Reimagining U S Food and Nutrition Policy Dariush

Reimagining U. S. Food and Nutrition Policy Dariush Mozaffarian, MD, Dr. PH Dean Jean Mayer Professor of Nutrition & Medicine The Harkin Institute for Public Policy & Citizen Engagement, Drake University March 8, 2021

The Harkin Institute for Public Policy & Citizen Engagement “To inform citizens, inspire creative cooperation, and catalyze change on issues of social justice, fairness, and opportunity. ” Senator Tom Harkin

1969 White House Conference on Food, Nutrition, and Health • Expansion of Food Stamps • Expansion of School Lunch • Creation of School Breakfast • Creation of WIC • Creation of Nutrition Facts Senators George Mc. Govern and Bob Dole https: //sites. tufts. edu/foodnutritionandhealth 2019/

Food & Nutrition Crisis Health and wellbeing Hunger, disparities Health care costs and access Government budgets Private business, economic growth Sustainability and climate change National security

Our Food: The #1 Cause of Poor Health US Burden of Disease Collaborators, JAMA 2018

Diet-Related Disease in the U. S. • More Americans are sick than are healthy • Half of adults have diabetes or prediabetes. • More than half have cardiovascular disease, causing 841, 000 deaths each year – 2, 300 deaths each day. • 3 in 4 adults are overweight or obese. • Only 12% of adults are metabolically healthy. • Tremendous economic costs • Healthcare costs have skyrocketed from : • 5% to 28% of federal and 29% of state budgets • $79 billion to $1, 180 billion for US businesses • >11, 000/year per man, woman, and child in the US Centers for Medicare & Medicaid Services, 2018 American Heart Association, Heart Disease and Stroke Statistics, 2018 The Milken Institute, America’s Obesity Crisis, 2018

Major Dietary Disparities Percent of U. S. adults with poor diet quality, by income 80 Percentage of U. S. adults with a poor quality diet (AHA diet score) 70 60. 6% 60 50 40 35. 7% 30 20 10 0 2003 -04 2005 -06 2007 -08 Rehm et al. , JAMA 2016 2009 -10 2011 -12 Ratio of family income to poverty level <1. 30 -1. 84 1. 85 -2. 99 ≥ 3. 00

Major Dietary Disparities Percentage of U. S. children with poor diet quality, 2015 -16 60 56, 8 56, 2 54, 2 55 49, 1 49, 8 50 52, 6 49, 6 47, 2 45 43, 9 42, 3 40 35 Race/Ethnicty Poverty. Income Ratio ar gi na Se l cu re w Lo M Ve ry lo w 0 ≥ 3. 0 . 9 9 52 1. 8 01 . 8 4 . 3 0 1. 3 <1 hi te W ni c H is pa ac k 30 Bl Percent 55, 6 Household Food Security Liu et al. , JAMA 2020

Major Diet-Related Health Disparities Conrad et al. , AJPH 2017

Food & Nutrition: Public Confusion Source: Google images

www. strongnation. org/missionreadiness

COVID-19: A Fast Pandemic on a Slow Pandemic Diet-related diseases with endothelial dysfunction and systemic inflammation linked to far worse outcomes from COVID-19: → diabetes, obesity, hypertension Teuwen et al. , 2020 Nat Rev Immun Ackermann et al. , 2020 NEJM

Excess COVID-19 Hospitalizations from Diet-Related Diseases Nearly 600, 000 excess COVID-19 hospitalizations in 2020 Values do not sum due to proportional risks. O’Hearn JAHA 2021

Dietary Priorities: A Time for Foods Benefit Protective Foods Fruits, Nuts, Fish Vegetables, Plant Oils Whole Grains, Beans, Yogurt Emerging Science: Gut Microbiome Personalized Nutrition Phenolics/Flavonols Eat in Moderation Avoid Cheese Poultry, Milk Eggs, Butter Food Processing Unprocessed Red Meats Brain Health Additives Timing of Meals Immunity Refined Grains, Starches, Sugars Processed Meats, High Sodium Foods Industrial Trans Fat Harm Allergies Cancer Mozaffarian D, Circulation 2016

“Best Buy” Policy and Systems Innovations Science & Innovation • National Institute of Nutrition (NIN) • Public-private partnerships • Fundamental discovery • Big data, technology Economic Incentives Healthcare • Medically tailored meals • Produce Prescriptions • Nutrition education for providers • Nutrition in the EHR • Billing & quality metrics • Govt feeding programs (SNAP, WIC) • Tax policy for food/nutrition innovation • ESG metrics, investor vehicles • B Corps • Taxes on SSBs, sugar, salt Schools Worksite Wellness Standards and Labeling • School meal standards • Procurement standards • Competitive food standards • Behavioral economics • Breakfast in the classroom, summer meals • Technology wellness platforms • Fresh F&V programs • Wellness incentives for • Qualified healthy food health claims • School gardens • Retail incentives www. food-price. org, Mozaffarian et al. BMJ 2018 • Additives (trans fat, salt, sugar) • FOP, menu, and warning labels • Marketing to children

Food is Medicine Produce Prescription Programs https: //foodismedicinema. org

Food is Medicine: Medically Tailored Meals (MTMs) • Providing home MTMs to chronically ill, food insecure patients reduces hospitalizations, ER visits, nursing home admits, and costs. • Using the 2011 -2015 Massachusetts All Payers Database, MTMs: • Hospital admissions: ↓ by 49% • Nursing home admits: ↓ by 72% • Net savings: $9, 036/year per patient • Number needed to treat (NNT): • 2. 0 per saved hospital admission • 1. 1 per saved nursing home admit http: //www. fimcoalition. org, Berkowitz et al. , JAMA Int Med 2019 Mozaffarian et al, JAMA Int Med 2019

Food is Medicine: Produce Prescriptions 26 Produce Rx Programs • Most targeted specific diseases (e. g. , diabetes) • 10 of 26 focused on low-income or food insecure patients • Nearly all were quasi-experimental (pre/post) F&V Provision • Vouchers, subsidized food boxes, cash-back rebate • Only 3 increased incentives for the whole household • Most brief (4 -16 weeks), a few longer (6 -12 months) Outcomes • 21 of 22 found ↑ F&V intake and/or diet quality • 3 of 4 found ↓ Hb. A 1 c • 2 of 5 found ↓ weight of BMI Veldheer et al. , J Nutr 2020 Hager et al. , J Nutr 2020

Produce Rx in Medicare/Medicaid: Cost-Effectiveness 175 000 Overall Medicare Medicaid Dual-eligible 150 000 Cost-Effective : <$150, 000/QALY 125 000 ICER ($/QALY) 100 000 75 000 50 000 37, 000 25 000 Highly Cost-Effective: <$50, 000/QALY Statins Primary Prevention (Pandya et al, JAMA 2015) 0 5 yrs 10 yrs 20 yrs Duration of Incentive Program Lee et al, Plos Med 2019 www. food-price. org Lifetime

Food is Medicine: Medical Education Key recommended actions: 1. Update LCME and ACGME accreditation standards to require nutrition education 2. Tie federal funding for medical schools to nutrition education 3. Incorporate nutrition into USMLE, Board, and CME exams 4. Provide technical assistance and resources to support nutritioncurricula development www. chlpi. org/wp-content/uploads/2013/12/Doctoring-Our-Diet_-September-2019 -V 2. pdf

Food is Medicine: Rapidly Accelerating Actions • 2016 John Hancock: Vitality, first life insurance program to reward clients for buying healthy food, up to $600/year + premium discounts • 2018 U. S. Farm Bill: $25 million to test Produce Rx in healthcare • 2018 State of California: $6 million to test Medically Tailored Meals (MTMs) in Medicaid • 2019 Kaiser Permanente: Food for Life, major new focus on nutrition security including SNAP (Cal. Fresh), MTMs, community interventions • 2020 Massachusetts: $150 million for ACO Flexible Services on food and housing; new bill Food and Health Pilot Program (H. 4278, S. 2453) • 2020 U. S. House: New bill Medically Tailored Home-Delivered Meals Demonstration Pilot Act (H. R. 6774)

Nutrition Security “Our nation suffers from nutrition insecurity. We must do more to ensure access to the nutritious foods that can protect and promote health. ” - Secretary Vilsack, Senate Confirmation Hearing, Feb 3, 2021 • The phrase “food insecurity” has helped address problems of food access and affordability over the last 25 years. • But, food quality – nutrition – has been underemphasized, with rising disparities in diet-related diseases. • A national shift to a broader, more holistic focus on “nutrition insecurity” is the next natural evolution to help us promote equitable well-being for all Americans. Mozaffarian, Fleischhacker, Andres, JAMA in press

Nutrition Security: Leveraging SNAP F&V Incentive (30% subsidy) + SSB Restriction Prevent 300, 000 lifetime CVD events Prevent 800, 000 lifetime CVD events Prevent 940, 000 lifetime CVD events Cost-effective: Cost-savings: $550 k/QALY at 5 yrs $158 k/QALY at 5 yrs $10 B at 5 yrs $66 k/QALY lifetime $5 k/QALY lifetime $63 B lifetime (QALY = quality-adjusted life year) Liu et al, Plos Medicine 2018 www. food-price. org SNAP Plus Healthy foods (30% subsidy) Unhealthy foods (30% disincentive)

Nutrition Research & Innovation: Opportunities sites. tufts. edu/nutritionadvisory, Fleischhacker et al. AJCN 2020

Federal Nutrition Research: Investments are Flat NIH sites. tufts. edu/nutritionadvisory, Fleischhacker et al. AJCN 2020 USDA

Current Federal Nutrition Research Landscape

Calls for Greater Nutrition Research Coordination 1978 Congressional report, Nutrition Research Alternatives Congress chartered the Joint Subcommittee on Human Nutrition Research (JSHNR) 2016 1983 -1993 JSHNR completed report leading to Interagency Committee on Human Nutrition Research (ICHNR) White House Conference on Food, Nutrition, and Health 1970 Congress created the USDA Office of the Chief Scientist 1990 Congress’ National Nutrition Monitoring and Related Research Act 1982 Government Accountability Office report 1969 2008 1980 JSHNR report 2019 2013 -2020 Interagency Committee on Human Nutrition Research Requires DGAs to be reviewed by USDA and HHS 1985 Congress’ Food Security Act 1980 Food and Nutrition Regulatory Policies GAO report on nutrition education 2016 1991 -2002 National Nutrition Research Road Map 2016 -2021 New Interagency Board for Nutrition Monitoring and Related Research 1990 Congress instructed NASEM to review and recommend updates to DGAs process 2000 Nutrition Education and Promotion sites. tufts. edu/nutritionadvisory, Fleischhacker et al. AJCN 2020 2010 2020 National Nutrition Research Databases

Strengthening National Nutrition Research & Policy Sheila Fleischhacker, Cathie Woteki, Paul Coates, Van Hubbard, Grace Flaherty, Dan Glickman, Tom Harkin, David Kessler, William Li, Joe Loscalzo, Anand Parekh, Sylvia Rowe, Patrick Stover, Angie Tagtow, Joon Yun, Dariush Mozaffarian Fleischhacker et al. AJCN 2020 sites. tufts. edu/nutritionadvisory

sites. tufts. edu/nutritionadvisory, Fleischhacker et al. AJCN 2020

Greater Nutrition Research: Return on Investment • Each $1 in NIH funding: $1. 70 - $3. 20 economic return • Better leverage large federal investments in food and nutritionrelated programs, e. g. at USDA (~$100 B/year), USAID (~$27 B/year), Do. D, VA, FDA, CDC, CMS, FEMA, and more • Reduce diet-related diseases and health disparities • Reduce $$ Billions in spiraling healthcare costs • Catalyze and unlock economic growth, including new PPPs, private capital investment, small business creation, job creation • Advance economic vibrancy of US farmers and rural communities • Improve national resilience against acute threats (e. g. COVID-19) sites. tufts. edu/nutritionadvisory, Fleischhacker et al. AJCN 2020

Growing Coalition of Businesses and Advocacy Groups in Support Academy of Nutrition and Dietetics Acasti Pharma American Academy of Pediatrics American Cancer Society Cancer Action Network American College of Lifestyle Medicine American Diabetes Association American Public Health Association American Society for Nutrition American Society for Parenteral and Enteral Nutrition Angiogenesis Foundation Association of Public and Land-Grant Universities Association of State Public Health Nutritionists Azuluna Brightseed Center for Health Law and Policy Innovation, Harvard Law School Center for Science in the Public Interest Community Servings Day. Two Defeat Malnutrition Today The dia. Tribe Foundation 84. 51° Health Elysium Health End Allergies Together Feed the Truth Filtricine FARE (Food Allergy Research and Education) Food & Nutrition Innovation Institute, Tufts U. Food is Medicine Coalition Food Law and Policy Clinic, Harvard Law School Food Tank Food team @ Google General Mills Inc. Gods’ Love We Deliver The Good Food Institute Good Measures The Greater Boston Food Bank Gretchen Swanson Center for Nutrition The Harkin Institute for Public Policy & Citizen Engagement, Drake U. Healthy Food America Human. Co Hunger Free America Institute of Food Technologists January, Inc. John Hancock Juice Press KIND Snacks Kroger Laurie M. Tisch Center for Food, Education & Policy, Columbia U. Manna Tree Partners Mc. Cormick Science Institute The Milken Institute Mission: Readiness National Association for the Advancement of Colored People National Association of Nutrition and Aging Services Programs National WIC Association Novo Nordisk Nutrition & Obesity Interest Group, National Academy of Medicine The Obesity Society Ocean Spray Oldways Partnership for a Healthier America sites. tufts. edu/nutritionadvisory/white-paper-signatories Pepsi. Co Power. Plant Ventures Produce for Better Health Foundation Resnick Center for Food Law and Policy, UCLA School of Law Rhode Island Community Food Bank The Rockefeller Foundation The Rudd Center for Food Policy & Obesity, U. Connecticut Sage Mountain Farm Season Share Our Strength Society for Nutrition Education and Behavior Tangelo Teens for Food Justice 1, 000 Days Trust for America’s Health 2 RHealth Union of Concerned Scientists United Fresh Produce Association Urban School Food Alliance The Well Wholesome Wave World Central Kitchen World Food Policy Center, Duke U.

Business Innovation & Disruption >60% decline in stock, $15 B write-off Kraft-Heinz / 3 G Beyond Meat Vital Farms Market cap: $8. 5 billion Market cap: $1. 6 billion

Financial Rewards for Nutrition, Equity, Sustainability • Market expansion: New efforts for greater public knowledge and understanding of the benefits and value of healthier foods. • Tax policy: Tax strategies and other economic incentives across sectors (agriculture, retail, manufacturing, restaurant, healthcare, wellness) for R&D, marketing, and sales of healthier, more accessible foods. • Healthcare, life insurance, nutrition assistance: Leveage healthcare, insurance, food assistance dollars to support effective nutrition products and interventions. • ESG, mission-driven investment: Encourage and convene investment standards and vehicles for food-related companies centered on health and equity. • Catalyze entrepreneurship: Develop and support a national strategy to build an ecosystem of evidence-driven innovation for a healthier food system. • B-corporations: Encourage and highlight B corporation status across sectors to recognize and reward integration of social and environmental priorities. • Opportunity zones: Expand encourage opportunity zone incentives for food, nutrition, and wellness investments to improve equity and reduce disparities.

TUFTS FOOD & NUTRITION INNOVATION INSTITUTE A HEALTHIER, MORE EQUITABLE, MORE SUSTAINABLE FOOD SYSTEM: TRUE PROFITS FOR ALL Discover Incubate Connect Inform Advance Build innovation. nutrition. tufts. edu

A Reimagined Food System • A new national consensus and strategy on food and nutrition • A reinvigorated national health and science infrastructure • Food as Medicine for better health and lower healthcare spending • Nutrition security for the COVID-19 recovery and beyond • Sustainable nutrition, jobs, and climate • Business innovation and jobs that increase consumer choice, nutrition, equity, and sustainability