This is the final installment in our series on Healing America, a proposal we published earlier this year that charts a path that policymakers can follow to avoid issues that arise when policy lags behind food and agtech investment and innovation in three key areas. Check out our other articles on rural renaissance, and part 1, part 2 and part 3 in our resilient supply chain series.
The idea of food as medicine has risen to prominence recently as more research is emerging about food’s ability to prevent and address a number of health issues. The food as medicine movement holds that increasing access to nutritious food through health care helps prevent, manage and treat diet-related illness. Food is becoming a particular focus of doctors, hospitals, insurers and even employers who are frustrated by the slow progress of drug treatments in reducing food related diseases.
But eating healthy isn’t as simple as popping a pill. There are many factors that influence diet such as nutrition education and lifestyle, but two of the most oft-cited barriers to healthy eating are cost and availability. Given the declining state of health in the US, the rising cost of healthcare, and the connection between food insecurity and adverse health outcomes, nutrition policy needs to be about more than just preventing hunger. Access to nutritious foods should be a significant focus of national security efforts.
One of the great modern American paradoxes is that despite this country’s wealth and relatively high health care expenditures, Americans are in fact not healthy. US healthcare expenditures greatly exceed those of other high-income countries with spending levels that have risen continuously over the last three decades. Currently, US healthcare costs are growing 1.1 percent faster than the annual GDP. National healthcare expenditure is estimated to reach $6.2 trillion by 2028 and account for 20% of GDP.
But despite spending substantially more on healthcare compared with residents of other developed countries, Americans don’t enjoy better health outcomes. A 2018 study found that only 12 percent of Americans are metabolically healthy. In the last 30 years obesity rates have doubled in adults, tripled in children and quadrupled in adolescents. More than 34.2 million Americans have diabetes and another 88 million adults have pre-diabetes which puts them at risk for type 2 diabetes. 121.5 million or 48 percent of adults in the US have cardiovascular disease which is the leading cause of death in the US.
The Hidden Costs of Food
The most obvious consequence of America’s declining health standards are the resulting costs. Heart disease costs the US about $363 billion each year due to the cost of healthcare services, medicines and lost productivity. A study conducted by the Milken Institute found that chronic diseases driven by obesity and overweight risk factors accounted for $480.7 billion in direct healthcare costs in the US with an additional $1.24 trillion in indirect costs due to lost economic productivity. Obesity is by far the greatest contributor to the burden of chronic disease in the US accounting for 47.1 percent of the total cost of chronic disease nationwide. On average people with diabetes have medical expenditures approximately 2.3 times higher than expenditures in the absence of diabetes and most of the costs for diabetes care in the US (around 67 percent) is provided by government insurance (Medicare, Medicaid, and the military).
But there are a number of other less obvious consequences of our national health crisis. It has become painfully clear that a high prevalence of diet related diseases make us more vulnerable to pandemics. Almost 95 percent of Covid-19 hospital admissions involved at least one comorbidity with heart disease and obesity being two of the three most common. The strongest risk factors for death after contracting Covid-19 are obesity and diabetes.
Another security risk associated with our declining health standard is that the percentage of the population fit to serve in the military is shrinking. Today, nearly one-third of 17-24-year-olds are too overweight to qualify for military service.
Lastly, there are educational implications to poor nutrition that could have crippling consequences for individuals and the country at large. Research suggests that nutritional deficiencies early in life can affect the cognitive development of school aged children and diets high in trans and saturated fats can negatively impact learning and memory. On the other hand, access to nutritious foods improves students' cognition, concentration and energy levels.
The Food Health Connection
One of the most significant social determinants of adverse health outcomes is food insecurity. Economically disadvantaged Americans have around a 70 percent higher prevalence of diabetes and a 19 percent higher prevalence of hypertension compared with high income populations. Living in a food desert, or an area where residents’ access to affordable, healthy food options are restricted or non-existent, is associated with 10 of the costliest and most deadly preventable diseases in the US including hypertension, diabetes, cancer and stroke. Poor health also increases expenses and reduces economic opportunities driving further nutrition insecurity.
The result is that the healthcare costs associated with food insecurity are enormous. Many SNAP (Supplemental Nutrition Assistance Program) participants are also Medicaid beneficiaries whose diet related health care costs contribute significantly to rising national health care expenditures. Average healthcare costs for food-insecure adults were $1,834 higher than food-secure adults--totalling $52.6 billion across all food-insecure households.
The issue is that getting enough calories is not the same as meeting nutritional needs. In fact, nearly 9 out of 10 SNAP participants say they face barriers to providing their households with a healthy diet. SNAP helps feed more than 1 in 8 Americans each month and is a far reaching powerful tool to ensure all Americans can put food on the table. But even after a historic increase in SNAP benefits this year with the average monthly per-person benefit rising from $121 to $157, it is still no surprise that participants prioritize the cheapest, most calorie dense and easy to prepare foods. More than half of SNAP benefits are used for meats, sweetened beverages, prepared foods and desserts, cheese, salty snacks, candy and sugar. For many low-income families the problem is no longer a lack of calories but a struggle to consistently be able to afford, access and prepare healthy foods.
But while food insecurity is currently a major factor in poor nutrition and chronic disease, there is a huge opportunity to improve health outcomes through better nutrition programs in food insecure communities. Modeling studies indicate that combined incentive and disincentive SNAP programs (combining 30 percent incentives for fruits, vegetables, nuts, whole grains, fish and plant based oils and 30 percent disincentives for sugar sweetened beverages, junk food, and processed meats) are cost neutral and lead to significant gains in health outcomes and healthcare cost savings amounting to about 10 billion over five years. In other studies or trial programs, providing free fresh food yielded a more than 40 percent decrease in the risk of death or severe complications from diabetes and a 20 percent incentive for fruit and vegetable purchases to Medicaid and Medicare beneficiaries could prevent 1.95 million cardiovascular events and save $40.9 billion in healthcare costs.
In addition, these programs could provide an opportunity to learn more about the correlations between diets and health. Roughly 65 percent of adults receiving SNAP are on Medicaid. This means we would have the ability to track how food and nutrition incentives can support better health outcomes and drive cost savings.
Private Sector Solutions
We believe our food system has a great capacity to address this growing health crisis and serve as a truly nourishing, healing force. To this end we are working with a number of companies that are innovating at the intersection of food and health and addressing both personal and community nutrition.
Companies that provide tailored nutrition advice and thoughtfully prepared meals based on individual health needs can empower patients to make diet modifications and achieve their health goals. NourishedRx is a food-as-medicine platform with a mission to unlock the power of food to improve health and reduce health care costs by integrating clinically tailored meals and diet education into the healthcare payment and delivery system. The company’s AI-enabled platform matches at-risk members with Registered Dietician-vetted food solutions and leverages behavioral science to support lasting dietary change and improved health outcomes.
While personalized nutrition interventions will be an essential tool in the food as medicine movement, solutions that operate on a community scale can address the systemic health issues in food insecure areas. To this end Everytable’s mission is simple: To make fresh, nutritious food accessible to everyone, everywhere. Based in LA, they have locations in food deserts and underserved communities as well as in affluent areas. Meals are priced according to the neighborhood to ensure everyone can afford the same meals. The company is able to do this through a unique business model where chefs at central kitchens create fresh, wholesome meals which are then sold through grab-and-go storefronts, drastically reducing the costs of the standard restaurant model.
Lastly, brands that make healthy options accessible and desirable can shift food choices on a national scale. Once Upon a Farm sells organic baby and kid foods with clean labels, no dairy and no added sugar. Unlike shelf stable alternatives, Once Upon a Farm pouches are cold pressed using high pressure processing to maintain a higher nutritional content and fresher less sugary flavors. The company's goal is to provide a great product kids love that also nourishes their bodies and minds. Once Upon a Farm Baby Food Bowls have also been WIC approved in a number of states which means they are more accessible for families who might otherwise struggle to purchase higher end healthy options.
The Missing Policy Piece
While the private sector is working to bridge the gap between eating habits and health outcomes, targeted policy interventions are crucial to support the use of food as a prophylactic treatment for diet related health conditions and enable effective solutions to scale.
Strengthen the Ties Between Food and Healthcare
One opportunity for policy interventions is to enable government healthcare programs to support healthy food assistance. Medicare and Medicaid currently don’t support food as a solution. But trial or small scale Produce Prescription Programs have been found to be highly cost effective and improve health outcomes, reduce food and nutrition insecurity, and decrease long term health care costs. Results from one study estimate that providing Medicare and Medicaid patients with a thirty percent subsidy for the purchase of fruits and vegetables would save $39.7 billion in formal healthcare costs if enacted on a national level over a lifetime.
Funding to support Produce Prescription Programs has historically been provided on a limited basis by community based organizations, research institutions or government grants. While these funding sources are important, their short-term nature has made it difficult to scale access and has limited the development of these programs as medical interventions. The 2018 Farm Bill included expansion of the fruit and vegetable subsidy program and a new $25 million Produce Prescription Program, but a proposed amendment to include pilot testing for medically tailored meals was rejected. And while the new program is promising, it represents a relatively small investment.
The government can utilize existing Medicaid funding mechanisms to increase access to healthy foods for patients and support public-private partnerships that encourage innovation and promote programmatic efficiency. Making nutrition a core SNAP objective and creating synergies in Medicaid and SNAP for dually eligible individuals and families can improve the lives of millions of low income families while reducing health care costs and disparities.
Improve Access in Food Deserts
Geographic access can be a major barrier for consumers to buy healthy food. According to the USDA’s most recent food access research report, about 19 million people--or 6.2 percent of the nation’s total population--have limited access to a supermarket or grocery store. Efforts to subsidize the development of grocery stores or create incentives for existing stores to stock healthy food would directly address the lack of access to nutritious foods in underserved areas. Even if there is a store not too far away, transportation is often an obstacle for SNAP participants. Programs that improve public transportation routes in areas with limited access or provide transportation subsidies could also be an effective way to reduce access barriers.
Another option is to expand the opportunity for food delivery. The SNAP Online Purchasing Pilot is currently testing the feasibility and implications of allowing retail food stores to accept SNAP benefits online and has the potential to overcome geographic barriers to food and nutrition insecurity. But there are still a number of challenges preventing SNAP users from taking advantage of the program. In addition to waiving the delivery fee, the program could also provide retailers with the necessary technology to participate and a mobile app could overcome some of the internet access disparities.
Lastly, the government could improve consumers’ purchasing power by making SNAP benefits more responsive to different contexts. Currently SNAP benefits are based on the nationally averaged cost of the Thrifty Food Plan which recently received a much needed update. But the plan is still in need of modernization to better reflect the economic, dietary and geographic diversity across the country. Policymakers could also scale support for successful community-driven food security strategies to promote food security such as the Seniors Farmers’ Market Nutrition Program, Double Up Food Bucks, and the Connecticut Fresh Match Program.
Increase Funding for Nutrition Research
Even as Americans become increasingly health conscious the federal government has devoted only a tiny fraction of its research funding to nutrition, a level that has not nearly kept pace with the rise of diet related diseases. A POLITICO review revealed that at the National Institute of Health and the Department of Agriculture, two agencies that fund the majority of government backed nutrition science, the share of research dollars devoted to nutrition has stayed mostly constant for three decades. In 2018 the NIH invested $1.8 billion in nutritional research or under 5 percent of its total budget. USDA’s agricultural research service spent just 88 million or about 7 percent of its overall budget on nutrition. To put that in perspective, Americans spent $10 billion on Halloween candy this year. The lack of federal investment has also left room for consumer confusion with food industry funded studies filling the gap with market driven findings. More than half of these studies yield outcomes favorable to company products.
Modern nutrition science is young, and strong government funding for nutrition and applied research and innovation is essential for developing evidence based priorities. A stronger body of research could also be used to improve training for medical professionals, including nutrition training in medical school, as doctors serve as trusted advisors for patients seeking dietary advice. Lastly, enhanced coordination between federal nutrition research agencies and a renewed priority for nutrition at USDA’s premier competitive research arm, the Agriculture and Food Research Initiative, would signal its importance and encourage applicants to think creatively about innovation in this area.
At S2G we are working to bring food front and center in the conversation around health and wellness and zero in on the connection between nutrition and health outcomes. Policy support for the food as medicine movement would enable these innovative solutions to scale and become mainstream with the outcome being significantly reduced national healthcare expenditures and a healthier more empowered nation. It is time to make not just food security, but nutrition security, a focus of our national security efforts.