First, the good news: 200 programs and activities within 21 federal agencies have a mission to improve health and nutrition outcomes for Americans, tackling, in various ways, the impacts of poor diet on disease. The bad news: An extensive new report from the Government Accountability Office (GAO) finds that these agencies have priorities and policies that work in direct conflict with their own and others’ programs. As a result, the federal government spends vast sums to educate people about healthy foods, improve access to them, research best methods for doing this, and issue requirements for producers and retailers—while simultaneously spending billions to treat diet-related cardiovascular disease, cancers, diabetes, and obesity. 

The goal of GAO’s investigation was to better understand how, despite concerted work at agencies such as the Food and Drug Administration (FDA), Department of Agriculture (USDA), Health and Human Services (HHS), and Department of Defense (DOD), about half of—or 1.5 million—annual deaths in the U.S. are still caused by preventable, diet-related diseases like diabetes and obesity. These eat up well over half of the U.S. government’s healthcare budget of $383.6 billion to treat them; GAO examined hundreds of documents and interviewed a number of agency officials and experts over two years to determine how this comes about. The audit takes on special poignancy in light of the pandemic: People with cardiovascular disease, the report points out, are six times more likely to be hospitalized or die of Covid, while obesity also increases the risk of severe Covid effects. 

The diseases covered by the audit are both deadly and costly, said Sharon Silas, GAO’s health care director and report contributor. But effectively addressing them is a challenge “because efforts are fragmented and each agency is doing its own thing,” she said. While some agencies may hold programs accountable for the success (or failure) of outcomes, there’s no overarching, cohesive strategy or coordination that spans agencies and programs to ensure that these efforts are not working at cross-purposes.

For example, USDA subsidizes corn production, leading to a pervasively low cost for high-fructose corn syrup and a lingering prevalence in American diets. But this runs contrary to HHS’s recommendation to reduce consumption of all added sugars, including corn syrup, which thwart people’s efforts to eat healthfully without consuming too many calories. Said Silas, “This is my favorite example of how there are these good things these agencies are trying to achieve that are at cross-purposes” with the work of other agencies. Another conflict, not mentioned in the report: USDA also oversees the National School Lunch Program, whose nutrition standards do not include limits on added sugars; as a result, the vast majority of U.S. public schools exceed HHS’s suggestion that sugar intake be limited to less than 10 percent of total calories, according to research published earlier this year. 

Another issue arises around an HHS recommendation for Americans to eat more fruits and vegetables. USDA programs like SNAP and WIC are meant to help provide affordable food to millions of low-income Americans within their own communities. Still, despite a 2011 National Prevention Strategy that helped federal agencies coordinate on devising healthy food guidelines and ways to remind people to fill up half their plates with fresh produce,  “officials responsible for the strategy said that the subsequent administration did not implement the strategy or report on progress toward meeting 2021 targets because it was not a policy priority for the former Executive Office of the President,” according to the report. At DOD, the ShipShape program educates active-duty service members about how to reduce calorie intake. Yet over 30 percent of young Americans aged 17-24 don’t even qualify for military service because of their weight—made unhealthy by a range of factors, from diet, to lack of exercise, to tobacco use, long before they seek to join the armed services. A key takeaway from the report’s findings, said Silas, is that someone has to make sure various diet-related health and nutrition goals are not in conflict.

To achieve better cohesion, and possibly better public health and fiscal outcomes, GAO recommended that Congress create or name a federal entity to develop a comprehensive strategy for achieving diet-related health and nutrition goals across federal agencies—officials at five of 16 agencies questioned by GAO researchers said they were in favor of this. Having defined leadership, whether under the Surgeon General or a new or existing governmental agency, “could be really helpful in centralizing accountability, speeding decision-making, and mitigating potential conflicts,” Silas said. 

This rings a similar bell to calls for a national food policy to holistically manage agriculture and the food system across all sectors. However, some nutrition policy experts see this recommendation as potentially unfeasible. Influencing U.S. food and nutrition policy are “public health and nutrition stakeholders but also manufacturers, retailers, agricultural producers, and the anti-hunger community,” said Parke Wilde, an economist and professor at Tufts University, noting that all these parties wield influence over the dozens of policies summarized in the GAO report. “I can see the appeal of GAO’s proposal to have one authority in charge of nutrition policy, but I anticipate that…some stakeholders will want a public health nutrition agency in command, while others will want an agriculture agency in this role,” Wilde said. 

Instead, said Wilde, “Public health and nutrition folks should not spend time wishing they were given authority over all food and farming policy, but to focus on thinking of the array of food and farming policies that are…harmful to nutrition without doing much good for farmers anyway.” A better approach, he said, would be to “continue to work on a wide variety of smaller food policy reforms, such as increasing demand for fruits and vegetables in small ways throughout the federal bureaucracy, from farm subsidy programs to school meals procurement, while avoiding policies that promote overconsumption of red meat.” (As Modern Farmer points out, fruits, vegetables, and nuts are all considered “specialty crops” and are not eligible for subsidies under the Farm Bill—although there is now some subsidy allowance for farmers transitioning to organic production.)

Norbert Wilson, professor of food, economics, and community at Duke Divinity School, agrees that centralizing agency efforts may be unviable. “I ​​would love to see that happen but I have concerns that agencies would give up authority to cover certain [issues] so that a meta-agency could deal with them,” he said. He also felt that there were a few important talking points left out of, or only modestly covered by, the GAO report. “Great, let’s talk about a coherent thread of policy that leads to [positive] health outcomes,” he said. “But we need to be taking into account what is health, not just biologically but also when it comes to issues around sustainability, climate change, equity of access, and recognizing the different cultures and identities we have in this country.” 

Where Wilson feels optimistic is around the possibility of a new White House Conference on Food, Nutrition, Hunger, and Health, a bipartisan bill for which will be introduced into the Senate by Democratic Senator Cory Booker and Republican Senator Mike Braun, and which is garnering a lot of (non-Congressional) support from people like former U.S. Secretary of Health and Human Services Donna Shalala, and dean of Tufts’ Friedman School of Nutrition Science & Policy, Dariush Mozaffarian. This would be the modern-day equivalent of 1969’s White House Conference on Food, Nutrition, and Health, which led to such seminal nutrition and anti-hunger programs as WIC, the National School Lunch Program, and the Dietary Guidelines for Americans. “Imagine … being interested in bringing together folks experiencing these [nutrition] challenges to have their voices heard,” Wilson said. Such a conference could actually move the needle on taking food and nutrition out of their silos and recontextualizing them alongside health, agriculture, environment, and social safety net policies. “Yeah,” said Wilson, “I’m getting excited about that potential.”