalition.org)
16. ^{^} $6 million Medicaid intervention (calfimc.org)
17. ^{^} ABO PHOTOGRAPHY/Shutterstock.com (www.shutterstock.com)
18. ^{^} nonprofit and private insurance programs (www.wholesomewave.org)
19. ^{^} specific government policies (link.springer.com)
20. ^{^} recent reviews (www.bmj.com)
21. ^{^} our new research (food-price.org)
22. ^{^} nutrition standards (journals.plos.org)
23. ^{^} schools (journals.plos.org)
24. ^{^} personalized, interactive technology platforms, gameification and economic incentives (jhrewardslife.johnhancockinsurance.com)
25. ^{^} federal excise tax (now.tufts.edu)
26. ^{^} sugar-sweetened beverages (journals.plos.org)
27. ^{^} subsidize healthier foods (bmcmedicine.biomedcentral.com)
28. ^{^} Integrating nutrition into health care (www.bmj.com)
29. ^{^} better nutrition for low-income families (www.bipartisanpolicy.org)
30. ^{^} SNAP-Education (snaped.fns.usda.gov)
31. ^{^} subsidies for fruits and vegetables (jech.bmj.com)
32. ^{^} combined food incentive/disincentive program (journals.plos.org)
33. ^{^} labeling standards and limits (journals.plos.org)