Improving Health in the Land of Plenty Part 1: How Lack of Access to Nutritious Food Compounds Our Epidemic of Chronic Illness

Why does America have the highest per capita healthcare costs in the world and the lowest life expectancy among the most economically prosperous (OECD) nations? Our healthcare system still struggles to effectively prevent, address, and manage chronic illness, especially in vulnerable populations.?

?Of the $4.4 trillion the US spends on healthcare, 90% is devoted to people with chronic illness and mental health conditions. Chronic illness is so extensive: 60% of adults in the US have one chronic illness, and 40% have 2 or more. In 2022, approximately 1.9 million people died of chronic disease, accounting for 58% of all US deaths.?

?Medical care and drug therapies are simply not enough to turn these grim numbers around because non-medical factors such as socioeconomic status, historical exclusion, lifestyle, and access to care play such an important role in chronic disease onset, progression, and outcomes–and potentially most importantly, the structures of the US food system continue to prioritize and incentivize highly-processed, nutrient-deficient foods. While health plans and health systems increasingly focus on social barriers to health as part of their chronic disease care management programs, the powerful impact of nutrition on chronic illness – and the difficulties that millions of Americans face in accessing quality food – is still not fully appreciated.?

?Finding ways to meet that nutrition deficit will be critical if we are going to improve health and reduce care costs related to chronic disease sustainably, effectively, and at scale. That starts by examining why access to nutrition is difficult both at a national level and in specific communities across the country.

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The Powerful Impact of Nutrition?

?8 of the 10 leading causes of death in the US are from some form of chronic disease. Poor diet is one of the top factors contributing to disability-adjusted-life years due to chronic illnesses such as diabetes, kidney disease, obesity, and cardiovascular disease. The impact is enormous. 37 million people in the US have type 2 diabetes, or 11.3% of the population, with direct medical costs of $307 billion. 97.6 million adults are pre-diabetic, or 38% of the population. Around 41.9% of US adults are obese, with estimated care costs of $170 billion.?

?A healthy diet is made up of fruits and vegetables, whole grains, lean proteins, healthy fats, limited processed foods, and good hydration. When combined with moderate and regular intake, consistent exercise, and high-quality sleep, a healthy diet significantly delays or prevents chronic illness. For people already chronically ill, a healthy diet has also been shown to slow and even reverse the progression of their disease. For example, studies show that an improved diet can reduce the risk of diabetes by 71% .

?An unhealthy diet consists of high intakes of saturated and trans fats, salt, sugar, refined carbohydrates, high-calorie beverages, excessive alcohol, and high-processed foods. The highly addictive nature of such foods actually encourages larger portion sizes and overeating.?

?America’s growing chronic illness crisis correlates strongly with the rise of ultra-processed foods. Defined as “ready-to-eat/heat industrial formulations made mostly or entirely from substances derived from foods, including flavors, colors, texturizers, and other additives, with little if any intact whole food” ultra-processed foods are low in nutrition but dense in energy. Over time, they have a devastating impact on health.?

?According to a Washington Post examination, ultra-processed foods correspond to a 40 to 66% higher risk of death due to heart disease, Type 2 diabetes, and sleep problems, as well as a 22% higher risk of depression. Children are inundated with ultra-processed foods, which make up a larger portion of their diet than fruits or vegetables by the age of 2. Childhood obesity is on the rise, as a result, leading to adult chronic diseases like fatty liver, hypertension, and diabetes. Needless to say, this leads to long-term health problems that will further exacerbate America’s chronic illness challenge.?

?Simply switching to healthier food is not an option for many people, however, because their access to quality nutrition is so limited. 54 million in America are food insecure and 23.5 million live in food deserts which lack quality grocery stores or produce markets. Increasingly, food deserts are being described as food swamps because these areas are actually inundated with fast-food restaurants, convenience stores, and gas stations where ultra-processed food is readily available and relatively inexpensive.?

?As a country, how did we find ourselves in this situation? Undoubtedly, market forces and food system dynamics lead to high-quality and expensive grocery stores being located in wealthier neighborhoods and inexpensive convenience stores and fast-food restaurants in poorer communities. Income inequality contributes to poor health, as families turn to higher-calorie, lower-quality food just to get by.?

?American agriculture practices and policies exacerbate this problem. The Farm Bill, first enacted in 1933 and reenacted approximately every five years since, is meant to support farmers and food insecure people. However, more than half of the subsidies meant for farmers go to producers of corn, rice, soybean, and wheat that are the basis of livestock feed, ethanol for fuel, and ingredients used for ultra-processed and fast food.?

“Specialty crops”–i.e. the whole foods that people can eat, like fruits and vegetables and nuts–receive only 10% of the subsidies of the Farm Bill. Large farms which can efficiently focus on monoculture produce like corn and soybeans benefit most from Farm Bill subsidies . Not surprisingly, smaller family-owned farms have been increasingly consolidated by the largest farms–leading to the loss of over 140,000 farms between 2017 to 2022.?

?In other words, taxpayers pay to grow the food that causes diabetes, kidney disease, cancer, heart disease, and other chronic conditions–which we then pay our healthcare system enormous expenditures to treat.

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Targeting Answers

A number of government programs seek to alleviate the socio-economic challenges of food access.?

?Roughly 75% of the Farm Bill’s funds are devoted to nutrition, and 95% of that goes to the Supplemental Nutrition Assistance Program (SNAP). SNAP provides monthly financial support to low-income people, usually at or below 130% of the Federal Poverty Level, so they can buy food. In 2023, 41.9 million people (12.5% of the total population) received SNAP benefits. In 2020, 63% of recipients were adults and 36% were children. The amount of the benefit varies across states but is designed to enable people to buy groceries that are part of a “nutritious, practical, cost-effective diet.”

WIC, or the Special Supplemental Nutrition Program for Women, Infants, and Children, supports low-income pregnant or postpartum women and pre-school-age children who are not yet eligible for school breakfast and lunch programs. Funded by the US Department of Agriculture, the WIC program reaches about 6.4 million people monthly. Though similar to SNAP, WIC was designed to focus even more directly on nutrition and health with food packages that contain healthy, nutritious foods; benefits that can only be used to purchase nutritious food at designated stores or outlets; nutrition education to help instill lifelong habits; and clinics that screen for other health and social care needs.?

?SNAP often comes under criticism for alternately costing too much or doing too little. One common critique is that SNAP recipients can spend food supplement resources on unhealthy processed food such as sweetened beverages, desserts, salty snacks, and sugary items. However, SNAP and non-SNAP recipients alike spend 20% of their food money on unhealthy food–likely because their options are limited.

?Despite real or perceived limitations of these programs, SNAP has moved the needle on food insecurity and overall healthcare costs . Yet, SNAP and WIC have proven insufficient on their own in meeting nutrition access needs across the country, and do not support anyone just above the poverty line. That’s where food-as-medicine programs have tried to help fill the gap. Targeted nutrition programs have proven to be effective in improving health, limiting or reversing the progression of disease, and reducing healthcare costs – including a projected $40 billion in annual medical spending for people with diabetes – while also reducing healthcare utilization dramatically.?

?Such programs will need to be part of the overall solution.

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Connecting the Dots

?If we’re going to fundamentally transform America’s chronic illness crisis, food will be a major part of the answer. The challenge that remains, however, is reaching people in need with the right programs through the right partners, including local food producers. Food on its own is not enough. That food must also be healthy, appealing and culturally relevant, and the program that delivers it must also include support, education, and motivation to help recipients develop healthy habits around buying, preparing and eating food on their own. In this way, they can sustain those benefits and extend them to others for years to come.?

?At NourishedRx , we’re learning more with each program we implement across the country, and the impact of those programs has been profound. As we’ll discuss in the next article, food access, culture, and infrastructure is different in almost every region, state, and community across the country. Meeting needs effectively requires expertise in designing impactful nutrition programs, systematic understanding of unique local circumstances, trusted collaboration and coordination among local agencies, providers, community-based organizations, health plans, and healthcare providers–as well as a fundamental rethinking of how and where we source locally-produced, seasonally available food.

Given the alarming trends in chronic disease, this is not only a challenge we must learn to face, but a transformation we must find ways to make happen.

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