This brief is part of the Brookings Blueprints for American Renewal & Prosperity project.
Richard V. Reeves
John C. and Nancy D. Whitehead Chair
Senior Fellow - Economic Studies
There are wide gaps by race in health, as well as health care. Too little attention is paid to prevention, as opposed to treatment. The U.S. has dropped to the near-bottom of the OECD ranking on the key aggregate metric of age-standardized death rate. Food and nutrition policies contribute significantly to large racial health disparities in the United States. The whole food system of the U.S., from crop to store, is broken: compromised by special interests, out of line with research, and exacerbated by inequality, by race as well as class. Policy solutions include the provision of free, nutritious school meals, great investments in nutrition research, and a national tax on sugary drinks, using all proceeds for public health in underserved communities.
A broken food system in the United States is damaging the health and shortening the lives of millions of Americans – especially Black and Latino or Hispanic Americans.
The COVID-19 pandemic hit the U.S. harder than most other nations for many reasons, not least because of the vacillating and inconsistent response of the Trump Administration, an absence of preparedness, and a weak public health infrastructure. But the pandemic has also served to highlight the general state of America’s health when the virus hit our shores – especially in terms of pre-existing conditions, or co-morbidities that are associated with poorer outcomes, and the deep racial divides in health and health care.
Comprehensive studies conducted by large teams of NIH experts show that the U.S. lags behind other wealthy nations, especially in terms of chronic disability and morbidity. Diet-related risks now account for more deaths than any other factor. The U.S. has dropped from 18th to 27th place among 34 OECD nations on the key aggregate metric of age-standardized death rate. A good yardstick of overall progress in terms of health is life expectancy, which has risen considerably in recent decades in most countries in the world. But the U.S. has seen slower increases than comparable countries (Figure 11). Perhaps most worrying, life expectancy in the U.S. is now trending downwards, a break with both the historical trend and with other countries.
The poor health of the U.S., by comparison to other similar nations, is even more striking given health care spending. Seventeen percent of U.S. GDP went towards health care in 2017, compared to an average of 10 percent in comparable nations. This illustrates not only the cost and inefficiency of the U.S. health care system, but also, taken with the health outcome data above, the important distinction between health and health care. The treatment of chronic diseases, which affect 60 percent of the population, now accounts for at least two-thirds of health care spending.
In terms of physical health, there are troubling overall trends in hypertension, obesity, and diabetes. One in two adults has diabetes or pre-diabetes. Diabetes accounts for $237 billion in direct medical costs and $90 billion in lost productivity. In each case there are some stark race gaps, too. Alongside the well-known racial wealth gap, there is a racial health gap. The stark race gaps in COVID-19 death rates result from a complex set of factors, but one factor is clearly the different rates of health conditions that increase vulnerability to the virus. Rates of diabetes, obesity, and hypertension – all risk factors for COVID-19 – are considerably higher among Black and Hispanic men and women (with different subgroups facing different risks for different conditions).
Hypertension is a leading risk factor for mortality from COVID-19. Overall, just under a third of adult Americans suffer from this condition, with higher rates among men and older people. Risk factors include high cholesterol and obesity (see below). An overview article in the journal Hypertension notes that “poor diet, physical inactivity, and excess intake of alcohol, alone or in combination, are the underlying cause of a large proportion of hypertension.” Progress has been made in recent years in controlling high blood pressure, but a large proportion remains uncontrolled, according to the CDC.
Differences by race and gender for hypertension are significant. Most striking are the higher rates for Black Americans. Two in five Black men (42%) and Black women (43%) suffer from hypertension, compared to 31% of white men and 27% of white women. There are also large race and gender gaps in the likelihood that hypertension is being controlled with medication. There are twice as many Black, Asian, and Hispanic men in the U.S. with uncontrolled hypertension as there are with controlled hypertension, for example.
Two in five Americans are now obese, and obesity is associated with many chronic health conditions, including, according to the CDC, “diabetes, hypertension, high cholesterol, cardiovascular disease, stroke, arthritis, and certain cancers.” Childhood obesity rates are falling in well-educated and more affluent households but continuing to rise for others.
Again, there are significant inequities by race and gender, according to CDC data. Overall rates of obesity (with a body mass index (BMI) of 30+) are highest among Black women (at 57%), followed by Hispanic women (49%). There are even starker race gaps for rates of severe obesity (BMI of 40+). Black women have the highest risk of being severely obese (with a BMI of 40 kg/m2 or higher), at a rate of 16%, followed by Hispanic women at 10%, and white women at 9%. There are almost as many Black women falling into the morbidly obese category as into the “normal weight” category (18%, not shown).1
One in 10 Americans already have diabetes, and that number could rise to one in three by 2050 if current trends continue. Diabetes is a risk factor for poor outcomes from COVID-19 infection. Americans diagnosed with diabetes are likely to be either obese (46%) or severely obese (16%), according to CDC. Again, there are wide inequities by race and gender. For diagnosed diabetes, Hispanics men are at the highest risk (14%), followed by Black women (12%), Hispanic women (12%), and Black men (11%). Whites have the lowest rates.
These national inequities can also be seen through a more local lens: in Ward 8 of Washington, D.C., the poorest in the city and predominantly Black, for example, the rate of Type 2 diabetes is 15 percent; in Ward 3, the richest and whitest, the rate is two percent.
There are many reasons why the physical health of our nation is deteriorating and for the stark divides by class and race. But one stands out: food and nutrition. Over the long term, no single change could improve Americans’ physical health more than improving diet and nutrition – and especially, reducing sugar consumption. The issue of “food justice” – access to affordable, healthy food – is a racial justice issue. Americans of color are much more likely to live in areas described as “food swamps,” locales with a high density of fast food outlets and convenience stores selling highly-processed foods.
Limits of historic and existing policies
Public policy has not only failed to address these challenges adequately; it has made them worse and continues to do so. Public policy distorts the food system in an unhealthy direction by subsidizing the production of less healthy food through agricultural subsidies and government food programs.
In the years since the passage of the 1973 U.S. Farm Bill, over $200 billion of subsidies have gone to support the production of certain foods, largely grain-based. As Jeffrey Tucker, from the free-market Heartland Institute points out, corn production is actually rising despite growing health concerns. “Government intervention has created corn nation,” he writes. “We feed it to our cars, our animals, ourselves.”
The net result of this spending has been to make Americans sicker, as Karen Siegel and co-authors show in an article published in JAMA Internal Medicine. Here’s why: “A large proportion of these subsidized commodities are converted into high-fat meat and dairy products, refined grains, high-calorie juices and soft drinks (sweetened with corn sweeteners), and processed and packaged foods.”
The primary policy approach to improving healthy eating has been to focus on information and education, especially through food labeling. There is some evidence that labels can influence consumer behavior, reducing calorie intake by around seven percent, for example. But these effects are relatively small when considered against broader trends in healthy eating.
Good policymaking in this area has been hampered by political constraints. On the one hand, a heavy stress has been placed on individual responsibility, especially on the political right, thereby obviating the need for structural reform. At the same time, many policymakers, especially on the political left, are anxious not to be seen as “blaming the victim.” But individuals do not act in a vacuum. As Mozaffarian, along with fellow nutrition scientist David Ludwig and economist Kenneth Rogoff, writes:
“Suboptimal diet quality is the leading factor associated with death and disability in the U.S. and globally. Presently, strategies to address suboptimal diet focus on nutrition education through dietary guidelines and food package labeling. However, this approach places responsibility for healthier diets on an individual’s ability to make informed choices, rather than addressing the complex, powerful environmental determinants of dietary habits. Not surprisingly, this strategy has fallen short, as demonstrated by the increasing rates of obesity, diabetes, and other diet-related illness.”
There are also powerful vested interests arrayed against reform, including the current beneficiaries of agricultural subsidies and the “big food” manufacturers of processed food and beverages.
The problem of rising chronic physical disease, driven in large part by diet and nutrition, must now be seen through an equity lens. There are large inequities by class, gender, and race. Black and Hispanic women are more likely to be obese, as shown above, but are also much more likely to report that they suffer from food insecurity, i.e., reporting not having enough money to buy food. A similar relationship between food insecurity and obesity risk is found among very young children.
The apparent contradiction here can be explained by food quality. Poor-quality, less nutritious food – especially sugary food – causes weight gain but also creates hunger. It is also less expensive because it is highly processed and heavily subsidized all the way up the supply chain. The problems of food poverty and of poor-quality food are very often two sides of the same coin.
The rise in diet-driven chronic disease calls for of the transformation of our entire broken food system – from agricultural subsidies (especially for high-fructose corn syrup), official dietary guidelines, advertising, school lunches, and budget choices. Here I offer one key policy proposal – a tax on sugary drinks that offers the prospect of some real, immediate impact. This should be seen as one element in a broader set of required reforms: necessary, but far from sufficient. To that end I also offer three other complementary proposals intended to illustrate the other directions in which policy needs to move.
The headline proposal is to tax sugary drinks in an effort to influence the demand side of the market, especially regarding high levels of sugar consumption. The evidence for the impact of sugary foods and drinks on health is now clear. One-third of the added sugar in the American diet (for children and adults) comes in the form of sugar-sweetened beverages. Sugar-sweetened beverages contribute directly to unhealthy weight gain. For every one to two daily servings of soda consumed, the lifetime risk of developing diabetes increases by 30 percent.
Many cities have introduced a tax on soda; some, like Chicago, have later repealed them. One problem is that consumers very often simply drive to the neighboring county. Soda sales in the city of Philadelphia fell by 51 percent after the introduction of a 1.5 cents per ounce tax – but sales in nearby areas increased by 43 percent.
The solution is to follow Mexico’s lead and enact a national tax on sweetened drinks at a rate high enough to deliver real health benefits. In Mexico, this tax reduced consumption of taxed beverages by 5.5% in the first year after implementation and 9.7% in the second year.
Previous legislative efforts in the U.S., including those led by Congresswoman Rosa DeLauro, have failed. “It’s an idea that we should be exploring,” said former President Barack Obama in 2009, before quickly shelving the idea. But COVID-19 has turned a harsh light on the implications of poor metabolic health for quality of life and for the risk of death. There is a case in theory for a graduated tax on damaging ingredients, especially sugar and starch in all processed foods and drinks. But in practice, it is easier to tax the main delivery mechanism (in the U.S.): sweetened beverages. In terms of design, the best approach is to tax sugar and corn syrup content, rather than just the volume of the drink itself. A tiered tax, with the highest rate (two cents an ounce), levied on drinks with the highest sugar content (20 grams per eight ounce serving), as proposed by the American Heart Association, would be especially effective.
Over a lifetime, on reasonable assumptions, this tax would save half a million lives and cut health care costs by $100 billion. A tax of this kind would also raise around $5 billion a year, according to the Congressional Budget Office. This additional revenue should be earmarked for preventive measures proven to reduce health disparities. These funds could be used, for example, to more than double the current level of federal support for the 1,400 Community Health Centers across the country which are particularly important providers to Hispanic and Black families.
Such a tax initially looks “regressive” in pure economic terms, since lower-income families spend more on sugary drinks. But considering welfare more broadly it is either neutral or slightly progressive, since the biggest health benefits are also experienced among the less affluent. Consumption of sugar by young people would be most effectively decreased, with potentially lifetime benefits. The health benefits also differ by race. The tax would reduce cardiovascular disease rates (per million) for Black and Hispanic Americans by 15,000, compared to 9,000 for whites. The idea of taxing sugary drinks is gaining support among professional organizations, including in 2019, the American Academy of Pediatrics.
It hardly needs to be said that such a tax will be considered by many to be illiberal and paternalistic. These are reasonable concerns, similar to those made against taxes on alcohol and tobacco. But few policymakers now object to the idea of taxes on alcohol or tobacco, for instance, and they work in terms of moderating consumption. If we are serious about arresting the trends in worsening physical health, especially for Americans of color, this is the kind of policy that needs to be on the table.
Four other areas for policy consideration, mentioned here only in summary form, are to improve school meals; invest in research; re-task the Agriculture Department; and reform agricultural subsidies.
- Good food at school. After SNAP, the largest direct government food program is the National School Lunch Program (NSLP), supplying around five billion meals every year, largely to lower-income students. This is a vital connection point between public policy and nutrition, since schoolchildren consume between one-third and one-half of their meals at school. The federal school lunch program was born in part from national security concerns after World War II, when the malnutrition of many American children became apparent to the military. Similarly worries about mission readiness are being expressed by military leaders today, but with obesity and associated health problems now the primary concern. Balancing cost, quality and take-up in school meals is a difficult challenge. Overstretched school districts often struggle to provide good food to their students within prescribed spending limits. The 2010 Healthy, Hunger-Free Kids Act was a small step in the right direction, but bolder action is now required. As a nation we should adopt Boston’s approach to school meals, making them free to all students regardless of income, and cooking real food in actual kitchens, rather than reheating processed food shipped by food conglomerates. This could dramatically improve health outcomes.
- Invest in nutrition research. We also need better research on the impact of nutrition on chronic health conditions. A very good start would be the establishment of a National Institute of Nutrition at the National Institutes of Health.
- Rename the Department of Agriculture the Department of Food and Agriculture. This would be an important signal of a new focus on the Department’s role in shaping the whole food and nutrition system in the nation, and its responsibility for promoting the health of all our citizens.
- Shift agricultural subsidies to healthier foods. As discussed above, the Federal government, through the current structure of agricultural subsidies, spends money to make Americans sicker, and thereby drives up health costs. The winners are not ordinary farmers – the winners are Big Ag, Big Food, and Big Pharma. The departure of some key pro-subsidy Congressmen following the 2020 election increases the odds of some long-overdue improvement, especially in the 2023 Farm Bill. The goal should not be to eliminate agricultural support, crucial to many rural economies, but to shift support towards the production of healthier, “protective” foods, especially fruits and vegetables. Finland’s reform along these lines provides some important lessons.
Health policy needs to shift in the direction of prevention rather than cure; nowhere is this more true than in relation to diet- and nutrition-related disease. Too many of our citizens have suffered or died in the COVID-19 pandemic, especially Black Americans, who as Dayna Bowen Matthew, Dean of the Law School at George Washington University puts it, already “live sicker and die quicker.” One structural barrier to better health, and to greater health equity, is the broken food system, in which the incentives and pressures facing consumers are not in tune with their own health and well-being.
In September 2019, then-Presidential candidate Sen. Kamala Harris said: “As a nation we need a real priority at the highest level of government around what we eat and in terms of healthy eating, because we have a problem in America…We can talk about the amount of sugar in everything, we can talk about soda…” On January 20, Harris will become Vice President and will have a chance to show that she meant what she said. The connections between food, health, and racial justice are now crystal clear. The question is whether policymakers can rise to the challenge.
- The flaws in BMI are broadly accepted in the medical and public health communities, especially in terms of making binary distinctions such as “normal weight” versus “overweight”; it is much better to think of it as a continuum. There are also much better ways to measure risks to metabolic health. But for now, BMI data is the most broadly collected reliable data. And despite its drawbacks, there is no serious doubt that a high BMI predicts poorer health overall.