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Viewpoint
June 28, 2018

Potential Policy Approaches to Address Diet-Related Diseases

Author Affiliations
  • 1Center for Science in the Public Interest, Washington, DC
  • 2Healthy Food America, Seattle, Washington
  • 3Sanford School of Public Policy at Duke University, Durham, North Carolina
JAMA. Published online June 28, 2018. doi:10.1001/jama.2018.7434

The Centers for Disease Control and Prevention (CDC) recently published 2 reports that should inspire vigorous action to improve the diets of individuals in the United States. One report found that in 2015-2016 the prevalence of obesity (BMI ≥30) in adults (39.6%) increased to new highs, and obesity levels remained disturbingly high among youth (18.5%).1 By comparison, in 1976-1980, only 15.0% of adults and 5.5% of youth were obese. Each uptick in the prevalence of obesity increases the risks of hypertension, stroke, myocardial infarction, certain cancers, and, especially, type 2 diabetes. High BMI is responsible for an estimated 386 000 excess deaths per year.2

A second report, based on 24-hour urinary excretion samples from 827 individuals, found that mean sodium consumption was approximately 4000 mg/d, or more than 1.5 times the recommended daily limit of 2300 mg.3 High sodium intake increases the risk of hypertension and, thus, myocardial infarction and stroke. Excess sodium intake may cause as many as 92 000 deaths annually.4

According to a report from the US Burden of Disease Collaborators, dietary factors were associated with 529 299 deaths in 2016 in the United States, making them the leading risk factor for mortality.2 Social inequities in dietary patterns are increasing. It may be expected that such findings would prompt concern among policy makers, but neither Congress nor the executive branch has proposed a comprehensive plan to improve the US diet.

It is time to reinvigorate the discussion about preventing diet-related diseases. While more research on effective interventions is needed, this Viewpoint presents a 7-pronged policy-oriented proposal intended to promote a healthier food supply and improve diet quality to prevent disease.

Tax Sugar-Sweetened Beverages

Because sugar-sweetened beverages promote weight gain and are associated with type 2 diabetes, cardiovascular disease, and poor oral health, some health advocates encourage taxation of these products to lower consumption, raise revenues to prevent these conditions, reduce sugar content, and decrease health inequities. Such taxes have been passed in more than 25 countries including the United Kingdom, Chile, India, and South Africa, and in 7 US cities including Philadelphia, Seattle, and San Francisco. Mexico’s tax on sugar-sweetened beverages levied in 2014 was associated with a 9.7% reduction in consumption of these products in 2015, with steeper declines in lower-income households.5 A tax in Berkeley, California, was associated with decreased sales of sugar-sweetened beverages and increased water sales. The UK tax, scaled to the sugar content of beverages, prompted some companies to preemptively reduce sugar levels in beverages even before the April 2018 implementation date.

Local and state jurisdictions should continue efforts to tax distributors of sugar-sweetened beverages. Industry efforts to preempt local taxes should be opposed. Congress should consider levying on manufacturers a tax based on the sugar content of sugar-sweetened beverages. A national sugar-based tax could prevent consumers from evading local taxes by shopping in nearby jurisdictions.

Another option would be for the US Food and Drug Administration (FDA) to recognize that current consumption of added sugars in sugar-sweetened beverages is not “generally recognized as safe” (a legal category) and limit the amounts of sugar in full-sugar drinks to a quarter of current levels.

Reduce Sodium Levels in Processed Foods

High-sodium diets are a global problem. South Africa, Argentina, and several other nations have limited the sodium content of key foods.6 The United Kingdom and Canada have adopted voluntary sodium-reduction targets for dozens of categories of foods. FDA Commissioner Scott Gottlieb has stated that “There remains no single more effective public health action related to nutrition than the reduction of sodium in the diet.”7 In 2016, FDA proposed voluntary targets for sodium levels in approximately 150 food categories, which are expected to be finalized in 2019. However, judging from the experiences in the United Kingdom and Canada, for sodium targets to be effective, they must be supplemented by robust efforts by government authorities (such as FDA) to press companies to reach the targets. If sodium levels remained excessive, voluntary targets could be replaced by mandatory limits. In addition, the US Department of Agriculture should not further delay reductions of sodium in school lunches, which are both achievable and essential to the health of millions of schoolchildren.

Require Effective Front-of-Package Nutrition Labels

Nutrition Facts labels present valuable information but have not improved the nutritional quality of foods or diets adequately (except for accelerating reductions in partially hydrogenated oil and trans fat). An additional simpler label could provide information that is more easily understood. Chile has adopted front-of-package labels that display black stop sign–shaped symbols to highlight excessive levels of calories, saturated fat, sodium, and sugar. Those labels led manufacturers to reformulate 25% of foods to avoid “high in” labels.8 Israel, Canada, and other countries are planning similar labeling. The United States could require such labels, which may be especially helpful to consumers who have difficulty interpreting number-heavy Nutrition Facts labels.

Eliminate Marketing of Unhealthy Food to Children

Virtually all food advertising aimed at children promotes processed and restaurant foods with higher-than-recommended levels of calories, sodium, added sugars, or saturated fat. Fruits, vegetables, and other healthful foods are rarely advertised. Food advertising directed to children is still mostly on television, but increasingly industry is using digital media to reach children.

Several countries have acted to protect children from food advertising (which may be inherently deceptive, because children do not understand the intent of advertising and the consequences of eating unhealthy foods). Chile, for instance, does not permit foods bearing one or more black labels to be advertised to children. Sweden and Quebec have long banned all advertising directed to children. Congress should consider restricting the marketing of unhealthy foods to children. In the meantime, companies could strengthen their nutrition standards for food marketing to children and apply them to all their marketing to children 14 years and younger.

Increase Subsidies to Low-Income People for the Purchase of Healthy Foods

Consumption of fruits and vegetables is well below recommended levels, especially among low-income individuals, in part because of cost. A US Department of Agriculture study found that a 30% subsidy for recipients of the Supplemental Nutrition Assistance Program boosted produce purchases by 26%.9 A systematic review of 30 food pricing intervention studies concluded that such interventions increase the sales and consumption of healthy foods.10 Funds for healthy food subsidies could be provided by taxes on sugar-sweetened beverages.

Improve Restaurant Meals

The US population gets one-third of its calories from food consumed outside the home. Many individual restaurant meals provide more than a full day’s worth of calories, sodium, added sugars, or saturated fat. New York City and Philadelphia require chain restaurants to add warnings in the form of saltshaker icons on menus for items that provide 2300 mg or more of sodium (the recommended daily limit) in addition to a previous requirement to list calorie information (a national requirement took effect in May 2018). That measure, possibly expanded to include icons for calories, sugar, or saturated fat, could be replicated elsewhere and then nationally. Additionally, local governments should consider setting nutrition standards for restaurant meals that are heavily marketed to children. These standards could include removal of sugar-sweetened beverages as default beverages—as several major chains and about a dozen US cities have done—and include more fruits, vegetables, and whole grains.

Mount Campaigns to Promote Healthier Diets

Robust campaigns using the mass media, internet, youth engagement, and other approaches to help counter the aggressive marketing of unhealthy foods could be an effective adjunct to policies. Counteradvertising has reduced tobacco use and sugar-sweetened beverage consumption and could also motivate people to eat more produce and other healthful foods, read labels carefully, and cook more meals at home. Campaigns could be funded by the proposed tax on sugar-sweetened beverages.

Conclusions

The food industry and legislators who prefer less regulation will likely oppose these proposals, so health-minded advocates and legislators will need to advocate vigorously for robust measures that support healthier diets. Although evidence regarding the effects of these proposed approaches on health outcomes is not yet available, emerging data show improvements in diet quality for some of these strategies. Given the substantial effects that diet has on chronic diseases, an ambitious, multipronged effort to reshape the food environment so that healthy foods are readily accessible and exposure to unhealthy foods is limited is worthy of much greater public investment and advocacy.

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Article Information

Corresponding Author: James Krieger, MD, MPH, Healthy Food America, PO Box 22260, Seattle, WA 98122 (jkrieger@hfamerica.org).

Published Online: June 28, 2018. doi:10.1001/jama.2018.7434

Correction: This article was corrected on July 9, 2018, to provide the correct email address for the corresponding author.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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