Sugar-sweetened beverages (SSBs) are considered any liquid with added forms of sugar including regular soda, fruit drinks, sports drinks, energy drinks, sweetened waters, and sweetened coffee and tea drinks (24). According to the 2020–2025 Dietary Guidelines for Americans, added sugars should be limited to less than 10% of daily caloric intake (25). However, SSBs remain inexpensive, widely consumed, are the leading source of modifiable sugar consumption in the U.S. and are linked to increased body mass index and obesity, preventable death/disability, and global diet-related chronic diseases such as T2D and CVD (26–28). U.S. SSB consumption is higher in males, young adults ages 20–39 years, non-Hispanic Black individuals and Mexican Americans, and adults with low incomes below 130% of the poverty line (24, 28). DiFrancesco et al.’s comprehensive trend analysis of sugar intake trends in 72,829 U.S. National Health and Nutrition Examination Survey (NHANES) adult participants from 2001 to 2018, indicated although SSB consumption trends decreased over time, they remained the most significant source of added sugar intake at 37% in 2017–2018 (28). Consumption of artificially sweetened beverages (ASBs) are also associated with developing T2D, CVD, obesity, hypertension and all-cause mortality; however, more scientific evidence is needed to understand conflicting associations, effects strengths and possible carcinogenic impacts at high doses (29).

Food secure households maintain consistent food access for a healthy and active lifestyle. In 2022, 12.8% of U.S. households were food insecure, and even reached as high as 20.4% during the lockdown portions of COVID-19 (April 2020), demonstrating increased vulnerability during times of economic disruption and uncertainty (30). Of the 17 million Americans that were food insecure in 2022, they met the thresholds of low (10.2 million) and very low food security (6.8 million) (30). Low food security leads to disruptions in eating patterns and a need for federal assistance such as SNAP benefits, while very low food security results in disrupted patterns and reduced food intake (30). In 2022, 11.7 million adults and 783,000 children, faced very low food security, where food intake steadily decreased throughout the year due to direct lack of money and resources for which to purchase healthy food (30). According to a 2019 national population-based CDC survey, approximately 90% of all Americans do not consume the recommended amounts of F/V (31, 32). Common U.S. barriers to purchasing, preparing and consuming F/V are more pervasive in low resource communities with lower food security and are high priority areas for benefit design prioritization (33). Food insecurity is linked to additional healthcare from skipping and delaying medications and healthcare visits, further perpetuating the problem of poor health (34). U.S. food insecurity demonstrates well-characterized rural and urban geographic, regional patterns with disproportionate impacts on high poverty counties with African American, Alaska Native/American Indian, racial and ethnic minority groups (35, 36). During the COVID-19 pandemic, all U.S. counties were impacted by hunger and food insecurity, and after the pandemic, food insecurity rates among African Americans/Black individuals or Latinos were higher than white individuals in nearly all counties (99%) (36). Nine of ten high food insecurity counties are rural; 82% of the highest food insecurity counties are located in the South and directly linked to unemployment and poverty (35, 36). Current 2024–2034 Congressional Budget Office post-pandemic SNAP projections expect participation of 41.1 million individuals and a 17% cost decrease ($23 billion) due to the end of COVID-19 emergency funds supporting additional food benefits to families with children (37).

UPFs are foods that have undergone multiple industrial production processes, include frequent use of cosmetic additives for longer shelf-life and hyper-palatability, and involve synthetic formulations of energy dense ingredients including sugar, salt, and trans fats (38). Population based cross-sectional studies indicate UPFs are common staples of the “Westernized diet” for the past two decades (14, 39, 40). They are often found in “food deserts,” where healthful nutrition is minimal, and “food swamps,” where UPF-market retailers dominate the healthier options (41). UPFs induce a high glycemic response, possess low satiety, and account for more than half the total dietary energy consumed in the U.S. (38). Srour et al. (42, 43) found higher UPF grams per day intake was associated with higher risks of CVD, T2D, coronary heart and cerebrovascular disease. “Westernized” UPF eating patterns have grown in prevalence globally and possess both negative human health and environmental impacts (44). Existing obesity, chronic disease and undernutrition health challenges for which UPF contribute, are significantly compounded by climate change, sustainable agriculture and food production availability. Three factors—undernutrition, obesity and climate are a “synergy of pandemics” (45). To reduce UPFs, harmful production and consumption supply chains must be neutralized, while increasing availability of minimally processed nutritious foods sourced from environmentally sustainable agriculture and climate-smart farming practices. Diets lower in animal products generally emit fewer greenhouse gases (GHG) than meat heavy Western diets. Climate smart and resilient foods feature diet diversification with whole grains, legumes, fruits, and vegetables sourced from environmentally sustainable food systems, reduced meat sources, focus on key energy and nutrient crops (i.e., vitamin B12, folate) and parallel agriculture and livestock designs with minimal food waste losses (46, 47). Nutritious dairy, lean meats, and fresh produce grown in protected conditions and/or distributed through air transportation may have higher total GHG environmental impacts despite being very healthy. Ensuring U.S. food and nutrition policy can synergistically advance improvements in both human and environmental health, simultaneously protects both key determinants of human welfare. Per Willet et al. “food is the single strongest lever to optimize human health and environmental sustainability on Earth” (47).

As shown in Table 3, prevalence and financial burdens of T2D, CVD and other diet-related chronic disease has reached epidemic levels; these issues must use a multifactorial approach with diet at the center. “Food is medicine” (or produce prescriptions), is an evidence-based policy approach gaining much interest and favorable feedback from multi-sectoral stakeholders across the political spectrum to facilitate consistent use of USDA-DHHS dietary nutrition guidelines in routine healthcare, especially for those with limited access to healthy foods and health insurance coverage (25, 48). For example, Scrafford et al.’s economic modeling projections estimated $16.7–$31.5 billion healthcare cost savings from conformance with the 2015–2020 U.S. Dietary Guidelines (49). Although protocols vary, several studies indicate U.S. guidelines with greater intakes of whole grains, vegetables, fruits, legumes, nuts and lower intakes of processed foods, meat and poultry, and SSBs, can be tailored to reflect a wide variety of cultural preferences and ethnic traditions (48–50). Community based organizations (CBOs) help ensure appropriateness of “food is medicine” offerings by preserving cultural heritage, while maintaining healthful dietary guidelines and ensuring reduced sugars, saturated fats, and sodium (25, 48–50).

“Food is medicine” interventions typically feature prescriptions based on a person’s unique health, lifestyle and diet-related disease medical diagnosis requirements that can be linked to insurance reimbursement, care coordination and case management structures. Specific formats include medically tailored meals (MTM), customized groceries, food insecurity produce prescriptions, precision medicine, precision health, and precision nutrition science. Although these disciplines and interventions can help combat diet-related chronic disease and significantly reduce healthcare costs, sufficient scientific evidence is needed for upscaling reimbursable interventions in clinical and community settings, especially for ethnic minority, vulnerable and underserved populations (48, 51–53). For example, Berkowitz et al. found 50% fewer inpatient admissions and 70% fewer emergency department visits for dual eligible Medicare-Medicaid participants that received MTM for 6 months with an average net savings of $220 per patient (54). An additional study by Berkowitz et al. found MTM service with 10 weekly meals was associated with significantly decreased inpatient admissions, fewer skilled nursing facility admissions, and ~ $753 less medical expenditures per person (55). Nutritionally calibrated “food is medicine” interventions, continue to show significant promise by empowering patients and caregivers to optimally prevent and manage chronic diseases and related complications (48).

Well-designed taxation structures consistently demonstrate evidence of effective SSB consumption decreases contributing to prevention and control of non-communicable diet-related chronic diseases, such that more than 85 countries at national or subnational governance levels use some sort of SSB taxation (56–59). A 20% tax on SSBs, such as that advised by the World Health Organization, can help reduce sugar consumption with little nutritional value by disincentivizing SSB purchases for healthier consumer options, reduce risk of diet-related chronic diseases and strengthen community health (59). For example, Krieger et al. collected data on 7 U.S. cities with a 1–2 cents per ounce SSB excise tax; annual tax revenue was $133.9 million with allocations of $133.2 million back into community infrastructure and programs for a full fiscal year (60). Roberto et al. evaluated a beverage excise tax implemented on both SSBs and ASBs in Philadelphia, resulting in a 51% purchase decrease, but this was offset by increased sales in bordering regions without the tax (61). Price plays a key role in food choice, making SSB tax an important tool to target the largest sugar contributor to the U.S. diet and reduce SSB purchases. Revenue should be allocated into a tax fund with clear specifications, governed for promoting health equity, addressing key SDOH priorities and tailored to community needs.

Vendors, retailers and small grocers in high poverty environments have lower access to nutrient dense foods from producers (62). A significant obstacle is that current U.S. F/V subsidy programs are piecemeal and not applied to the entire population. Pomeranz et al. examined the feasibility of various national F/V subsidies in existing local programs and their population health outcome impacts and concluded a nationally mandated subsidy can help reduce diet-related chronic disease and U.S. health economic burdens (62). These programs should be broadly expanded in the 2023–24 Farm Bill and integrated into Electronic Benefits Transfer (EBT) modalities while broadly upscaling other innovative digital program administration and online grocery purchase options that work well for consumer preferences, such as the popular F/V ‘double-bucks’ formats (63–65). Ensuring a greater variety of access, ordering and delivery approaches with online modalities, sufficient Broadband infrastructure and retail hub access will be key to advancing innovative SNAP benefit participation and utilization, especially in rural areas featuring complex interactions between individual state, multi-state, federal and commerce networks (62). Supporting and empowering lower income and underserved communities to strengthen access to healthy, fresh and unprocessed foods at affordable prices, with adequate SNAP benefits, in convenient consumer empowerment formats, even during times of market uncertainty and government crisis (i.e., COVID-19), are key to reducing U.S. nutritional and diet-related health disparities (66, 67).

Policy options for government regulations reducing consumption of UPFs and food additives, to strengthen promotion of SNAP benefits for minimally processed F/V from sustainably sourced food systems, would greatly improve nutrition, consumer choices supporting specialty growers, products and crops (68, 69). Adherence to mandatory or recommended industry quality standards for limits on unhealthy ingredients and formulations using trans fats, salt, and sugar provide a well-defined approach and yield predictable results based on political feasibility. Although no singular policy on its own can change the U.S. food system to prevent T2D and CVD, thoughtfully designed interconnected policies that mutually reinforce UPF reduction and consumption in vulnerable populations and environmental contexts, are increasingly recognized as a valuable strategy for promoting healthier diets and nutritionally equitable, food secure landscapes (44). Policies to reduce and mitigate UPF harms can be enacted in a step-wise approach, and include front of packages (FOP) warning labels, marketing limitations and ingredient restrictions, particularly for young children, adolescents (44, 70, 71). Several countries have adopted the use of a warning label on UPFs, directly informing consumers leading to a decrease in consumption (44). Since most U.S. rural areas with greater poverty levels rely on mid-size and family farm economies, government must also foster an equitable, climate-smart food system by integrating both human health and environmental sustainability priorities to be sufficiently resilient to withstand natural disasters, adverse weather events and agricultural conditions (72, 73). Climate-smart and sustainable diets should consist largely plant based foods, unsaturated fats, reduced amounts of animal food sources and limited UPFs, trans fats, refined grains, added sugars (45, 47). Government-promoted shifts and bipartisan multi-sectoral collaborations can be harnessed to help ensure the U.S. food system to achieve sustainability, minimize waste byproducts, and stay within necessary boundaries to protect domestic and global earth systems (47, 72). Critical boundaries for consideration include GHG emissions targets, practical feasibility for cropland usage and climate disaster impacts, freshwater usage, nitrogen and phosphorus cycling, and biodiversity loss mitigation.

The EAT-Lancet Commission Report outlines an integrated global framework with quantitative scientific targets for both healthy diets and sustainable food production to avoid severe environmental degradation and prevent approximately 11 million human deaths annually (47). This landmark report recommends regionally tailored healthy diets within optimal caloric intake guidelines comprised of a diversity of plant-based foods and unsaturated fats, while limiting amounts of animal source foods, refined grains, highly processed foods and added sugars to support large scale production and sustainability models.

Evidence-based “food is medicine” interventions and nutrition access including MTM, medically tailored groceries, precision medicine, nutrition, health and others should be prioritized for research funding and implementation in the U.S. healthcare system (18–20, 52, 53). Risk predictions, pilot interventions and community based supports for Medicare/Medicaid high cost/high need patients (dual-eligibles) and other at-risk populations shouldering high burdens of chronic diet-related illnesses should be especially prioritized if unable to cook or shop for themselves. Patients with high cost chronic conditions T2D, CVD and other diet-related chronic illness should be screened by CBOs within the healthcare SDOH contexts for “food is medicine” intervention eligibility (6, 48, 74). Culturally tailored interventions and community preferences must be honored in clinical and scientific research initiatives. However, Medicare, Medicaid and private insurers should reimburse CBOs, providers, and retailers for “food is medicine” interventions and services to ensure they are available for as many as possible. Healthcare providers should receive reimbursements for screenings according to the strength of evidence from robust federal scientific initiatives, guideline recommendations and population level nutritional surveillance programs.