The Intersection Between Health and Politics: A Conversation with Dr. Sara Naomi Bleich on Obesity, COVID-19, and the Role of the Government

INTERVIEW BY LAYLA CHAARAOUI

HHPR Senior Editor Layla Chaaraoui interviewed Dr. Sara Naomi Bleich, PhD. Dr. Bleich is a Professor of Public Health Policy at the Harvard Chan School of Public Health in the Department of Health Policy and Management and the Carol K. Pforzheimer Professor at the Radcliffe Institute for Advanced Study. Dr. Bleich’s research focuses on obesity prevention and diet-related diseases. She is currently working on projects relating to COVID-19’s implications on food and the Supplemental Nutrition Assistance Program (SNAP). Her work has been published in the New England Journal of Medicine, the British Medical Journal, Health Affairs, and the American Journal of Public Health. She has held a number of positions, including a Senior Policy Advisor to the U.S. Department of Agriculture and Vice Provost for Special Projects at Harvard University. Dr. Bleich earned her BA degree from Columbia University in Psychology and her PhD from Harvard University in Health Policy.

Layla Chaaraoui (LC): Thank you for allowing me the time to speak with you today. Could you provide a brief introduction to your interests and the roles that you have had in health policy and at Harvard?

Dr. Sara Naomi Bleich (SNB): I have long been interested in public health and really thinking about, “How can you maximize people's well being?” So for most of my career, I have focused on Food Nutrition Policy Research, and spent some time in the Biden administration working on COVID and nutrition security and health equity. I have increasingly gotten interested in disparities, and how we can really maximize the well-being of first directly underserved populations. I most recently took a position at the University as Vice Provost for special projects with the charge of leading the implementation of the Harvard Legacy of Slavery Report. That's focused on ”How do we implement the committee's recommendations to really think about the important reparative efforts based on the truths that we unveiled with that report?”

LC: At Harvard, you are a professor of Public Policy, professor at the Radcliffe Institute, and a member of faculty at Harvard Kennedy School. I am curious to learn more about this intersection for you: why was this combination of interest to you, and how has this joint of health and government aided your research and job opportunities?

SNB: I don't know of another way to reach people at scale than the federal government. If you take, for example, the federal nutrition assistance programs, there are about 15 of them in total. Together, they reach one in four Americans over the course of a year. So even small changes can have massive impacts on millions of people. That's just one tiny slice of government. When you add in health care, transportation, and housing, there are so many different ways that government programs touch people's lives. So for me, it's really exciting to see the possibilities to bring things to scale, and the federal government and research is a really important piece of trying to create evidence based options that policymakers who are in a position to make changes can potentially adopt. For me, one of the main reasons I wanted to go into government, first with the Obama administration, and then with the Biden administration, is that I wanted to understand the role of research in policy making. It was fascinating to see that particularly in the context of COVID, where the research was changing so quickly. I think that as I reflect on government service with my researcher hat, the opportunity to see policymaking up close and personal has allowed me to learn how to ask better research questions, which are often more policy relevant, and with answers that will matter in a really short or in some defined amount of time.

LC: A lot of your research examines obesity, food consumption, and nutrition. Can you further explain the obesity epidemic in the United States, and how obesity impacts our population?

SNB: Let me explain the obesity epidemic, and let me explain food insecurity. Obesity is defined as having a body mass index for adults at least, that's greater than 30, which is your weight in kilograms over your height and meter squared. Statistically, about one in three adults have obesity in this country, and about one in five children have obesity in this country. But if you look at it by different demographic groups, you see that it really varies quite a bit. For example, about 80%, or eight out of 10 black women are overweight or obese. Amongst children, you also see differences by race and ethnicity. So while obesity impacts large swaths of the population, it does not do so equally. We see similarly higher rates among low-income individuals, for example, and we know of course, that income and race are highly correlated. The thing about obesity is that it is not just people who are carrying around excess body weight. There are mountains of literature in epidemiology and other disciplines which show that as the person's body mass index (BMI) increases, so too does the risk of cardiovascular disease, heart disease, hypertension, and others. Pick your problem, and obesity is often related. So, if we can figure out ways to address root causes of obesity, that can have profound effects on people's well being and healthcare costs.

Food insecurity is the idea that people lack consistent, reliable access to food. It's an economic measure. Based on the most current federal data, about 34 million Americans experienced food insecurity in 2021. The good news is that food insecurity among households with children was at a two decade low in that report, so that's great, particularly in the context of the COVID pandemic, which we know obviously had a huge impact on food insecurity. The challenge is that just like obesity disproportionately impacts low-income and racially ethnic minorities, so does insecurity. It is not uncommon for a household to at the same time be experiencing both obesity and food insecurity. If we step back for a second, a reason why that is often happening are these broader social determinants of health, such as poverty, poor access to health care, or limited education, but there's a broader set of root factors that are driving the disparities that we see in many diet related conditions.

LC: How have issues of food security and equity changed since your first position within the White House, your first work in the White House under President Obama and then your to now with your more current work under the Biden administration?

SNB: When I was with the Obama administration, I was joined between USDA, which is where I primarily sat. I also worked on the First Lady's Let's Move campaign. In terms of the evolution, the most significant change is that the USDA, which is the federal agency responsible for tracking food insecurity, is decades-long work. With this administration, there has been a widening of the aperture because we don't care about just food insecurity. We also care about nutrition security, which refers to consistent and equitable access to healthy safe and affordable food for optimal health and well-being. That's really significant, because essentially, that is saying that we don't just want people to have calories. We want people to have calories that count and improve their health and well-being. This is the start of what will hopefully also be a decades-long journey of the government considering both food and nutrition security as we think about health outcomes and as we think about implications for federal programs.

LC: Nutritional access in developing and low-income countries is limited, as hundreds of millions of people remain undernourished and suffer from undernutrition. However, developed countries also face these same challenges, which you discuss in your piece “Why is the Developed World Obese?” Could you further explain this phenomenon?

SNB: If we look around the world, what we are seeing consistently is that body weight is going up. It's not happening at the same rate all around the world. It's probably increasing most rapidly in countries like the United States, Mexico, and parts of the Middle East. So, the slope is different, but the fact that body weight is steadily going up is a global phenomenon. If we step back and ask ourselves the question: “Okay, well, what is driving that?” There are two fundamental things that are happening: either we're eating too much, or we're exercising too little. The factors that are driving either that overconsumption of food or the under amount of physical activity vary widely from country to country. Then, if you take a step back even further, the broader social determinants of health which drive our exercise are food consumptions, which also vary significantly from country to country. You really have to understand the local context to understand why things are out of balance. But what's clear globally is that things are out of balance. What we're also seeing is that there are a lot of higher-income countries that still suffer from undernutrition. You can be someone who has obesity and still have trouble with nutrition because even if you're taking in too many calories, they may not be the right types of calories. We also in this country have a huge problem with poverty. Particularly in the context of the COVID-19 pandemic, not just the US but in many developed countries, there are a lot of people who can't afford food. If you can't afford food, often you're making choices that may not be nutritionally adequate but makes sense from a financial perspective. There are a lot of reasons why in this country, we have this dual burden of over-nutrition, which is driving obesity in excess body weight, and undernutrition, which is driving a lot of diet related health conditions. That is a phenomenon that is not unique to this country.

LC: You’ve also examined how providing caloric information can reduce purchases of sugar-sweetened beverages among low-income Black Adolescents. The paper discusses two groups disproportionately affected by obesity: minority and youth populations. How can we use these findings to better regulate fast food marketing?

SNB: That was probably one of my favorite research studies. I'm from inner city Baltimore, and I grew up going to the corner stores in Baltimore in my neighborhood with my little allowance, which used to be 75 cents a week. I'd buy red hot potato chips, and I love them. But I would notice how much time people spent in the stores, including myself, and how much junk there was available. The stores are very, very small, and they sell huge amounts of soda. It's a bank of beverage cases. They also sell lots and lots of chips and candy. The other thing I noticed is that if you look at a bottle of soda, it would say calories on it. But most young people, and frankly most people, have no idea how many calories are in the food they consume. So, I just figured, “What if you just gave folks the exact same information, but say it in a way that they can understand?” What we essentially said was that a bottle of soda, which is 200 calories, is equivalent to a mile of walking, or 50 minutes of running, or X number of teaspoons of sugar. The way that experiment happened is that we're targeting Black adolescents. In these corner stores in Baltimore, they would walk in and there'll be these beverage cases. On the beverage case, it would be one of the four signs we were testing. What we found at the end is essentially the sign that reduced purchases of sugary beverages by telling kids that a bottle of soda was equivalent to 50 minutes of running. We did a follow up study, and found that it was the mile of walking that really got kids. I think that might be because in Maryland, you have to pass a one mile fitness test to get out of high school, so people understand what a mile means. The other thing we showed is that the signs also encouraged people toward a smaller volume, such as from a 20 oz bottle to a 12 ounce can, which as far as I'm concerned is a public health achievement. We also found that some kids walked in and didn't buy a drink at all. The thought process is, well ‘maybe you're not thirsty and you just want something to drink, but you learn this information, so you decide to maybe go drink some water.’

The other piece is, “Well, what are some of the different solutions that might work for limiting sugary beverage consumption?” What we find from decades of public health research is necessary, but often not sufficient to change information. This study was pretty novel and we did see some results which were sustained over time, about six weeks out. But what we are seeing from other research that we've done is that if you really want to move the needle, you need to use a little bit more of a stick than a carrot. So for example, we did a lot of work on the Philadelphia beverage tax, so 1.5ȼ per ounce on sweetened beverages, which includes Coke and Diet Coke. What we found is that in lots of different types of retailers, both the big ones and small ones, putting that tax in place passed through to consumers, so consumers absorbed the price. The amount depends on the type of retailer, but does that change what consumers are buying? Yes, it did significantly so. In the case of small stores, what we found is it actually seemed to result in some money in the pocket. But taking a step back, “why do we care about sugar beverages?” They are one of the largest sources of added sugar in the diet and provide no nutritional value. So, there are a suite of different policy options that you can use to try to get in individuals generally to stop drinking sugary beverages. I was particularly interested in Black adolescents, because they have both one of the highest rates of sugary beverage consumption and amongst adolescents some of the highest rates of obesity. They were a very important target population. The bottom line is, we have a lot of strategies, which we know work.

LC: Your more recent work looks at enhancing the SNAP program and analyzing COVID-19’s effect on food security. Given that SNAP only gives a family of four a maximum monthly benefit of $969 per month, it may not be sufficient to provide meals for many families. What other policies should be implemented to aid SNAP in this fight for equal food access?

SNB: [With] the recent reevaluation of something called the Thrifty Food Plan, which underpins the calculation for SNAP, the maximum monthly benefit in October of 2022 was $969. That's still not perfect, but that is accounting for inflation. This accounts for this permanent increase that happened as a result of the evaluation of the Thrifty Food Plan in 2021. Now, what also just happened is that there's something called the “SNAP Emergency Allotments.” Those were authorized as part of the Family First Step, which ended at the end of the issuance periods in February, so just about a month or so ago. What those allotments did is it gave families the maximum amount for their family size, or $95 a month, whichever was larger. So on average, families are losing about $80 per month. But still, the benefits are considerably higher than they were prior to the start of the pandemic. That said, food prices remain high and families are struggling. SNAP remains the country's frontline defense against hunger. I think where there needs to be more work is where there is dual eligibility. So, you are also able to enroll in WIC, which we need to improve the number of families who are a part of because only about half of the folks who are eligible for WIC actually enroll. That's a really important program as it is a program that is statutorily required to improve health. That's just one example. There are many ways to think about how we can supplement SNAP. Another example is through SNAP education, which is a portion of the SNAP program. There are a lot of opportunities to use policy systems and environmental change strategies to promote the purchase and consumption of healthier foods among individuals who are leveraging SNAP benefits.

LC: What have you learned from working in both health and public policy? And what are some things you hope to accomplish next, in your research, or within one of your roles?

SNB: I have learned that there's probably not a more exciting field than public health and health policy. I think the reason for that is, there are probably jobs that I cannot imagine in this field that exist as little as five years out. COVID showed us the importance of having a public health orientation to massive population level problem solving, and was so important to identifying solutions. I think one of my biggest lessons learned is that public health/health policy provides you with a really strong toolkit. What I found in my work in the Biden administration in COVID is the ability to really think critically about crisis management. I would say that's something that I've really taken away. In terms of next steps now I'm applying a public health perspective to the Legacy of Slavery work. Totally separate, but still under this umbrella of, “how do we lift all boats? How do we maximize well being for historically underserved populations?” So, I'm really excited about this next chapter. I'm excited to leverage public health skills. I'm excited to think about the intersections with health policy. I think it's a really, really exciting field. For students who are considering it, I would strongly encourage them to give it a try.