SETTING THE STAGE ON DIETARY PATTERNS AND CHRONIC DISEASE

Jill Reedy, National Institutes of Health, reviewed the evolution of the assessment of dietary patterns over the life course and how researchers have conceptualized diet as a multidimensional behavior and exposure. She noted that much of the original evidence base involved analyzing single nutrients to determine the relationship between diet and health outcomes. However, this reductionist approach has led to concerns, so she highlighted an alternative integrative approach that considers the effects of the totality of eating patterns, recounting efforts over the past decade to synergize evidence, define dietary patterns, advance assessment methods, and draft frameworks to look at levels across the food supply. It has become increasingly clear that individuals cannot be expected to make healthy choices if those are not readily available in different settings, she said. Following a Dietary Patterns Methods Project to strengthen evidence and establish a systematic method ahead of the revision of the Dietary Guidelines for Americans, researchers found common underlying constructs across four selected dietary quality indexes, but different methods used different components and scoring approaches. Across three distinct cohorts, with different diet quality indexes, Reedy said, higher quality was associated with lower mortality (Liese et al., 2015). This project showed multiple ways to eat a healthy diet and illustrated the potential of dietary patterns to inform policy makers and those developing guidelines. She advocated for the concept of a healthy eating trajectory across the life course, with examples of a stable healthy trajectory and varying trajectories, that could help identify target points for intervention and how they might be used in models with healthy outcomes (see Figure 1).

FIGURE 1

Dietary trajectories through different life stages. SOURCES: Presented by Jill Reedy on August 15, 2023, from Chong (2022). Reprinted with permission from Cambridge University Press.

Reedy summarized that opportunities and challenges to measure and model the multidimensionality and dynamism of dietary patterns at different life stages and across the life course include: using a shared conceptual framework across research questions; matching appropriate diet assessment methods to research questions, including contextual and dynamic attributes of dietary patterns in different populations; developing methods and models that fully capture total dietary patterns at different life stages; considering relevant periods of timing and frequency of dietary patterns; and applying systems-oriented approaches that consider measures of other related exposures and their interactions within the context of dietary patterns.

The human diet is an extremely complex exposure, said Johanna Lampe, Fred Hutchinson Cancer Center, and when it comes to understanding the effects on chronic disease, it is important to think about the totality of diet. The simpler people try to design dietary assessment instruments, she said, the more potential exists for bias and inaccuracies in measurement. She explained that dietary biomarkers provide objective evaluation of exposure to nutrients, validate dietary assessments, calibrate dietary intake data, and establish biological links between diet and health outcomes. In addition to the development of dietary biomarkers over past decades, she noted the advancement of -omics technologies, allowing analysis of thousands of different compounds. Lampe shared some examples of applications of dietary pattern biomarkers, such as a serum metabolomic profile in a cancer prevention study that found that different indexes picked up different metabolites. However, she explained, many compounds have yet to be identified in these untargeted metabolomics platforms, so gaps in knowledge persist as to what kinds of compounds help define different diet scores. In some cases, a few select metabolites may have the same predictive value as an entire list. Last, she mentioned measures of the gut microbiome as another way to monitor diet quality. For example, one way to characterize the microbiome is by looking at alpha diversity, where higher diversity is typically a marker of a healthy microbiome, often achieved through fruit and vegetable intake. She identified blood and urine metabolomic markers showing strong utility as objective measures of diet quality but mentioned gaps in replication of the results with more ethnically diverse populations, and a lack of longitudinal studies examining biomarkers of dietary patterns and diet quality in the context of chronic disease progression.

Edward Giovannucci, Harvard University, reviewed the three main approaches to dietary pattern assessment: based on indexes or scores, empirically derived from dietary data, and hypothesis oriented. The indexes often have a lot of overlap among dietary patterns but differ in how they treat certain items. The empirical method is typically a principal components analysis, he said, with general concordance in derived patterns across diverse countries, although some differences exist based on culture or availability of items. The hypothesis approach selects biomarkers and then defines the diet to see what foods assess them, but more studies on this method are needed for it to be more robust, he noted. Focusing on individual foods can exaggerate beneficial effects, said Giovannucci, so defining the whole dietary pattern is more likely to provide a realistic effect estimate of a healthy pattern. The bottom line is finding shared attributes among different dietary patterns and seeing how they relate to major chronic diseases. He shared recent study results, saying that the Alternative Healthy Eating Index, Mediterranean diet, plant-based diet, and Dietary Approaches to Stop Hypertension were all strongly protective, with up to 24 percent reduction in diabetes risk. Despite different pathways for disease and great overlap in dietary patterns, he concluded that the key message is that these patterns represent a useful approach for research and public health messaging.

Robert Waterland, Baylor College of Medicine, prefaced his presentation by saying his group recently discovered a major problem affecting the field of epigenetic epidemiology and, consequently, the field of developmental origins of health and disease (DOHaD). To introduce DOHaD, he shared a 1999 magazine cover story about obesity, cancer, and heart attacks having their odds determined when an individual is still in the womb. This refers to the paradigm that during critical periods of development, nutrients, and other stimuli can affect developmental pathways and permanently affect chronic disease risk. He described the introduction of “metabolic imprinting” as a conceptual framework to guide investigations into the biological mechanisms potentially underlying DOHaD. One such mechanism, epigenetics, describes molecular modifications, such as DNA methylation, that underlie the long-term stability of cellular differentiation (the developmental process that establishes different cell types). Documenting a role for epigenetics in DOHaD, he explained, involves a two-step causal pathway. First, an environmental exposure during development must induce a stable epigenetic change. Second, this change must persist to influence the risk of disease later in life. The first example of such a pathway was demonstrated in 2003 when it was shown that methyl donor supplementation of female mice before and during pregnancy could change DNA methylation at the agouti viable locus, permanently shifting the coat color of the offspring toward brown. Because agouti viable yellow is known as a “metastable epiallele,” Waterland’s lab has since worked to identify putative metastable epialleles in humans, and, through a study in Gambia, found that children conceived in the rainy season tended to have higher methylation at these loci compared to those conceived in the dry season (Waterland et al., 2010). Extensive work from his and other groups now shows that nutrition around the time of conception influences the establishment of these persistent methylation marks, substantiating the first step of the two-step pathway, said Waterland.

Waterland noted that this now places the focus on the second step of the causal pathway, which is epigenetic epidemiology, and that this is much more complicated than genetic epidemiology. In particular, the major problem that Waterland’s lab discovered is that epigenetic epidemiologists have, for over a decade, relied almost exclusively on a commercial DNA methylation array platform, on which 95 percent of the methylation sites interrogated show negligible interindividual variation in normal somatic tissue. He emphasized that without interindividual variation, it is impossible to detect associations in epigenetic epidemiology. This problem came to their attention following their large screening study in 2019 that identified nearly 10,000 correlated regions of systemic interindividual epigenetic variation. Although strongly genetically determined, these also exhibit sensitivity to periconceptional nutrition. Waterland firmly believes that focusing on these systemic interindividual epigenetic variants will greatly improve the ability to detect associations with disease, and he called for a fresh start in the field.

DIMENSIONS OF FOOD CHOICE AND INFLUENCES ON DIETARY PATTERNS

When looking at national trends in adult diet quality, modest improvements have been made from 1999 to 2010, said Cindy Leung, Harvard University. But stratifying by socioeconomic status shows that the gains are predominantly by those in the highest group. She emphasized that interventions developed to improve diet quality should be universal but ideally will reduce disparities as well.

Although individual factors can influence disparities, Leung acknowledged, she focused on the structural drivers of food insecurity. In 2021, the national prevalence was just over 10 percent, she said, and it exists nationwide. Those at higher risk include households that have children, are headed by a single parent, or are Black and Hispanic. Those who are food insecure often have lower scores in the aforementioned healthy diet patterns, she said. Key themes emerged in her work looking qualitatively at food security, such as environmental nudges people receive toward foods that do not support health, the additional cognitive and physical demands of food insecurity, and food insecurity as a source of toxic stress.

When the COVID-19 pandemic began, Leung said, she was surprised that food insecurity levels did not spike as early studies had shown. She stated that one of the main reasons for this was mobilizing the Supplemental Nutrition Assistance Program (SNAP), including greater administrative flexibility and increased benefits that were sustained throughout the pandemic. To further improve the program, she shared survey responses from low-income adults with suggestions such as increasing the minimum benefit to $30/month, increasing benefit distribution frequency from monthly to biweekly, and subsidizing online grocery delivery fees. Nearly 90 percent of respondents wanted extra money to be used for fruits and vegetables, she added. Furthermore, although food assistance programs are critical to ensuring food security, it might be time to look beyond traditional federal programs, Leung concluded, and economic programs should be considered as food insecurity interventions instead of always going straight to SNAP.

Adolescence is an amazing time to establish healthy behaviors, said Tashara M. Leak, Cornell University, partially because adolescents start to have more autonomy and purchasing power when it comes to food. She described how in low-income and racial/ethnic minoritized households, adolescents often do the grocery shopping and cooking for the entire family. In addition, obesity in adolescence is linked to increased risk of prediabetes in adulthood, said Leak. This risk is not evenly distributed, with income and racial disparities in the prevalence of prediabetes nationally (Liu et al., 2022). She described that structural barriers prevent many adolescents from making healthier choices in urban environments, such as the abundance of corner stores offering less healthy options and the high number of quick service restaurants located near public schools. She shared examples of interventions in schools, clinical settings, and community centers, but emphasized the importance of dissemination and implementation across all settings to promote sustainability.

Understanding food choice and dietary patterns in the United States can be informed by data on access to healthy diets worldwide, said William Masters, Tufts University. New research on food prices for nutrition reveals similar costs to consumers at different income levels, he explained, so the big differences in consumption observed are driven mainly by income and food choice among affordable items. Food price spikes can cause damaging food crises, but even when food prices are low, he noted, many people cannot afford healthy diets. He described new work using least-cost diets to meet dietary guidelines allowing measurement of access and affordability of sufficiently nutritious food, distinguishing among three possible causes of poor diet quality: high cost of nutritious foods, insufficient income to acquire them, and food choice among affordable items. Masters shared different average costs of the least expensive items globally in 2017, ranging from daily energy (only meeting caloric needs) at $0.83/day to an international Healthy Diet Basket² standard (meeting commonalities among national dietary guidelines) at $3.31/day. These new findings revealed that over three billion people worldwide cannot afford even this minimalist set of least-cost foods, Masters said. Most of this unaffordability is due to low incomes, so healthier diets worldwide will require higher earnings, whereas, in the United States and other high-income countries, the cause of poor diet quality is displacement of healthier items by less healthy items. For a healthy diet to be affordable does not mean people are food secure, he clarified, as these measure different things. Food insecurity means having run out of money to buy food at least once in the previous year, whereas affordability means having sufficient income to buy healthy foods on average over the year. Masters concluded with areas to consider for intervention, including analysis of time use and cost of meal preparation, which items have the most potential to improve diets, and which people need higher incomes to afford healthy diets.

Food is central to health outcomes, said Kevin Volpp, University of Pennsylvania, but fewer than one in 10 Americans meets requirements for fruit and vegetable intake. He focused on the behavioral challenges preventing people from eating healthy food, explaining that people have trouble making tradeoffs between the present and the future, and decades of research in behavioral economics have shown that the mind has multiple types of behavioral reflexes. He explained that these are often used to bypass cognition because every single decision in a day cannot be weighed by risk and benefit and probabilities of potential outcomes. He offered three implications for thinking about interventions. First, changing default choices increases the likelihood of healthy choices, such as “opt-out” defaults for programs instead of “opt-in” or listing healthier choices first. Second, financial incentives, such as a sugary beverage tax, can decrease consumption of less healthy choices. But, conversely, subsidizing healthy foods has not been shown to increase consumption that much. He pointed out that the incentives do not need to be large to work but just need to be immediate, salient, and easy to understand. Last, he referred to the American Heart Association Food Is Medicine initiative launching, with a goal of building evidence to scale these programs more widely. Lifestyle interventions can be very effective but are not always covered by insurance at the same rate as pharmaceuticals, he said, making it difficult to keep them in operation. One of the focal points for the program is human-centered design to better understand current behavior and more rapidly iterate the aspects of the program to be more successful. The plan is to maximize learnings across pilot sites and use automated trial platforms to more easily replicate and scale efforts. Overall, he concluded, this initiative will be very focused on improving health equity and building programs to be scaled.

ROLE OF INDUSTRY AND CONSUMER PERSPECTIVES

Marco Palma, Texas A&M University, provided an overview of the challenges consumers face, with other panel speakers sharing what their organizations are doing and the role industry is playing in improving healthy choices. Palma reviewed the neurophysiology of consumer food choice, beginning with an evolutionary biology perspective of when humans were hunters and gatherers and spent most of their time and energy securing food for survival. Our brains rewarded us in ways similar to how they respond to addictive substances today, he said. Now, humans typically spend much less time securing food, making it relatively cheaper, but brain evolution has not kept pace with the rapid advances of agriculture, so the brain still provides rewards for finding and consuming sugar-dense food. Palma described how some evidence shows the ridges of the brain that are activated with words such as “healthy eating” are different than those for more emotionally driven food-related messages. But not everyone faces the same self-control urges, he said, with two predominant and seemingly contradictory theories. One suggests self-control is like a snowball: the more one engages in an activity, the more motivation is generated and the greater the likelihood of exerting self-control in the same or unrelated activities. Another theory says self-control is like a finite resource: once a person runs out, they are unable to access and use it. However, Palma proposed these are not two different theories but two pieces of the same theory that are missing a compliance link. Essentially, the initial act enhances subsequent acts, but it is difficult to continue once it is overdone or after drastic measures (Palma et al., 2018). Demonstrating the importance of non-food attributes, he shared a study where consumers were given wine to taste that was identical except for price, and the reward center of the brain was measured through functional MRIs. They found that the brain activated more with the more expensive bottle of wine (Plassmann et al., 2008).

Beatrice Abiero, Instacart, discussed how the grocery technology company partners to provide grocery delivery access to more than 95 percent of households across North America. Last year, it launched Instacart Health to expand access to nutritious food, inspire healthy choices, and scale “food as medicine” programs. She highlighted Fresh Funds, an Instacart Health product that allows any entity, including hospitals or researchers, to offer produce stipends and related “food as medicine” programs online. A second feature she described is Virtual Storefronts, which allow entities to provide a branded, customized experience to show different dietary regimens. Given Instacart’s technology and reach across North America, it is uniquely positioned to provide infrastructure to programs, she said. For example, it partnered with the University of Kentucky and No Kid Hungry to conduct a study that found individuals living with low incomes could stretch their food budgets, decrease stigma, and save time when grocery shopping online and they purchased more fruits and vegetables when shopping online than in-store shoppers did without increasing their total bill. These studies shape how Instacart centers the user experience, and Abiero is excited to continue working with researchers and collaborating to empower consumers to navigate the food system and improve their health.

Sarah Ludmer, Kellogg Company, shared its plan to give “better days” to three million people by the end of 2030, saying that it is approaching the goal in four intersecting ways: sustainability, well-being, hunger, and equity, diversity, and inclusion. Over the past 20 years, Kellogg has focused on making food healthier while also reducing “negative ingredients,” such as sodium and sugar, but she said a shift is needed in how to continually provide equitable access and what is defined as nourishing. For example, Kellogg petitioned the Food and Drug Administration (FDA) in 2016 to increase the amount of Vitamin D allowed in cereals. FDA approved this at the end of 2022, so it can now offer higher Vitamin D levels. She emphasized the importance of focusing on positives and eating more healthy foods, saying efforts can be more impactful than just avoiding the intake of unhealthy foods. She highlighted the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program and how it puts positives first with health outcomes in mind but includes foods that would not necessarily meet the definition of “healthy” but can be complemented with healthier foods, such as fruit, and provide diversity in diet. In closing, she called for increasing redemption within the WIC program, as only 60 percent of people redeem their WIC cereal dollars.

Josh Hix, Season Health, characterized his company as a Food Is Medicine platform, offering three primary interventions to help drive health outcomes: clinical services, a food marketplace, and benefits. The virtual clinic offers registered dietitians for support, the marketplace offers diverse food options and medically tailored meals, and the benefits bank works with food credits, waivers, and programs, such as SNAP and WIC, so that participants can make the most of their funding to change behaviors. Together, he noted, these three elements map to the comments on choice architecture, changing the food environment, and making the healthy choice the obvious choice. Although it is a for-profit business, he clarified that it only gets paid by driving health outcomes and does not monetize any food options. It focuses on populations already living with chronic disease, said Hix, but he is hopeful that in several years, this model will be more akin to driving reimbursement for healthier populations in a more preventative sense. In response to questions on the cultural appropriateness of foods, he emphasized the importance of aligning incentives with health plans and partnering across the spectrum of grocers and meal companies, helping to establish local kitchens and suppliers where the density supports it, enabling people from the community to prepare the food.

LESSONS LEARNED FOR THE FUTURE

Melissa Laska, University of Minnesota, began by explaining that her work builds on the premise that all Americans do not have equal access to healthy food, which has been known for quite some time. Disparities clearly cut across race, ethnicity, and income, she said. To address this, she described the approach of leveraging small venues, such as bodegas and corner stores, that are trusted retailers and can play a key role in communities. For example, she said, one in three customers surveyed when exiting small food stores in Minneapolis and St. Paul, Minnesota reported they shop in that store daily, offering an avenue for intervention with so many frequent touch points with customers. However, working with small food stores also has challenges, she said, as many of them have not built their business model on perishable foods and have infrastructure limitations and procurement issues. Efforts targeting these stores to promote healthy food availability began around 15 years ago, with technical assistance provided, especially to supply produce, but several difficulties in implementation arose—especially for scalability and sustainability. She shared an example from 2014, when the Minneapolis Staple Foods ordinance mandated stores to stock minimum quantities of certain varieties of healthy staple foods. However, researchers found that, due to complications with compliance with the ordinance, there were no consistent improvements in the nutritional quality of purchases, compared to nearby St. Paul which did not have the ordinance. She also shared a 2022 review looking at retailer strategies that have been tested and found mixed results in changes in sales, purchasing, and dietary outcomes. One of the more rigorously tested strategies in food stores is nutrition scoring, she said: shelf tags have quantified labels of how healthy a product is. Ultimately, Ludmer concluded that the industry controls the store environment and product placement in many instances, with a lot of opportunity to improve healthy choices in understanding the scope of these influences.

As a Washington, D.C. community pediatrician at Children’s National Hospital, Kofi Essel, now primarily the food as medicine director at Elevance Health, advocated for providing nutrition information and nutrition counseling for patients and families. This routine was not always part of his practice, though. Essel reflected on an interaction with a family and their 4-month-old baby during his pediatric residency program when he realized he, his colleagues, and his physician supervisors were not equipped to talk to them about infant feeding and child nutrition. This aligns with the literature, he said, as 71 percent of medical schools do not provide the minimum 25 hours of baseline nutrition education, with a third of schools offering less than half that amount. Although he acknowledged that physicians do not need to become dietitians, they should feel comfortable enough to support families with meaningful dietary advice. He also acknowledged that pediatricians should be comfortable providing nutrition support in the first 1,000 days of a child’s life, which is often a missed opportunity to set up the child and their family for success later in life. Essel explained that by targeting an earlier age group, behaviors such as picky eating are often avoidable, and parental coping mechanisms can be more effective. These issues are compounded when families face sudden financial hardship and the risk of food insecurity increases, which can cause anxiety around food and meals. He said that the diet can often become quite monotonous and include hyperpalatable, familiar foods to preserve cognitive bandwidth, reduce waste, and ultimately save money. Considering the hierarchy of food needs, simply having enough food to feed everyone is the most critical point for many families, he noted. Kids often will not eat novel or unfamiliar healthier foods, so they will go to waste, adding to the caregiver’s stress.

Beginning in 2016, Children’s National Hospital started screening all families in its clinical spaces for food insecurity and were surprised by the high rates, said Essel. To address this, it realized it needed more than a piece of paper offering resources, so it created a clinical community partnership with the Young Men’s Christian Association and the American Heart Association, called the “Family Lifestyle Program.” It used “food as medicine” approaches to address food insecurity and diet-related chronic diseases. Despite several layers to any food as medicine program, Essel said it focused mainly on connecting families to federal nutrition programs and delivering fresh fruits and vegetables through produce prescriptions, coupling this with community-centered nutrition education. Following a small pilot project with families, it found that fruit and vegetable intake did increase in families, and families reported that this allowed them to try new foods without worrying about waste, expanded their purchasing power, and helped diversify their diet. Essel argued that this is a beneficial intervention in improving the quality of food for families with children who experience food insecurity but highlighted the multifaceted approach that is necessary—building partnerships, designing focus groups, and creating materials in different languages to make progress.

Joel Gittelsohn, Johns Hopkins University, highlighted his work in Baltimore to improve the food environment, calling attention to the food desert map that was recently created demonstrating the 20–25 percent of residents who live in Healthy Food Priority Areas (previously called “food deserts”). Those areas not only lack access to healthy food, he said, but have an abundance of unhealthy food resources. The food environment in Baltimore is large and complex, said Gittelsohn, with numerous public markets, food pantries, supermarkets, convenience stores, and more, making it difficult to know how to prioritize their efforts. He explained how they developed a few main approaches including changing the availability of healthy and unhealthy options, manipulating the price, and considering the location of foods (including store location and placement within the store). Summarizing past studies, he said they found that food environment interventions can effectively address key risk behaviors for chronic disease in communities who are disadvantaged by improving access, increasing consumption of healthy foods, and sometimes impacting obesity, but they realized that it is critical to combine educational, access, and policy approaches whenever possible, and community engagement is key at every level. Describing the current work, Gittelsohn shared five lessons:

1.

Invest heavily in formative research (i.e., mixed methods, triangulation, emergent, flexible design).

2.

Engage with communities for the long term to build trust and sustain food environment intervention work.

3.

When designing a food environment intervention, pay attention to intervention exposure to ensure that sufficient levels of exposure are achieved, set success standards at the beginning, and modify plans throughout the intervention as needed.

4.

Work at multiple levels of the system (i.e., consumers, retailers, suppliers, policy makers).

5.

Consider working at the policy level to support environmental interventions.

COMMUNITY-BASED ORGANIZATION EXPERIENCES

Celia Cole, Feeding Texas, introduced its work supporting 21 food banks across the state. Four million Texans participate in food bank programs annually, offered through a network of 3,000 community partners. It is not possible to “food bank our way out of hunger,” she said, but it is leveraging its core strengths beyond meal provision to implement strategies that improve overall health and well-being. She shared three key ways it connects food access with health: creating access to healthy foods, providing nutrition education, and developing partnerships with health care providers. Texas has an abundance of produce, so the food bank focuses on relationships with growers and rescuing produce that cannot make it to market, enabling cost-effective access. Other core strategies include mobile food deliveries, connecting families to SNAP and services to increase their food resources, and using its trained cadre of dietitians to help people make healthier food choices. Finally, she highlighted its newer role in health partnerships with providers, hospitals, and clinics to identify and address food insecurity. In terms of future direction, she said it is focusing on working with managed care organizations to develop approaches to value-based care and reimbursement models to sustain this role. Last, she called attention to the upcoming farm bill to address the adequacy of SNAP benefits, focusing policy advocacy on strengthening other income support programs and creating good jobs to indirectly affect food security for families.

Robert S. Harvey, FoodCorps, shared its recent focus on the theory of change, prioritizing efforts targeting the school system to influence connections between food and health. The school cafeteria is the largest food infrastructure we can impact, he said, but it is often missed as a potential target. To transform the ways “systemic and intergenerational food disease” has occurred, he offered three approaches: programming; policy work at the local, state, and federal levels; and digital advocacy and campaigns intended to help bring families along in the journey of food justice and food literacy. FoodCorps is deeply oriented around a family engagement strategy, and although half a million people are impacted daily through direct services, it targets more than 10 million other young people through policy and advocacy work, focusing on free, nourishing, locally procured meals in schools. He concluded by saying that those young people can then take what they are learning on a journey of agency and justice as they grow and continue to push for change.

Brent Ling, Wholesome Wave, reiterated the immensely complicated food system everyone is working within but identified a lot of potential in the demand side of the equation. Wholesome Wave was founded 16 years ago by a food business chef who knew the industry but was facing diabetes challenges within his own family. It wanted to address the market failure of the lack of healthy, high-quality produce available to everyone. It has learned that shoppers do not want to be treated differently just because they are low-income. It founded a program allowing SNAP benefits to be doubled for purchases at farmers’ markets. However, he noted that SNAP shoppers are required to go to a special booth to get validated and then receive a special token, and the vendors need to know which foods it covers. When that is used to pay, it is a public signal that this customer is low income, said Ling. This special and different experience leads to less interest in using the benefits and adds the extra step of going to the booth, potentially keeping people from accessing the market. He concluded with the message that everyone should be able to participate in the same food economy and access healthy food in the same way.

LEGAL AND POLICY CHALLENGES FOR INTERVENTION

Jennifer Pomeranz, New York University, shared legal and policy opportunities relevant to the workshop discussions, offering several prominent themes. First, she noted the power of experimentation at the state and local levels. This is important because in some states, such as Mississippi, the state legislatures have withdrawn the ability of local governments to act. She reiterated that the food environment nudges people to unhealthy food and urged policy makers and food industry stakeholders to act to make the healthy option the default. Also, healthy food comes in many forms, but it is unclear if consumers can identify multiple types of healthy food beyond things such as kale. Finally, she noted the gaps in figuring out how to help all consumers and the need to focus on disparities and elevating access. She shared research and policies related to online food retail, in-store retail, and food labeling along with regulatory challenges.

Online purchasing has increased in recent years, especially since COVID-19, said Pomeranz. She shared a study analyzing online food labeling that found that four key elements (nutrition facts, ingredients, common food allergens, and percent juice, where applicable) were only present and legible for about 36 percent of products. But voluntary claims, such as nutrient content claims, were available for more than 63 percent (Pomeranz et al., 2022). The information available had gaps across not only products but also retailers. To enable consumers to have access to important information, she believes USDA can drive change, as it regulates SNAP retail stores and can decide to make this a requirement online. FDA now regulates labeling, she explained, and this also includes shelf tags, but although we can argue that online food retail qualifies as labeling, no clear direction exists on how FDA would regulate it.

Many in-store retailers operate at a very low profit margin, stated Pomeranz, so it is important that any structural changes do not result in them increasing the price of food or going out of business. Policy at the state and local levels focusing particularly on checkout aisles and endcap displays would nudge consumers toward healthier options. She said the goal would be to move healthier food to locations that encourage purchasing, leaving the unhealthy items, such as candy, in their designated aisles. This could be achieved through conditional licensing or direct regulation. Some self-regulatory opportunities also exist, such as the Raley’s supermarket chain creating a family-friendly checkout lane without unhealthy items to support consumers. She also highlighted pharmacies, as they are SNAP-approved food stores that can self-regulate, such as CVS did when it removed tobacco products from all stores.

Moving to food labels directly, Pomeranz asked whether consumers can easily identify healthy food. Based on several studies, she said consumers are confused about what is healthy, and reducing this confusion is a key element to success. In one example, 29–47 percent of study participants incorrectly identified a less healthy, whole grain product as healthier—even with access to the nutrition facts label (Wilde et al., 2020). Another study related to popular fruit drink beverages for children found that the majority of respondents could not identify the drinks with nonnutritive sweeteners, and many thought sweetened flavored waters had no sugar and that unsweetened juices did have sugar (Harris and Pomeranz, 2021). Last, she focused on toddler formula-type drinks, targeted at ages 1–3 years. She said that medical consensus from professional associations recommends against these, noting they are unnecessary and expensive, yet they look very similar to infant formula. Toddler drink labels make several structure-function claims, Pomeranz noted, but FDA says it does not have the authority to regulate such claims for food. So not only are parents giving these to their toddlers unnecessarily while believing it is a healthy choice, but sometimes caregivers also mistakenly give them to infants because of the similar packaging. Emphasizing how powerful marketing and labeling can be across products, she said research has shown more than 50 percent of infant caregivers believed infant formula was better than breastmilk (Romo-Palafox et al., 2020). In conclusion, she advocated for more opportunities for cross-pollination between retailers, manufacturers, researchers, and community members and suggested maintaining focus on institutionalizing programs through Congress to ensure sustainability across administrations.

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Suggested citation:

National Academies of Sciences, Engineering, and Medicine. 2023. Dietary patterns to prevent and manage diet-related disease across the lifespan: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27400.