As National Public Health Week winds down, I’m left thinking about what it really means to prevent disease and promote good health. And whether our food system, and the public policies in place to guide it, are set up to do that. (Spoiler alert: They’re not.)
I’m a long-time member of the American Public Health Association (which sponsors NPHW), and a strong believer in prevention. I practice it personally: I don’t smoke; I do use seat belts, sunscreen, and my cough pocket; and I carry hand sanitizer with me everywhere I go (but especially on subways…eww).
Extending that kind of preventive action to whole communities and nations is what public health is all about. With organized efforts to educate the public, incentivize healthy behaviors, and discourage unhealthy ones, we can nip many risks in the bud, avoid unnecessary disease and injuries, and promote health and wellness for all. That’s good for people, of course, and it makes economic sense, too. As the old saying goes, an ounce of prevention is worth a pound of cure.
Unfortunately, we’re doing a lousy job of that in our food system today.
The US Department of Agriculture spends about $9 billion annually subsidizing crop insurance programs, mostly for corn, soybeans, and other processed food ingredients. Anyone with eyes can see the result—an overwhelming abundance of easily accessible, artificially cheap junk food, everywhere.
Our national obesity crisis and skyrocketing rates of diet-related diseases such as type 2 diabetes are the further result of all those in-your-face empty calories. According to recent estimates from the US Centers for Disease Control, nearly 30 million Americans suffer from diabetes, and the disease costs our country $245 billion annually. (A new report out from the World Health Organization today revealed that diabetes rates are up globally as well, nearly doubling since 1980.)
Prevention: at the source, or downstream?
The New York Times reported a couple of weeks ago about a new proposal announced by the US Department of Health and Human Services (HHS). The proposal would expand Medicare to pay for pre-diabetic patients to complete a program of diet and exercise counseling.
This is good. The patients it would help have a condition called pre-diabetes, which means they already have high blood sugar, just not high enough to be full-on type 2 diabetes. Without intervention, they are at risk of becoming diabetic within 10 years. Preventing that outcome is important for these patients, their families, and the health care system, for sure. A federally funded eight-state study of Medicare patients enrolled in programs such as those HHS now proposes to cover found that taxpayers saved more than enough per patient over 15 months to cover the costs.
Still, an initiative like this is what the public health community calls “secondary” prevention. And once people are already diabetic, any interventions are “tertiary,” helping them manage this complicated health condition. Both are important, and can prevent or blunt some of the worst consequences of a disease like diabetes. But what if, as a nation, we set our aim a little higher on the prevention scale?
What would primary prevention look like in the food system?
Primary prevention means addressing the root causes of disease—in the case of obesity and type 2 diabetes, our unhealthy national diet heavy in processed foods. But that doesn’t happen today, because our system of food policy isn’t about health, it’s about money. So subsidies for junk food ingredients continue, in one form or another, despite widespread opposition. Efforts to help Americans eat more healthfully are mostly small-scale or, in the case of the HHS initiative described above, too far downstream. Even improving national dietary recommendations to help educate Americans about healthier choices is an uphill climb; when federal agencies had the chance to do so recently, they largely punted.
And it seems to be the case that this country isn’t very good at prevention in the health arena generally. According to the Robert Wood Johnson Foundation, for every dollar we spend on health care, only about four cents goes towards public health and prevention. A 2015 report by the Commonwealth Fund examined healthcare spending and health outcomes in the United States and 12 other wealthy countries, and the results weren’t pretty: we spend a lot more, and yet are less healthy.
We can do much better, and I’d argue that a comprehensive national food policy that aligns our current food and health systems is an obvious place to start. Rather than spending billions to subsidize junk food ingredients, and then spending billions more to address the health outcomes of our national diet, we could get serious about prevention, and overhaul food and health policies around that notion.
As in, increased incentives for farmers to grow fruits and vegetables. Greatly expanded initiatives to make fresh produce available and affordable in low-income neighborhoods. More robust investment to ensure that every kid in America gets healthy school meals and nutrition education at an early age. And so on.
That is what prevention would look like.
CORRECTION: This post originally stated that global diabetes rates had quadrupled globally since 1980. The global prevalence of diabetes has quadrupled, but the rate (percentage of population) has only nearly doubled.