Not long ago few doctors – not even pediatricians – concerned themselves much with nutrition. This has changed, and dramatically: As childhood obesity gains recognition as a true health crisis, more and more doctors are publicly expressing alarm at the impact the standard American diet is having on health.
"I never saw Type 2 diabetes during my training, 20 years ago," David Ludwig, a pediatrician, told me the other day, referring to what was once called "adult-onset" diabetes, the form that is often caused by obesity. "Never. Now about a quarter of the new diabetes cases we're seeing are Type 2."
Ludwig, who is director of the New Balance Foundation Obesity Prevention Center in Boston, is one of three authors, all medical doctors of an essay ("Viewpoint") in the current issue of the Journal of the American Medical Association titled "Opportunities to Reduce Childhood Hunger and Obesity."
That title that would once have been impossible, but now it's merely paradoxical. Because the situation is this: 17 percent of children in the United States are obese, 16 percent are food-insecure (this means they have inconsistent access to food), and some number, which is impossible to nail down, are both. Seven times as many poor children are obese as those who are underweight, an indication that government aid in the form of food stamps, now officially called SNAP, does a good job of addressing hunger but encourages the consumption of unhealthy calories.
The doctors' piece, which addresses these issues, was written by Ludwig along with Susan Blumenthal, a former assistant Surgeon General and U.S.D.A. medical adviser, and Walter Willett, chair of Harvard's Department of Nutrition (and a stalwart of sound nutrition research for more than 30 years). It's essentially a plea to tweak SNAP regulations Supplemental Nutrition Assistance Benefits, the program formerly and more familiarly known as Food Stamps) so that the program concerns itself with the quality of calories instead of just their quantity.
"It's shocking," says Ludwig, "how little we consider food quality in the management of chronic diseases. And in the case of SNAP that failure costs taxpayers twice: We pay once when low-income families buy junk foods and sugary beverages with SNAP benefits, and we pay a second time when poor diet quality inevitably increases the costs of health care in general, and Medicaid and Medicare in particular."
The argument that soda and other junk masquerading as food should be made ineligible for purchase by food stamps, as are alcohol and tobacco, is one that's been gaining momentum in the last few years. It's also one that has led to a split in what might be called the nutrition advocacy community.
On the one side are "anti-hunger" groups who want to maintain SNAP's status quo; on the other are those who believe SNAP must be protected but also that it must be adjusted to take into account the changes in agriculture, marketing and diet that have occurred since SNAP was born 50 years ago, changes that have led to the obesity crisis.
I'm in that second camp, as are the authors of this article, who make a case that the rift is artificial, though both sides share the same fear: if we advocate any tinkering with SNAP, it may make the program more vulnerable to cuts which it can ill afford.
But the reality is that some billions of SNAP dollars (exact figures are unavailable, but the number most experts use is four) are being spent on soda, which is strictly speaking not food, and certainly not a nutritious substance, and is a leading cause of obesity. Seven percentof our calories come from sugar-sweetened beverages, none of them doing any of us any good.
Though there were those who argued against including soda when food stamps were created, the most pressing need was to address calorie deficiency, and that remains important. But the situation is different now: we recognize the harmful properties of added sugar, the importance of high-quality nutrients in children has been better analyzed, and obesity is a bigger problem than hunger. So funding low-quality, harmful calories is detrimental to both funders and recipients.
"It's time," says Ludwig, "for us to realize that the goals of anti-hunger and obesity prevention are not at cross purposes. In fact poor quality foods can actually increase hunger because they are inherently less filling." A child will become hungrier, sooner, after consuming 200 calories from a sugary beverage, compared to an apple and peanut butter with the same calories.
What's to be done? How to improve the quality of calories purchased by SNAP recipients? The answer is easy: Make sure that SNAP dollars are spent on nutritious food.
This could happen in two ways: first, remove the subsidy for sugar-sweetened beverages, since no one without a share in the profits can argue that the substance plays a constructive role in any diet. "There's no rationale for continuing to subsidize them through SNAP benefits," says Ludwig, "with the level of science we have linking their consumption to obesity, diabetes and heart disease." New York City proposed a pilot program that would do precisely this back in 2011; it was rejected by the Department of Agriculture (USDA) as "too complex."
Simultaneously, make it easier to buy real food; several cities, including New York, have programs that double the value of food stamps when used for purchases at farmers markets. The next step is to similarly increase the spending power of food stamps when they're used to buy fruits, vegetables, legumes and whole grains, not just in farmers markets but in supermarkets – indeed, everywhere people buy food.
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