The same week British Prime Minister Boris Johnson was admitted to intensive care for Covid-19, two studies came out identifying obesity as a significant risk factor for serious illness and death. It was April 2020, and doctors were scrambling to understand why coronavirus gave some people mild symptoms and left others so sick they were gasping for air.
After Johnson recovered, he became vocal about the role he believed his obesity had played in his brush with the virus: “When I went into ICU, when I was really ill … I was way overweight,” he said.
That summer, Johnson, a conservative who in the past has colorfully railed against “the continuing creep of the nanny state,” launched a new governmentwide obesity strategy, complete with a ban on junk food advertising on TV before 9 p.m., new mandates to label calories in restaurants and a requirement that healthier products be stocked near checkout lines. The prime minister began jogging daily and urged the public to adopt healthier habits.
Other countries, too, have ramped up action as officials begin to recognize diet-related diseases such as obesity, hypertension and diabetes have made their citizens much more vulnerable during the pandemic. Some states in Mexico recently went as far as banning junk food sales to children — on top of the country’s existing taxes on sugary drinks and fast food. Chile was already deep in its own crackdown on unhealthy products, having imposed the first mandatory, national warning labels for foods with high levels of salt, sugar and fat along with a ban on marketing such foods to kids.
In Washington, there has been no such wake-up call about the link between diet-related diseases and the pandemic. There is no national strategy. There is no systemswide approach, even as researchers increasingly recognize that obesity is a disease that is driven not by lack of willpower, but a modern society and food system that’s almost perfectly designed to encourage the overeating of empty calories, along with more stress, less sleep and less daily exercise, setting millions on a path to poor health outcomes that is extremely difficult to break from.
“Nobody is doing anything about this. Nobody is saying this has to stop,” said Marion Nestle, a longtime New York University professor and author of numerous books about food policy. “And how do we stop it? With great difficulty and political will.”
“If you’re going to do anything about it, you have to take on the food industry, which no one wants to do,” she added.
There’s also a deep-seated belief in America that obesity and other diet-related diseases are the result of personal choices and anything the government does to meddle with our diets is an assault on American liberty. That narrative is increasingly being challenged by science. Research shows that once someone has obesity, there are almost no dietary or exercise interventions that are successful at reversing the disease over the long term and many people lack access to more aggressive treatments like drugs and bariatric surgery. Humans, it turns out, are largely hardwired to keep weight on once they gain it.
The problem is deeply entrenched and staggering in scale: More than 42 percent of American adults — about 100 million people — had obesity before the pandemic began, according to the Centers for Disease Control and Prevention. Nearly three-fourths of American adults are overweight or have obesity. Roughly one in five children now have obesity. The costs associated with this epidemic, along with diabetes, hypertension, cardiovascular disease and cancer, all related to diet, are among the greatest threats to the fiscal future of the United States, not to mention the health, well-being and productivity of millions of people.
Researchers have estimated that nearly two-thirds of Covid-19 hospitalizations in the U.S. were related to obesity, diabetes, hypertension and heart failure. One study found that patients with a body mass index of 45 or higher (severe obesity) were about a third more likely to be hospitalized and more than 60 percent more likely to die from the virus compared with individuals without the disease.
The pandemic and resulting lockdowns have also worsened obesity rates for both adults and children, according to early data. There are a number of theories about why, from less exercise and less sleep to poor nutrition, more snacking and a whole lot more stress.
As the link between poor diets and the toll of Covid-19 became clear, some food industry leaders began bracing for a backlash, assuming that top government officials would be looking to take action in the aftermath of the pandemic, according to interviews with industry insiders. If former first lady Michelle Obama would take on childhood obesity without a pressing crisis like Covid-19, surely the government would again get serious about nutrition policy after hundreds of thousands of deaths. Food and beverage companies have been closely following whether marketing crackdowns, warning labels or other more aggressive measures could spread. So far, there isn’t much on the agenda in the U.S..
“Globally, these issues are on fire,” said one industry consultant, granted anonymity to speak candidly about a sensitive topic. “In the U.S., we’re like sucking our thumb.”
It was October 2020 when President Donald Trump announced he and first lady Melania Trump had tested positive for coronavirus. After spending three days in the hospital, Trump declared he was fine and headed back to the White House. After a cocktail of treatments, the president (who’s own BMI put him at greater risk for severe illness) exclaimed on Twitter: “I feel better than I did 20 years ago!”
Just a few days later, Boris Johnson gave a speech at the Conservative Party Conference alluding to his anti-obesity campaign by striking a personal chord: “I had a very common underlying condition: My friends, I was too fat.” The prime minister also mentioned he’d since lost 26 pounds. He went on to outline a vision for the future of Britain that included a healthier population, with more biking and walking.
Stateside, the U.S. government was still not raising the alarm about the link between rampant metabolic disease and greater risk. It was never part of White House messaging on the virus and the suite of policies needed to respond to the crisis — something that didn’t change when President Joe Biden took the reins, either.
“It’s not central to the discussion at all,” said Dan Glickman, who served as agriculture secretary during the Clinton administration and is now a senior fellow at the Bipartisan Policy Center.
Glickman noted that the country’s leading voices on coronavirus, including Anthony Fauci, don’t focus on underlying conditions and what could be done about them long term. Instead, the focus is solely on vaccines, which have been proven to be safe and effective.
“They hardly ever talk about prevention,” Glickman said. “It’s missing. It’s a gigantic gap in the discussion about how health care relates to Covid and how it relates to the prevention of disease.”
As the pandemic heads into its third year, the connection to diet-related diseases and the overall vulnerability of the American population is a theme that remains absent at the highest levels of government. The only high-level Biden administration official who routinely talks about the issue is Agriculture Secretary Tom Vilsack — and he brings it up often.
Vilsack, who’s serving in the role for a second time after eight years during the Obama administration, likes to point out in his speeches, for example, that the government now spends more treating diabetes than the entire budget of the USDA, which is about $150 billion.
In an interview with POLITICO, Vilsack noted that more than half of the $380 billion per year spent treating just cardiovascular disease, cancer and diabetes is now picked up by the government, including through programs like Medicare and Medicaid.
“Ironically, if you could eliminate those costs you would be able to afford a $3.5 trillion Build Back Better bill [without pay-fors],” he said.
“It’s a significant issue that requires elevation,” Vilsack said. “We’re moving the dials that we can move at USDA. I think, however, it takes more than that. I think it takes multiple departments focused on this and multiple leaders saying this is an issue that requires some attention.”
Dealing with diet-related diseases hasn’t been top of mind in Congress, either. For example, there’s a bipartisan bill to require Medicare to cover medications and more types of specialists to help treat obesity. The legislation has been introduced repeatedly since 2013, the year the American Medical Association formally recognized obesity as a disease, but has not gotten much traction even as major Covid aid bills have moved through Congress.
Fatima Cody Stanford, an obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School who is a key advocate for the bill, said the pandemic has sparked much more interest among lawmakers and staff, but it hasn’t yet translated into legislative action.
One of the biggest challenges, she said, is that most people still do not understand obesity is a complex disease, not something that can be blamed on or fixed by personal choices, and it often requires multidisciplinary treatment that many people do not have access to.
“We aren’t taught about obesity,” Stanford said, referring to a lack of education in medical schools. “If doctors don’t understand obesity, why would the general public? Why would policymakers?”
Last month, the Government Accountability Office released a report on the state of the country’s response to diet-related diseases, concluding that there are scattered efforts across the federal government, but there isn’t enough coordination, nor an overarching plan.
“Congress should consider identifying and directing a federal entity to lead development and implementation of a federal strategy for diet-related efforts aimed at reducing Americans’ risk of chronic health conditions,” the GAO recommended.
Jerold Mande, a professor at the Harvard T.H. Chan School of Public Health and a fellow at Tufts University, who served in high-level positions at FDA and USDA in the H.W. Bush, Clinton and Obama administrations, said the report should be a gut check. “We’re not serious,” he said. “You look at the GAO report, and you conclude we’re not serious.”
The GAO identified just six “regulatory” actions the government has taken to try to combat diet-related diseases, but those policies are “largely educational” Mande noted, citing the Nutrition Facts label, which he helped design and launch during the H.W. Bush administration.
The Biden administration is already working on some policies aimed at addressing diet-related diseases, but for the most part the actions are modest. For example: One item on the to-do list at USDA is simply putting back in place school nutrition standards that were enacted during the Obama administration but were relaxed under Trump and then further rolled back to make it easier on schools during the pandemic.
Top FDA officials said this month they are planning to update their nutrition strategy “very soon,” but many of the nutrition initiatives the agency set out to do several years ago have still not been completed. One example: The FDA has been working to update what foods can be labeled as “healthy” since 2018 and has yet to unveil a proposed rule, let alone finalize or enforce one. The agency this month released long-delayed voluntary sodium reduction goals for food-makers to try to nudge them to use less salt in their products over the next two years. The policy, which is voluntary, took the better part of a decade to develop amid some pushback from the food industry.
“One of the FDA’s highest priorities is reducing the burden of chronic disease through improved nutrition,” an FDA spokesperson said in an email. “As part of a whole-of-government approach, the FDA is committed to doing our part to reverse the trend of diet-related chronic diseases and advance health equity using the tools we have available to us.”
The spokesperson noted FDA is “actively working” on an updated nutrition plan. The agency also launched an educational campaign during the pandemic to help more consumers understand Nutrition Facts labels, which were updated during the Obama administration.
This month, the Biden administration enacted the biggest ever permanent increase in benefits in the Supplemental Nutrition Assistance Program, something some officials have suggested will help improve diets, but there’s a sharp disagreement on whether that’s the case. Conservatives have criticized the effort, less so for its cost — even though spending on the program has roughly doubled during the pandemic — but more because they argue it may lead to taxpayers footing the bill for more food that’s not healthy. (Research shows SNAP households tend to buy similar foods as non-SNAP households, though they do spend slightly more on sugar-sweetened beverages. Some conservatives and health advocates argue taxpayers shouldn’t be buying soda and other products that can contribute to poor health.)
“You’re pumping billions of dollars into a system that already provides unhealthy foods for low-income households and that’s extremely concerning,” said Angela Rachidi, a senior fellow at the conservative American Enterprise Institute. “I think it’s disingenuous to say this is our nutrition agenda.”
For its part, USDA is still mulling how best to use its policy levers to tackle diet-related diseases, within what’s politically possible. Some health advocates, for example, really want the department to use SNAP, which currently serves roughly 40 million people, to promote healthier eating, either by ramping up incentives to buy healthier food or by disincentivizing or even banning certain products like sugary drinks from being purchased with the benefits — something that’s been a third-rail issue for the food industry in the past. It’s also opposed by some of the most powerful elements of the anti-hunger advocacy community, which are closely aligned with Democrats on most policy issues.
When asked, Vilsack dodged on whether USDA would consider any disincentives or bans, saying he hadn’t yet discussed it yet with his staff.
While there is no coordinated nutrition policy to tackle diet-related diseases in the U.S., even that approach would probably be far too narrow to make much of a dent, experts say. The problem is driven by so many factors, including poverty and systemic inequality, lack of access to healthy foods, lack of time to cook, overall stress levels, trauma, poor sleep, a lack of access to safe walking paths and parks, to name just a few.
“We can’t even just look at the food environment,” said Chin Jou, a historian at the University of Sydney, who last year criticized Boris Johnson’s campaign against obesity as misguided for not tackling root causes. “We have to look at the whole environment and the socioeconomic environment.”
There aren’t easy answers for any of this. No country has reduced their obesity rates. It’s a politically difficult issue to take on. Michelle Obama had to weather a steady stream of critics on Capitol Hill and beyond for her childhood obesity campaign.
Johnson has been mercilessly mocked by the press for his efforts — including most recently for going for a run in a dress shirt and dress shoes — and the prime minister just last summer distanced himself from a call to impose a sugar and salt tax on foods in the U.K. as part of a broader government-commissioned food strategy.
“I’m not attracted to the idea of extra taxes on hard-working people,” Johnson said.
In Washington, Reps. Jim McGovern (D-Mass.) and Jackie Walorski (R-Ind.) as well as Sens. Cory Booker (D-N.J.) and Mike Braun (R-Ind.) are pushing for a White House conference on food, nutrition, hunger and health, just like one President Richard Nixon held 50 years ago, a convening that launched a lot of action, including the modern food stamp program. McGovern, who has long focused on tackling hunger, said he’s been talking to Cabinet members about the idea, including Energy Secretary Jennifer Granholm and Transportation Secretary Pete Buttigieg. Vilsack said in an interview he supports the idea.
The White House, however, isn’t quite sold, McGovern said. (The White House didn’t comment, but congressional staff said there are ongoing discussions about the idea.) Such a convening isn’t exactly on message, as the administration tries to muscle reconciliation and an infrastructure package through Congress, as well as push the ball forward on climate, while responding to a once-in-a-century pandemic that continues to stress the health care system. It’s also somewhat peculiar, politically, to raise the issue while Democrats control the White House, House and Senate, though narrowly so. It naturally raises the question: Well, why aren’t you tackling it?
The White House contends it is working on the issue.
“The Administration works daily to ensure there is a whole-of-government approach to our work on diet-related diseases, aligning work across multiple federal agencies, including HHS and USDA, among others,” a White House official said in an email. “We have already taken aggressive action to turn the tide against diet-related chronic disease, including the voluntary sodium guidelines for food manufacturers and increased SNAP benefits and will continue taking concrete and bold actions on this issue across government.”
The official also noted the reconciliation deal struck this week includes expanded access to free school meals for nearly 9 million children and an extension of a new program to give 30 million children SNAP-like grocery benefits to help replace meals missed at school in the summer.
Sam Kass, who served as White House chef and senior nutrition policy adviser during the Obama administration, lamented that much of the policy work done under Michelle Obama’s leadership was stalled during the Trump administration.
“The last four years and Covid has stopped that momentum,” he said. “It’s going to take a redoubling of our efforts and our resources and our leadership to get that back on track.”
Still, he said he’s “empathetic” about why leaders in Washington aren’t making this a focus right now.
“When the house is on fire, you’re not worried about the foundation,” he said. “You’re just trying to put the fire out. But we’ve got to get our arms around this. We’re still facing a tidal wave — a tsunami — of health problems that our healthcare system will not be able to handle. Covid has put that reality in stark relief.”