Cost Effectiveness of Health

Paul Keckley: Improving nutrition in the U.S. starts with addressing the elephants in the room

February 25, 2022 9:15 pm
Paul Keckley

Good nutrition is essential to healthiness. Most Americans, policymakers and health providers accept that premise. But improvements have been slow in coming.

Good nutrition remains elusive for many Americans because they face obstacles in being able to make healthy choices. These “elephants in the room” can only be addressed by policymakers, with the engagement of healthcare and other sectors of society.

Only baby steps, so far

Poor eating habits and lack of access to healthy foods are recognizable health problems, but improvements have been elusive. For example, in the Healthy People 2020 Progress Table released last year, improvement in nutrition and weight status from 2010 to 2020 was negligible. Of the 43 initiatives targeted for improvement, nutritional improvement was in the bottom five, only one of the 31 milestones for nutrition and weight status had been met, and on 21 other measures, there was no improvement at all.

The problems of poor health habits, obesity and food insecurity are not secrets. Local and state officials routinely adjust funding, targeting food sufficiency in state and local public health departments.

Federal officials have adjusted funds for notable programs like the Supplemental Nutrition Assistance Program (SNAP), school meals, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as circumstances allow. During the pandemic, Congress authorized funding to help low-income families put food on their tables vis-a-vis the Families First Coronavirus Response Act and American Rescue Plan. And the Biden Administration is now seeking approval of solutions like the Community Eligibility Provision (CEP) and Summer Electronic Benefit Transfer (Summer EBT) that expand eligibility for school meal programs and others. But these are temporary.

Time to shoot for the moon

President Biden relaunched the Obama-era Cancer Moonshot in February. What’s needed is aHealthy-Eating Moonshot.” It’s of equivalent significance to the health status of our population.

Such an initiative will require harvesting science-based solutions for a healthier food supply chain and updating dietary guidelines to address obstacles of consumer access and affordability. But if long-term results are to be achieved, policymakers must address four huge elephants in the room that stand in the way.

1 The need to directly engage food manufacturers. Although more than half of our national land mass and four-fifths of our territorial waters are devoted to food production, policymaking about food insecurity and nutrition has been ineffective. The food manufacturing industry (NAICS 311) includes hundreds of private companies that employ roughly 1.6 million people and control the U.S. food supply. The industry is politically influential and powerful, seeking to protect its business practices to enhance the interests of its shareholders. Often, and increasingly, the nutritional value of their products and the safety of their manufacturing processes is subject to regulator scrutiny and consumer concern. Efforts by the U.S. Department of Health and Human Services and state and local public health agencies have tended to overlook this industry.

2 The need for greater health literacy among Americans. Polls show the majority of Americans understand the correlation between what they eat and potential problems resulting from poor eating habits, but they source what they know from TV ads and social media, not health professionals. Terms like gluten-free, fat-free, natural, organic and others are not readily understood, contributing to poor health habits.

3 The need to better educate physicians on nutrition. Physicians acknowledge the importance of nutrition in patient care, but six of seven confess to inadequate professional training about nutrition science, and all say they rarely have time to discuss eating habits with their patients.a The National Academy of Sciences recommends a minimum of 25-30 classroom hours dedicated to nutrition, yet only 40% of medical schools meet that goal. A 2010 study of 127 accredited U.S. medical schools found that most of the 109 responding schools (94%) required “some form of nutrition education,” with only 25% of 105 respondents answering questions about courses actually requiring a dedicated nutrition course.b As a result, physicians default to their personal preferences and anecdotal insights and depend on registered dieticians when necessary.

4 The need for nutrition-related insurance coverage. With the exception of Medicare Advantage (MA) plans that offer meals and nutritional support as supplemental benefits (2019 CMS Implementing Supplemental Benefits for Chronically Ill Enrollees), health insurance coverage and employer benefits play a negligible role in advancing nutritional sufficiency and personal health habits. Notably, among all supplemental benefits offered by MA plans, food, produce and meal services are the most valued by enrollees. But insurers have, by and large, not been proactive in advancing nutrition despite research having shown a strong correlation to avoidable health costs.

To address nutrition, the national agenda must extend beyond supplemental coverage by MA plans and attention to food insecurity in at-risk households.

The time for addressing the elephants in the room is now

As early as 1903, Thomas Edison predicted, “The doctor of the future will give no medicine but will instruct his patient in the care of the human frame, in diet, and in the cause and prevention of disease.”

The clock is ticking, and the economic and societal costs of food insecurity for our nation will continue to mount if we do not act now. It’s time to launch the Healthy-Eating Moonshot.


a. Aggarwal, M., Devries, S., Freeman, A.M., et al, “The deficit of nutrition education of physicians,” The American Journal of Medicine, April 1, 2018.

b. Adams, K.M., Kohlmeier, M., and Zeisel, S., “Nutrition education in U.S. medical schools: Latest update of a national survey,” Academic Medicine, September 2010.

3 major problems undermining the nation’s health

The following three problems continue to plague the health of Americans because of obstacles that stand in the way of solutions.

1 Poor health habits. In the latest update of its dietary guidelines, the U.S. Department of Agriculture (USDA) reported that:a

  • 75% of Americans don’t consume enough nutrient dense fruits and vegetables
  • 63% consume foods that exceed the limit for added sugars
  • 77% exceed the limit for saturated fat
  • 90% exceed the limits for sodium

The USDA’s findings prompted the Consumer Healthcare Products Association to issue a statement noting that “health risks due to poor dietary practices continue to be an important public health issue.”b

2 High percentage of Americans being overweight or obese. According to the CDC, as of 2017-18, 42.4% of U.S. adults 20 or older were obese, with the prevalence of self-reported obesity ranging from 24.2% in Colorado to 39.7% in Mississippi.c In addition, 34.8% of U.S. adults are overweight, paralleling the upward trend in adult obesity as well as for adolescents 2-19 years of age as of 2017-18 (19.3% obese, 16.1% overweight).d

3 High incidence of food insecurity. USDA has reported that in 2020, 14.8% of U.S. households met the criteria for being food-insecure.e USDA also has reported that in 2020, households with the lowest incomes spent 27% of their income on food, while the highest-income households spent only about 7% of income. Meanwhile, retail prices for healthy foods have continued to rise since 2011. In 2021, food-at-home prices increased 3.5% and food-away-from-home prices increased 4.5%, but prices for fresh vegetables, milk and essentials increased even more.f


a. USDA, “Make every bite count with the Dietary Guidelines for Americans,” Infographic, December 2020.

b. Consumer Healthcare Products Association, “CHPA applauds the new dietary guidelines for Americans and recognizes the need to overcome nutrient gaps in the diet,” News release, December 2020.

c. National Center for Health Statistics, “Prevalence of obesity and severe obesity among adults: United States, 2017–2018,” NCHS Data Brief, CDC, February 2020; CDC, “Adult obesity prevalence maps,” 2020, Page last reviewed Sept. 27, 2021.

d. Fryer, C.D., Carroll, M.D., and Afful, J., “Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2017–2018,” National Center for Health Statistics, page last reviewed Feb. 8, 2021.

e. Coleman-Jensen, A., et al, Household food security in the United States in 2020, USDA Economic Research Service, September 2021.

f. USDA Economic Research Service, “Summary Findings: Food price outlook, 2022,” Jan. 25, 2022.



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