Make America healthy again by paying more attention to nutrition

Health care and health care policy were centerpieces of the 2020 presidential and congressional campaigns. It’s a shame that neither party focused on the underlying issue: the poor health of the American people, largely attributed to poor nutrition.

By many measures, the population of the United States is the unhealthiest of any high-income country despite spending much more money, as a share of the economy, on health care. The incidence of chronic disease is higher and life expectancy is lower.

Covid-19 has magnified the effects of Americans’ poor health. Those living with chronic disease are more likely to be hospitalized — and to die — with Covid-19 than those in good health. A recent report from the Centers for Disease Control and Prevention showed that 94% of those who have died from Covid-19 had an average of 2.6 additional conditions. A report in the Journal of the American Medical Association showed that since May 10 the U.S. has had the highest per capita death rate from Covid-19 and other causes among 18 other high-income countries.

The health of Americans has been in decline for years. “The tragedy is not that the U.S. is losing a contest with other countries,” concluded the authors of a 2013 report sponsored by the National Institutes of Health, “but that Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”

There are complex factors behind the U.S.’s high premature death rate. But it is a mistake to believe that the country’s abominable health outcomes are highly dependent on, say, preserving or repealing the Affordable Care Act. That’s because the U.S. health care system is really a “sick” care system that treats people after their health has declined.

Many chronic conditions plaguing Americans, such as obesity, diabetes, and high blood pressure, are avoidable with a prudent diet and lifestyle. Today, more than 42% of American adults have obesity, as do 19.3% of children of age 19 and under. The U.S. has the world’s 12th-highest obesity rate, after Kuwait. (The top 10 are all small Pacific island nations.)

Diet makes a difference. Nearly half of all deaths in the U.S. from heart disease, stroke, and type 2 diabetes are associated with diet, such as the overconsumption of processed meats and sugar-sweetened beverages and insufficient intake of fruits, vegetables, and whole grains. And cancer? Among individuals who don’t smoke, “avoidance of overweight is the most important strategy for cancer prevention,” according to a 2004 review of evidence regarding diet, nutrition, and the prevention of cancer.

Obesity poses a preeminent threat to the health of Americans and the stakes for tackling it have never been greater. Those who contract Covid-19 and have obesity — especially young people — face an elevated risk of complications and death. There is a clear need for action, particularly from Washington. Here are a few suggestions for the next administration.

Refocus federal research on nutrition. The NIH has a budget of nearly $42 billion to fund research devoted to “protecting and improving health.” But none of NIH’s 27 institutes or centers devotes research strictly to nutrition. The next administration could deliver a long-term boost to nutrition research by working with Congress to create a new research institute focused on the health effects of the foods we eat.

Make healthy food more affordable and unhealthy food less affordable. The average American consumes less than one serving of fruit daily but nearly twice as many servings of sugar-sweetened beverages. Researchers with the Friedman School of Nutrition Science and Policy at Tufts University projected that a 30% reduction in the price of fruits or vegetables and a corresponding increase in the price of red meat and sugary drinks would prevent an estimated 63,000 deaths annually. The next administration should explore subsidizing fruits and vegetables to make them less expensive and taxing the unhealthy products that contribute to obesity.

Teach doctors about nutrition. Americans say they have a high level of trust in doctors when it comes to nutrition, even though less than 1% of medical schools’ lecture hours are devoted to nutrition, and much of that limited time focuses on complex biochemistry. Maybe it shouldn’t be a surprise that in a survey of 12,000 doctors conducted last year for the Physicians Committee for Responsible Medicine, just 15% said they feel “totally prepared” to offer nutritional guidance to their patients. The next administration should work with medical schools to incorporate more nutrition education into their curricula.

Give recipients of federal nutrition assistance programs incentives to consume healthy foods. People with low incomes are more likely to have obesity than those with high incomes. While there are myriad reasons for this, the U.S. Department of Agriculture’s Supplemental Nutrition Assistance Program (SNAP) is one of the culprits. This federal nutrition program places no limits on food and beverage items that beneficiaries can purchase, and a USDA report shows that about 20 cents of every SNAP dollar is spent on sweetened beverages, desserts, salty snacks, candy, and sugar. There are ways to change that. In 2011-12, the USDA launched a pilot project in Hampden County, Mass., in which SNAP participants were given an extra 30 cents for every dollar of assistance if the money was spent on select fruits and vegetables at participating retailers. The effect? Consumption of fruits and vegetables was 26% higher among those in the pilot project than among those who weren’t. That model should become a feature of SNAP nationwide.

Use the bully pulpit. The future president should speak about the perils of the standard American diet (sometimes abbreviated, fittingly, as SAD). The administration should also pressure food and beverage companies, the restaurant sector, and supermarkets to exercise greater responsibility regarding the products they produce and sell and perhaps dangle threats of the advertising limits now faced by the tobacco and spirits industries.

A healthier eating campaign would bump up against the challenge of changing unhealthy behaviors. But change is possible. Take another public health issue once thought to be insurmountable: smoking. In 1964, about 42% of American adults were smokers. Today, that figure is below 14%.

Leaders of both parties need to recognize the strong connection between poor dietary patterns and the nation’s worsening health — a function of the majority of Americans being both overfed with unhealthy foods and undernourished with healthier ones. Hippocrates, the father of modern medicine, had it right when he wrote, “Let food be thy medicine and medicine thy food.”

If that idea can spread, and if eating habits can improve, we’ll be on the road to making America healthy again.

Vanita Rahman is an internal medicine physician, the director of clinical programs at Barnard Medical Center and Physicians Committee for Responsible Medicine in Washington D.C., a clinical instructor in medicine at the George Washington University School of Medicine, and author of “Stronger with Plants” (CitrusLLC, 2016). Matthew Rees is a senior fellow at Dartmouth College’s Tuck School of Business, the founder of the website Food and Health Facts, and a contributor to “Discovering Precision Health: Predict, Prevent, and Cure to Advance Health and Well-Being.”(Wiley-Blackwell, 2020).