Shireen: In today’s episode, we welcome Dr. Sarah Bleich, a leading policy expert and researcher who specializes in the prevention of diet related conditions, food insecurity, and racial inequality. She discusses the critical issues driving inadequate nutrition in underserved populations. We’ll explore how access to healthy food options plays a pivotal role in disease prevention and consider the policy changes necessary to combat food insecurity. Stay tuned. Dr. Sarah Bleich is a professor of public health policy at the Harvard T. H. Chan School of Public Health. She’s a policy expert and researcher who specializes in diet related diseases, food insecurity, And racial inequality with more than 180 peer reviewed publications. Previously, Sarah served in the Biden administration as the Director of Nutrition Security and Health Equity at the U. S. Department of Agriculture. Welcome, Dr. Bleich. 

Dr. Sarah Bleich: Thank you so much for having me.

Shireen: An absolute pleasure. I can’t wait to kick off this conversation. I’m really looking forward to what we’re going to talk about today. But first, Dr. Bleich, I would like to know what drew you to pursue a career in food and nutrition policy.

Dr. Bleich: So I love this question. Big picture. I’ve always been very drawn to food and thinking about food. And I generally like big issues that require creative and imaginative approaches. But if I’m being honest, When I look back, what really launched me on this path was a conversation that I had with my grandfather, my mother’s father, more than 20 years ago. So he was a corn farmer in Maryland, and when I got into Harvard for my PhD, it was a huge deal for him. I was living in California at the time. I drove cross country to see him on my way, because I’m from Baltimore, on my way up to Boston. And he pulled me aside, and he said, Sarah, don’t go up there to Boston and get uppity. And at the time, it was sort of in one ear and out the other, and then I’m doing research and working on my dissertation, and I had an advisor that was really pushing me to work on an area that I didn’t totally understand, and it certainly wasn’t a topic that I wanted to pursue. And one day he cornered me, and he said in a really sharp tone, What is it that you want to do? And I looked him dead in his eye, and I said, I’m going to focus on obesity, and he was like, why? And I said, because my grandfather will understand. And I can honestly say that in more than 20 years, I have yet to have a conversation with anyone, any walk of life, who I can’t learn something from around food, around nutrition, around obesity. And it’s just provided for me. It’s a fascinating career where you’re able to look at real problems that have promising solutions, and you can do your part to try to make an actual difference. 

Shireen: I love, you know, that passion from which this stems from, you know, which then takes me to, you’ve really spent much of your career focused on exactly that, on food and nutrition policy. I would love for you, if you could just start out this episode by describing some of these problems, these core issues of poor diet and food insecurity, particularly within underserved populations. We hear a lot in the news, but just really help us contextualize what does it mean and where do these problems really stem from.

Dr. Bleich: So let me first offer listeners a definition. So food insecurity means access by all members at all times to enough food for an active, healthy life. So what are the numbers look like? So in the United States right now about 1 in 10 households are food insecure. And those rates are about twice as high if you’re a black household or if you’re a Latinx household compared to white households. And so poor diet is one of the leading causes of preventable death. And there are a lot of ways that we look at diet quality in this country. There’s a measure called the Healthy Eating Index. It’s scored on a scale from 0 to 100. Where if you get 100, basically that’s saying you are eating in a way that’s consistent with the dietary guidelines for Americans, which are federal guidelines. Now if you look across the entire population in the United States, our HEI score, the Healthy Eating Index, on average is a 58. So the takeaway is that no matter how much money you have, no matter what racial ethnic background you come from, Most of us are falling short of meeting federal dietary guidance. So we don’t consume enough fruit, vegetables, whole grains, low fat dairy. We have diets that are high in sugar and sodium and solid fat. But the main message I want you all to realize is that poor diet is not just a problem of people who are low income. And as we think about poor diet, it’s really important to look at the problem of obesity because it captures so much of the poor dietary quality in this country. So just by the numbers, 42 percent of adults And 20 percent of youth in the United States have obesity and just like food insecurity clusters among black and Latin X groups. So does obesity and all of this is very expensive. And so the annual estimated medical cost of obesity in the U. S. Is about 173 billion dollars per year. But if you look at poor nutrition generally, there was just a study that came out which estimates that it costs the economy 1.1 trillion dollars each year. These are big expensive problems.

Shireen: Thank you for sharing that and Dr. Bleich with what you mentioned I also want to dispel a myth before we dive further into this, but help us understand. How does obesity exist? When there is abundance of the food, can you help us make that connection between sort of poor food choices, obesity, and also connecting the dots between some of the other key factors that lead to poor diet?

Dr. Bleich: Well, obesity essentially is a problem of consuming too many calories or exercising too little. You can put aside genetic factors because they simply cannot explain the massive rise in obesity we’ve seen over the past several decades. And so one of two things are happening. People are either eating too much or they’re not getting enough physical activity. For the vast majority of people, we are overeating.

And if you just look around, calories are everywhere. You know, if this was when I was a child. Yes, there was convenient food, but it’s not like it is now. If I wanted cookies, I’d probably have to ask my mom to make cookies. It would take a few hours. Now you can go to a vending machine and for a pretty low price, you can get an enormous amount of calories. So our ability to access cheap food. Relatively cheap food will probably talk more about price during this program, relatively cheap food and consume it very quickly is largely driving the obesity epidemic. And the last thing I would say is that it doesn’t take a large number of excess daily calories every day to cause weight to go up. So we’re really only talking about a few hundred calories every day, which cumulatively over time is going to then be responsible for the epidemic that we’re seeing amongst adults and amongst children. 

Shireen: And I like that you sort of took out genetic of being a core factor because Genetics has always been there. It’s not boiling down to genetics. It’s everything else that’s been sort of set up around us. And also, you know, when you talk about nutrition and calories, from what I gather from what you’re saying is these are going to be sort of not the foods that have been like nutrient dense foods. These are not those foods. We’re talking about sort of those processed, those cookies that you mentioned, chips, vending machines, just being able to have access to sort of some of those foods that are not nutrient dense for us. Is that correct? 

Dr. Bleich: So I would say it a little bit differently. So from a mathematical standpoint, if you’re eating too many calories, no matter the type of calories, you are going to gain weight. But the reality is that most of us have more access to calories that are not good for us. And those calories are processed very quickly. They can be turned into fat very quickly. So the quality of the diet does matter a lot. But anyone who overeats, no matter what they eat, can have a problem with their weight.

Shireen: Can you talk about the relationship between income, food access and poor nutrition? How are they related? 

Dr. Bleich: Yeah, so if someone is living in poverty, for them to maintain good health, to consume a nutritious diet, to manage any chronic diseases which affect the majority of the country, that’s a really big problem. People have limited finances, they have competing priorities, they have lack of access to healthy foods, and then if you also just take a step back away from the food world, We know that if someone lives in poverty, they probably also experience other hardships. Housing instability, they could not be able to pay their energy bills, and all of this stuff can contribute to poor nutrition and food security. And there’s a lot of research which shows that for people living in or near poverty, they have much worse health outcomes and they have less access to healthcare than those who don’t. And if you just sort of compare neighborhoods, those who live in neighborhoods with a higher concentration of folks with lower incomes often have fewer resources that promote health. Things like full service grocery stores, parks, recreational facilities that encourage physical activity.

And these neighborhoods, there just tends to be more environmental threats that can cause harm. And so you can think about things like poor air quality, poor housing conditions. One of the things that I really want to underscore for listeners is that poverty can have a really long arc. And so what do I mean by that? If you’re a child living in poverty, that can carry negative health implications into adulthood. And so if you’re a kid and you live in a poor household, that’s been linked to long term things like higher healthcare expenditures, lower educational achievement, which means you’re not completing high school, you’re not completing college, or you have lower earnings into adulthood. And so these are things that we really want to try to address when Children are young so that they are set on a trajectory for success. A final point to make here is that if you have food insecurity and you have limited financial resources, then you’re often forced to make tough decisions. Do I buy food or do I buy medicine? And these are decisions we don’t want people to have to make. And so when you put all this together, the main message is that poverty, Food insecurity and poor diet, they have serious consequences for health and well being. But one of my main messages for you all is that these are problems that are almost entirely preventable. 

Shireen: And I like that you’re taking the angle just to say that this is preventable. This is not, like you mentioned earlier, genetics. This is not something that it is what it is. These are preventable things that can move toward a positive outcome if changes are made. And I want to get into that in just a second. But you also mentioned the importance of act Access to healthy food choices. Could you really elaborate on how this access or lack thereof, really contributes to some of the diet related health issues and how that cascades? 

Dr. Bleich: Yeah, so we know, and if you just look around, you know that access to healthy food is not distributed equally, and so when healthy options are not available, And when people have limited resources, it is not uncommon to choose foods that are higher in calories and lower nutritional value. And there’s a lot of evidence to back this up. So for example, people that live in areas with fewer options for fresh produce. And lots of fast food restaurants or convenience stores. They are at higher risk for things like obesity and diabetes. The distance to grocery stores and lack of transportation are also big barriers to healthy food options. If you don’t have a car, if you don’t have convenient public transportation, if you can’t walk to healthy options, then it’s very hard. to follow a healthy eating pattern. And you probably won’t be surprised to hear that in predominantly black and Hispanic neighborhoods, you’ve got fewer large chain supermarkets than you have in mostly white neighborhoods. A final point, which I suspect will not surprise you, is that fresh fruits and vegetables and other healthier items are often more expensive. At convenience stores and small food stores as compared to these big box stores and the big grocery stores. So my twin sister lived in New York City for years and she’s always talked about just how high the prices are in small bodegas and convenience stores. But that’s not a New York City problem. If you just go into cities and you go to these little convenience stores, it’s just much more expensive to make healthier choices. 

Shireen: Which then takes me to the policy side of our discussion, and here’s where I want to refer to the work that you’ve done under the Biden administration. So you recently worked as a director of nutrition security and health equity at the USDA Food and Nutrition Service during Biden’s administration. Could you tell us about some of your responsibilities within the role and what you were really attempting to accomplish within it? 

Dr. Bleich: Yeah, so it was such a great experience. So I was there for the first two years of the Biden administration for the second year. I was the director of nutrition security and health equity. And within that portfolio, my job was to basically lead this whole of department approach on food nutrition security. And I will define nutrition security for you in just a second. But as part of the role, there was this huge focus on communications and engagement, basically building awareness about the importance of why do we need to tackle diet related diseases and disparities? Why is USDA positioned to lead this effort? Why should we be thinking about nutrition security alongside food insecurity? There was in September of 2022 a historic white house conference on hunger nutrition and health And so my job was to be one of the two points of contact from USDA to help organize that conference, and there was a national strategy that was released to basically provide this scaffolding for how do we end hunger and reduce diet related diseases and disparities by 2030.

And so I helped work on that. And then I had some other roles related to the dietary guidelines for Americans. But let me just take a minute and define nutrition security for listeners. So it means consistent and equitable access to healthy, safe and affordable food that is essential to optimal health and well being. So then naturally, the question is, well, all right, well, how does that differ from food insecurity, which has been something that’s been studied for decades by USDA and many folks around the country. So there are really two things to keep in mind. First and foremost, this concept in nutrition security, it is not replacing food security.

It is building on it. And there are two distinct ways that it’s doing that. First, nutrition security recognizes that we are not all maintaining an active, healthy life. That’s consistent with federal recommendations. And the second is that it really emphasizes focusing on equity. And so one thing for listeners to understand just about USDA is that there are a lot of programs that exist. So this is, USDA is the U. S. Department of Agriculture. It administers more than 15 nutrition assistance programs, which together serve one in four individuals in the U. S. annually. The largest is a program called SNAP. It used to be called Food Stamps. SNAP stands for the Supplemental Nutrition Assistance Program. It reaches 41 million Americans each month. Another really big program is School Meals. Which serves more than 30 million children each day, including my kids, I’m sure, including many of your children. And then there’s a program called wic, women, infants and Children, which serves nearly half of all infants each day. And so one of the things that is happening at USDA and happened while I was there, I was asking the question, how do we bring nutrition security more holistically into these long standing programs, which have had a lot of success around food insecurity. But now we want to think about also supporting and advancing nutrition security. Um, one final point that I’ll make just personally, is that one of the reasons why it was so rewarding for me to work at USDA on these programs is that when I was little, my family received SNAP. It was then called food stamps. We received WIC, we received school meals, and so it really was just a privilege as a recipient, as someone who knows firsthand that these programs matter, to have the chance to work on them at the federal level. I don’t know of another way to reach people at scale and help improve their nutrition the way you can federally, and so it was just really exciting and gratifying work. 

Shireen: Can you speak Dr. Bleich to what are some of the key changes the Biden administration is really making to achieve food security, but then also nutrition security, which you mentioned.

Dr. Bleich: Yeah. So let me, I mentioned the big programs, SNAP, WIC and school meals. Let me just quickly say some big changes for those. recognizing that we don’t have time to get into lots and lots of changes that have happened over the past several years. But for snap, the really big one is that there was a reevaluation of something called the Thrifty Food Plan that essentially serves as the basis for calculating the monthly snap benefit. So in 2021, That was reevaluated, and it led to the first permanent increase to the purchasing power of SNAP benefits since that concept, the Thrifty Food Plan, was introduced over four decades ago. What this meant, practically, is that benefits increased by 21 percent per month, or 36 per person per month. Now, on top of this, Snap is also designed to adjust annually for inflation. So and this happens each year. So in October of 2022, one year later, the snap benefit was adjusted for inflation. And all of you are well aware of how much food prices have gone up over the past couple of years. So that increase to snap benefits was that inflationary increase was about 12.5%, one of the largest in history. So practically speaking, when you put those things together, a family of four who qualifies for the maximum benefit We’ll get 939 per month this year. Now for WIC, one thing that’s happening is that there is a proposed rule to update what are called the WIC food packages and to get them to align with the latest dietary guidelines for Americans. These are basically the prescription that moms and young children receive when they participate in the program. One of the most significant things this proposed rule would do is it would make permanent something called the cash value benefit for fruits and vegetables. This basically gives moms and kids on the program between nine and 11 per month to purchase fruits and vegetables. In 2021, Congress tripled that amount. So women now receive between 45 and 49 a month and Children get 25. So the proposed rule would maintain these higher levels. Now, one thing for you all to be aware of is that the annual spending bill by House Republicans is looking to cut those cash benefits back to their pre covid level. So it’s something to keep an eye out for. And then for school meals, there’s a proposed rule to strengthen nutrition standards, which would include for the first time adding new sugar standards. So how much sugar can be in the in the food for kids. And the final thing I would say is that there’s a brand new federal nutrition assistance program that was stood up based on the 2022 omnibus bill, which basically made the summer electronic benefit program permanent. And so that means that beginning in summer of 2024, more than 29 million children will get 40 per month in benefits. 

Shireen: Tell us more about this policy. 

Dr. Bleich: Yeah. So there has been a, there was a pilot program that was basically answering the question. What do you do for kids in the summer months because they’re not getting food when the school year ends. And so this program has been shown to be really effective. Essentially, it is putting additional money on the SNAP benefit card for families that can go to the store and buy food for their kids. It’s been shown to reduce food insecurity. And so because there’s a lot of empirical evidence, which backs it up. What happened is that it has become permanent. And so now, when the school year ends, there’s this additional program that’s gonna help, again, more than 29 million children access food each month. So it’s really exciting, and it’s something that is gonna take a lot of effort to roll it out, and that’s actually an area where listeners can think about, you know, how can you lean in to help with an effort like that?

Shireen: I appreciate you giving us the overview there, Dr. Bleich. You also mentioned, and I wanted to also touch on, nutrition security more intentionally there. You mentioned the conference, for instance, that happened last year. It was a big, big one. I don’t think I recall a conference of that magnitude that has happened in the past, but can you give us some of the key takeaways from there? What can we expect? What do, you know, programs look like in the future that are very specific to nutrition security? 

Dr. Bleich: Yeah. So White House Conference on Hunger, 22. To sort of foot stomp on your point, it was a huge deal. It had been more than 50 years since there was a conference like this, so it really galvanized the nutrition and the food policy communities. The day of the conference there was, or the day before maybe, they released this national strategy, which essentially was a road map for how do we achieve the conference goals. Ending hunger and reducing dietary disparities by 2030. So it included a number of policy recommendations that different federal departments could do that Congress could take and that non federal actors can take. So if you are a school district, if you are a local government, if you are philanthropy, how can you lean in? It also had recommendations that can help with diabetes management and prevention. And so we’ve already talked about some of them. So updating the WIC nutrition standards to align with the dietary guidelines for Americans is something that is going to help people who have diabetes and are also participating in WIC. Another thing that’s included, which is not yet a policy, is thinking about Could you expand incentives for fruit and vegetables in the SNAP program, which again, reaches 41 million Americans per month. And so what you can watch out for is there’s really a flurry of activities that are happening across the executive branch to bring this national strategy to life. There were also, the day of the conference, eight and a half billion dollars of non federal commitments that were announced to help advance the conference goals. I think we can expect more announcements coming out of the White House to continue to look at how do we push this effort forward. But the main message to anyone who’s listening is that It is going to take a whole of country approach to solve these problems because they are a whole of country problems. And no matter how small the effort is, there are always ways you can think about leaning in. With family members, with friends, with strangers who you think you might be able to lend a hand to. These are everyday problems, but they are structural problems. So wagging your finger at someone is not the right thing to do. Asking yourself, how do we change people’s environments? How do we lend a helping hand? How do we do things to facilitate toward a healthier diet and less food insecurity? 

Shireen: I would be remiss if I didn’t mention the paper that you co authored recently, and the title of it, and we’re going to link it, by the way, in the show notes below this episode, the title of it is Food Insecurity and Diabetes, Overview of the Intersections and Potential Dual Solutions. Can you tell us a little bit, in the last couple minutes here, a few takeaways from this paper you authored? 

Dr. Bleich: Yeah, so the big thing that it’s trying to do, and it was co authored by Romney Levy and Hilary Seligman, is to really provide an overview. There’s this very complex relationship between food insecurity and diabetes. And essentially what we know is that food insecurity increases both the risk And the progression of diabetes. And what the paper does is it outlines the four pathways through which that happens. It also identifies a number of successful intervention areas, some of which we’ve actually already talked about, which can really help address These joint problems of diabetes and food insecurity. So I really encourage you to have a look if this is an area that’s of interest to you. 

Shireen: And again, like I mentioned, we will link it below in our show notes so folks can access it. We are coming to the end of the episode. Dr. Bleich, you mentioned just a moment ago that there are things individuals can do within their own communities. Can you give us a few examples? If there are passionate advocates in our audience here today, what are things that they can do today? 

Dr. Bleich: The most important message that I want to leave you all with is we’ve spent a little bit of time talking about the Nutrition Assistance Programs. They are very effective. They reach tens of millions of Americans. However, they are not fully utilized. So about one in five folks eligible for SNAP do not participate. Only about one in two eligible for WIC participate. And only a fraction of the kids who participate in summer meals during the year are also participating in summer feeding programs. What does this mean? If you are a healthcare provider, if you work in any sort of social assistance program, if you are interacting with members of your community who you think might be eligible for programs but are not enrolled, encourage them to enroll these safety net programs work. but they don’t work. Eligible people are not participating. And so I would just really think about how you can in your day to day life or in your professional life, how you can facilitate those linkages and raise awareness about the importance of the federal nutrition assistance program. 

Shireen: Appreciate that. With that, we are toward the end of the episode. Dr. Bleich, I feel like we could do a follow on episode. This is such a rich content that if we start peeling back, this could easily turn into a two hour episode, but I truly appreciate your time here with us today. Um, can you tell us how can our listeners connect with you and then just learn more about your work?

Dr. Bleich: Yeah, so I’m a frequent contributor to a journal called the JAMA Health Forum, and I use that platform to really talk about a lot of key issues related to food and nutrition policy. So if this, these topics that we’ve talked about are interesting, I really encourage you to follow me there. 

Shireen: Perfect. And again, we’ll link everything up in the show notes so folks can easily access it. Thank you again, Dr. Bleich for your time. And to our listeners, you know what time it is. Head over to our social media, Facebook, Instagram, and answer this quick question. How do you personally navigate the challenges of meal planning and food choices to effectively manage your health? We’ll continue the conversation there. Again, go to Yumlish on Facebook, on Instagram, find this podcast post and comment below to tell us how do you personally navigate the challenges of meal planning and food choices to effectively manage your health. We’ll continue there. The conversation, Dr. Bleich, it’s been an absolute pleasure.
Dr. Bleich: Thank you so much for having me.

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