Fiber and Healthcare Costs, Part 4: Where do we go from here?
The following series of posts are from Mandy’s Capstone project for her MPH program, focused on how fiber intake could reduce the number of Americans with chronic conditions and reduce healthcare spending for all.
As discussed, there are many different reasons why American adults do not consume the daily recommended amounts of fiber, from an understanding of what foods are good sources of fiber, to accessibility and affordability concerns. The diversity of reasons underlying low fiber intake in American adults leads to several ways to address and prevent low fiber intake.
Public Health Campaigns
Given the large gap between the number of Americans who meet daily recommended fiber goals (5%) and those who think they do (67%), there is a clear opportunity for an educational public health campaign to educate Americans on what good sources of fiber are and how much they should be eating (12). Public health campaigns could be a good avenue to help educate the average American adult, and have had some success in the past. A randomized-control trial published in 2018 that tested the effectiveness of online advertisements targeted at making healthier food choices and exercising, found a 50% increase in the number of people who searched for weight loss information in the month after viewing such a public health advertisement compared with the control group (37). The researchers found that an ability to use targeted online ads, as many large corporations do in order to advertise unhealthy goods and services, could be highly effective in driving behavior change (37). Such messages do need to be carefully crafted though, as Americans do not respond well to science-based messaging around nutrition, so messaging would need to be creative in order to educate Americans on the benefits of fiber and how they can get more fiber into each meal (38).
A good example of an advertisement for a food high in fiber would be the Avocados from Mexico ads, including a high-profile ad that aired during the 2023 Super Bowl on February 12, 2023 (39). While avocados are an excellent source of fiber, the ad only described how avocados “make everything better” (39). There was no science-based messaging in the ad, only a picturesque description and visual of how much better everything is when you eatavocados, which based on research is a more effective way to advertise to the average American adult (37, 39).
Food as Medicine
Historically in the US, despite poor diet being consistently linked with poor health outcomes, a focus has been on clinical interventions and prescription medications for chronic conditions, rather than dietary interventions, as providers have not had a way to do so. A movement toward “food as medicine” has been gaining steam in recent years, with programs varying from prescriptions for produce to food pharmacies to medically tailored meals, but all with the same goal of increasing whole food consumption and improving patient diets and nutrition (40). These programs are particularly beneficial for low-income individuals who may not be able to afford healthy food without additional assistance or have limited access to healthy foods. A case-control study conducted on a veggie Rx program in Albany, NY found a statistically significant decrease in BMI for the group that received produce coupons, designed to cover the cost of produce on a weekly basis, compared to a matched group who did not receive such coupons (41). In addition to the coupons, the program also had a mobile produce market that traveled to inner-city neighborhoods where produce availability is scarcer, helping to address both affordability and access issues (41). While this study did not measure fiber intake specifically, BMI is a risk factor for most chronic diseases and an increase in fruit and vegetable consumption would naturally result in an increase in fiber intake.
The University of Oklahoma developed a similar program through their OU Food Pharmacy pilot but went a step beyond just providing coupons for produce and provided participants monthly food packages which included beans, whole grains, lean proteins, healthy fats, fruits and vegetables, as well as information on healthy eating and easy to make healthy recipes (42). Participants of the program were found to have a significant increase in fiber intake over the course of the program, as well as a significant improvement in diastolic blood pressure for those that had hypertension at enrollment (42).
A matched cohort study looking at the impact of providing medically tailored meals found a 16% reduction in estimated health care costs for the group that received medically tailored meals, meals which are designed by a registered dietician to meet the nutrition needs of the patient, compared with the group that did not, primarily as a result of fewer hospital and skilled nursing admissions (43). CMS has recently started approving state Medicaid programs to include some of these “food as medicine” programs in order to address access and affordability issues for healthy foods, including many that are high in fiber (44). There are many different ways these programs can be structured, whether through providing vouchers for healthy foods, providing healthy groceries directly to patients, or delivering medically tailored meals to those who need them. While evidence of effectiveness is still emerging as more programs are implemented, there does appear to be promise in improving both clinical markers associated with chronic disease, as well as positively impact healthcare utilization.
Supplemental Nutrition Assistance Program
The Supplemental Nutrition Assistance Program (SNAP) is a government-sponsored program that provides low-income adults and families assistance in purchasing food at certain retailers. In 2021, over 41 million Americans utilized SNAP benefits. The Center on Budget and Policy Priorities conducted a simulation to see how increasing SNAP benefits would impact the intake of key nutrients, including dietary fiber (45). The analysis found that a 20% increase in benefits would result in a 6.7% increase in dietary fiber intake per adult male equivalent, and a 40% increase in benefits would result in a 13.3% increase in dietary fiber intake (45). Similar results were found when the simulation was limited to just families with children under age 18, suggesting this change would benefit not only American adults, but children and adolescents as well (45).
While the Center of Budget and Policy Priorities analysis was a simulation, there is some real-world evidence that providing additional dollars to low-income individuals can increase healthy food consumption. An analysis of a produce prescription program in North Carolina which provided participants with $40 per month for fruit and vegetables found a significant increase in the amount of fruit and vegetables purchased, as well as an increase in the diversity of produce purchased and share of total food costs going to fruits and vegetables (46). Based on simulations of how increased benefits would be spent as well as studies examining produce prescription programs and how they can increase produce consumption, increases to the amount provided to SNAP participants would likely result in higher fiber intake (45).
Advertising of Ultra-Processed Foods
It’s difficult to turn on the television in the US and not see an ad for some type of food, whether it be a fast-food restaurant, children’s cereal, or soda. It’s rare to see an advertisement for healthy food, with a few notable exceptions, as ads are typically placed by food manufacturers for ultra-processed foods. A 2014 study by Zimmerman and Shimoga examined how food advertising impacted food choices, and they found that people exposed to food advertising chose 28% more unhealthy snacks than the control group, which represented an additional 65 calories, on average (47). Other studies have found similar results, and this is significant because most foods advertised are highly processed and have little to no fiber. By viewing ads for unhealthy foods, people are more likely to choose unhealthy snacks, leaving less room in their diet for foods high in fiber. Limits on advertising of unhealthy foods outdoors or on publicly owned property have been implemented in certain countries and cities, and while research still needs to be done on the effectiveness of such policies, there is clear evidence from other studies on the association between advertising and consumption of unhealthy foods (48).
Farm Subsidies
The US Department of Agriculture provides subsidies to certain farmers in order to protect them from uncertain income due to issues outside their control, as well as ensure a constant food supply for Americans (49). However, corn, soybeans, rice, wheat, sorghum, dairy, and livestock are the primary beneficiaries of farm subsidies by the USDA, which provide little fiber to the US population. Farmers that grow fruits, vegetables, whole grains, and legumes, receive only a small portion of the subsidies each year, despite the known health benefits of these crops (49). Analyses have been performed to examine the relationship between highly subsidized crops and health factors in American adults, and it has been found that the higher the proportion of subsidized crops like corn and wheat in one’s diet, the higher their risk factor for cardiovascular disease (49).
Higher subsidization of crops that are high in fiber and linked to positive health outcomes and decreases in chronic disease, while decreasing subsidization of crops linked to poor health, like corn, could lead to an overall healthier diet for Americans and lower incidence of chronic disease. This would require major changes to the next Farm Bill and how subsidies are provided to farms in the US, shifting away from corn, soybeans, and wheat, and towards legumes, whole grains, and fruits and vegetables.
Conclusion
Healthcare spending in the US on chronic diseases is extremely high, at 90% of total healthcare costs being for people with chronic conditions. Many chronic conditions can be prevented or better managed through diet, with fiber intake proven to be a strong risk factor for chronic diseases like type II diabetes, cardiovascular disease, and colorectal cancer, among others. Evidence from a host of studies demonstrates reduced risk of chronic disease for those who eat higher amounts of fiber compared to those who eat less, with 25g - 35g per day as an inflection point for positive effects.
While it’s not likely that we could get every American adult to consume the recommended amount of fiber, if we could just increase the number of American adults who eat the daily recommended amount of fiber beyond the current level of 5%, any incremental progress could help decrease risk of chronic disease, and could potentially save not only billions of dollars nationally on healthcare, but also thousands of dollars per year at the individual level. This could result in both cost savings for government healthcare programs like Medicare and Medicaid, as well as commercial healthcare savings which are funded directly by consumers and employers. The focus of this paper is on healthcare costs, but quality of life would also improve for those with chronic disease, as well as mortality rates and life expectancy. There is no single reason for why American adults do not eat enough fiber, and thus there is no one solution to increase fiber consumption. Rather, a variety of solutions should be considered, including policies at the national level such as reforming agricultural subsidies to meet the nutritional needs of the population and policies at state and local levels, including creating effective and targeted public health campaigns to educate consumers on the importance of fiber and how to increase fiber consumption as well as interpret food labels to better understand fiber content, increasing SNAP benefits so that families who rely on that assistance are able to afford foods that are high in fiber, and potentially even limit advertising of ultra-processed foods as a way to discourage unhealthy eating. Health insurance companies and large employers that provide benefits to their employees should also consider produce prescription or veggie Rx programs in order to improve access to and affordability of foods high in fiber, which have been proven in small studies to improve the diets and nutritional intake of those that have access to them. It is encouraging that Medicaid is beginning to cover these programs, but more can be done to reach an even larger population and help improve the diet of all Americans. There are no known health risks to consuming fiber or too much fiber, and foods high in fiber do not need to be expensive, as many whole grains and legumes can be purchased relatively cheaply and have long shelf lives. There is no downside to increasing fiber consumption among Americans, and with so few Americans currently meeting adequate levels of fiber intake, there is truly only upside.
References
(37) Yom-Tov, Elad, et al. “The Effectiveness of Public Health Advertisements to Promote Health: A Randomized-controlled Trial on 794,000 Participants.” Npj Digital Medicine, vol. 1, no. 1, 30 Springer Science and Business Media LLC, June 2018, https://doi.org/10.1038/s41746-018-0031-7.
(38) Mobley, Amy, et al. “Identifying Practical Solutions to Meet America’s Fiber Needs: Proceedings From the Food and Fiber Summit.” Nutrients, vol. 6, no. 7, MDPI AG, July 2014, pp. 2540–51. https://doi.org/10.3390/nu6072540.
(39) Avocados from Mexico commercial. Fox, 12 Feb. 2023
(40) Hager, Kurt, et al. “Association of National Expansion of Insurance Coverage of Medically Tailored Meals With Estimated Hospitalizations and Health Care Expenditures in the US.” JAMA Network Open, vol. 5, no. 10, American Medical Association (AMA), Oct. 2022, p.e2236898. https://doi.org/10.1001/jamanetworkopen.2022.36898.
(41) Cavanagh, Michelle, et al. “Veggie Rx: An Outcome Evaluation of a Healthy Food Incentive Programme.” Public Health Nutrition, vol. 20, no. 14, Cambridge UP (CUP), Aug. 2016, pp. 2636–41. https://doi.org/10.1017/s1368980016002081.
(42) Wetherill, Marianna S., et al. “Design and Implementation of a Clinic-Based Food Pharmacy for Food Insecure, Uninsured Patients to Support Chronic Disease Self-Management.” Journal of Nutrition Education and Behavior, vol. 50, no. 9, Elsevier BV, Oct. 2018, pp. 947–49. https://doi.org/10.1016/j.jneb.2018.05.014.
(43) Berkowitz, Seth A et al. “Association Between Receipt of a Medically Tailored Meal Program and Health Care Use.” JAMA internal medicine vol. 179,6 (2019): 786-793. doi:10.1001/jamainternmed.2019.0198
(44) HHS Approves Groundbreaking Medicaid Initiatives in Massachusetts and Oregon | CMS. 27 Feb. 2023, www.cms.gov/newsroom/press-releases/hhs-approves-groundbreaking-medicaid-initiatives-massachusetts-and-oregon.
(45) Ver Ploeg And Chen Zhen, Michele. “Changes in SNAP Benefit Levels and Food Spending and Diet Quality: Simulations from the National Household Food Acquisition and Purchase Survey.” Center on Budget and Policy Priorities, 12 May 2022, https://www.cbpp.org/research/food-assistance/changes-in-snap-benefit-levels-and-food-spending-and-diet-quality.
(46) Xie, Julian et al. “The impact of a produce prescription programme on healthy food purchasing and diabetes-related health outcomes.” Public health nutrition vol. 24,12 (2021): 3945-3955. doi:10.1017/S1368980021001828
(47) Zimmerman, Frederick J., and Sandhya V. Shimoga. “The Effects of Food Advertising and Cognitive Load on Food Choices.” BMC Public Health, vol. 14, no. 1, Springer Science and Business Media LLC, Apr. 2014, https://doi.org/10.1186/1471-2458-14-342.
(48) Chung, Alexandra, et al. “Policies to Restrict Unhealthy Food and Beverage Advertising in Outdoor Spaces and on Publicly Owned Assets: A Scoping Review of the Literature.” Obesity Reviews, vol. 23, no. 2, Wiley, Nov. 2021, https://doi.org/10.1111/obr.13386.
(49) Do, Whitney L., et al. “Consumption of Foods Derived From Subsidized Crops Remains Associated With Cardiometabolic Risk: An Update on the Evidence Using the National Health and Nutrition Examination Survey 2009–2014.” Nutrients, vol. 12, no. 11, MDPI AG, Oct. 2020, p. 3244. https://doi.org/10.3390/nu12113244.