Food Policy,Systems,and Environment: Strategies for Making Healthful Food the Easiest Choice

Angie Tagtow: The goal of this roundtable is to have a discussion about the role of food policy, food systems and food environments in assuring that all people, but especially children, have regular access to healthful food. It is an opportunity to share your expertise and the contributions that each of you have made within the world of food systems. I especially would like you to share your vision of what is a healthy, sustainable, or resilient food system. Secondly, we want to discuss how practitioners can engage in this work and highlight tools and resources available to them. Joan, would you start by commenting on why there is increased attention by clinicians and practitioners to food policy, food systems, and food environments and their role in health?

Joan Gussow: I remember speaking 30 years ago and saying, what did we think was going to happen to the children who grew up being exposed to the kind of things they were seeing on television and the kinds of foods they were being encouraged to eat? We now know how they grew up. We have a health crisis in this country and our children are the leading edge. But there are a lot of overweight and obese adults too. We have serious problems in this country and I think people have woken up to that. Now they are saying, “What can we do?”

Cynicism aside, I think the way we make healthful food the easiest choice for all eaters, now and in the future, is to regulate innovation. I think that the number of products in the supermarket—the great majority of them things we don't want people to eat—makes it extremely hard. So my own feeling is we are all struggling to try to figure out what to do to change things. I salute people who try to work in the food marketplace and we have people from planning groups, actually, working on the environment now and seeing if they can involve themselves in the obesity issue and so forth. We have a lot of people engaged because we have such a serious problem.

Angie Tagtow: Great. Mary, Kate, or Jennifer?

Jennifer Wilkins: I really believe that there is increasing awareness that traditional approaches, such as providing information about nutrient and energy content of food, just aren't enough. At the January 31^st 2011 news conference where the new US Dietary Guidelines were unveiled, Secretary of Agriculture Tom Vilsack referred to adult, child, and adolescent obesity as a health crisis in the U.S. “that we can no longer ignore.” The new Dietary Guidelines actually offer numerous strategies at the individual, institutional, and community level that need to be employed to address the obesity crisis. ¹ There is more and more evidence that multi-level, integrated, and comprehensive approaches are needed. So, I think, given the resistance of obesity and other chronic diseases to traditional program delivery strategies, clinicians and practitioners are increasingly compelled to broaden their scope of practice to include food policy, food systems, and food environments as potential mechanisms for improving public health.

But also, and this is probably just as much a reason for an increasing focus on policy, systems, and food environments, is the recognition that there are, other looming and compelling crises that also cry out for a shift in diet. The obesity crisis is in the midst of a constellation of interrelated crises. Climate change, global energy supplies, and declining fish stocks are at the top of the list of global crises to which decisions about how much and what we eat contribute. Within this context, the issue of health and how to decrease over-consumption and ensure access to healthy food for the nation's children is quite complicated and begs the implementation of comprehensive, thoughtful approaches.

Mary Story: There has been positive movement the last few years in terms of a focus on environmental and policy approaches for obesity prevention. And there is more evidence-based research on environmental and policy research that we had not seen before.

Now there is growing recognition in the health and education fields that individual behavior change can only occur in a supportive environment that has access to affordable and healthy food choices and opportunities versus collectivity.

In public health, there is evidence that just education alone probably has the smallest impact on interventions to affect overall population health, and that changes to the social and physical environment may have the most impact. There have been very positive changes compared to five years ago in terms of changing the school food environment to have less unhealthy food and beverages and more healthy foods and beverages in vending machines. When you look at what the situation was like in the mid-2000s at schools, some of the school stores looked like mini-convenience stores.

However, there is still a need for continued changes in schools to improve school meals and have more quality physical education. But schools are one venue where there has been incredible political, legislative action the past decade to improve the food environment.

Kate Clancy: Jennifer, you used the phrase, and Mary just did, too, of wanting to improve access to healthier foods. I think there is a caveat there and that is that we may want to improve the access to a lot of healthier foods in a lot of different places, but I do not really think that is going to be enough. There are a lot of other personal and other choices here.

The other thing I would add is that I hope that we will not go through the whole conversation today without talking about physical activity. I know that you have brought together nutritionists, but we are all nutritionists, obviously, who are thinking about climate change and also the physical environment.

Angie Tagtow: What does the research say about how some of these policy, system, and environment changes may or may not have an effect on diet-related diseases? Mary, let's start with you as you have done a lot of research in the area of advertising and marketing to children.

Mary Story: We just did a recent review looking at neighborhood food environments. We know that poor dietary patterns and obesity are established risk factors for chronic diseases. These risk factors are linked to neighborhood deprivation. Differences in neighborhood access to healthy food have an important influence on health.

In our review, we found that research is strong showing that neighborhood residents who have better access to supermarkets tend to have healthier diets and lower levels of obesity.

With neighborhood disparities in access to healthy food and the link to health and wellbeing this speaks to the need to develop strategies to bring healthy food into low-income neighborhoods. This is being done by bringing more grocery stores into low-income areas and through local efforts such as community gardens and farmers' markets and mobile fruit and vegetable vendors.

But while we need to increase access to healthy foods for all Americans, we also have to decrease access to the unhealthy foods. We need to look at what we can do to reduce sugar-sweetened beverages (SSBs) since there is a link between sugar-sweetened beverages and weight gain. Schools have made positive changes in removing sugary drinks and now several states and localities are looking at taxes on SSBs.

Kate Clancy: Mary, do we have any data—and I think this is directly to the question of adult obesity, maybe, more than children. But with the increase in, let us say, obesity across the population, what do we know about the increased rate in the middle class in comparison to low-income adults?

Mary Story: Obesity is prevalent among all American adults—with two-thirds of the population being obese or overweight and one-third of children being overweight or obese. But the groups that are most affected are low-income and racial and ethnic minorities.

Angie Tagtow: Kate, do you want to talk more about creating environments in which physical activity becomes part of a daily routine?

Kate Clancy: I think that it is really a question of resources and political will, as well as a lot of other things, to make sure that changes are being made to address the issues. These include the lack of sidewalks in suburbs, no walkability to places to buy food and no PE, and the list goes on and on. I do think it is a great benefit that Joan already mentioned that the planning community has come into the conversation—actually, they came in about ten years ago—in terms of looking at the effects of sprawl on health and other things like that. I will add that I do not think we want to ever separate the food environment from what people call the built environment or the active environment.

Jennifer Wilkins: To go back to the question of what research can offer, some of the recent work that the Rudd Center has done looking at the impact of changes in pricing, adding a certain level of tax to, say, sodas is quite compelling. The role of pricing on intake of nutrient dense versus energy-dense options is, of course, complex, but using pricing through taxes or incentives may have a positive impact on intake in different sectors of the population. That kind of research, I think, can help in terms of policy having to do with the basic pricing, if you will, maybe even in terms of subsidies for commodities and how that relates, then, to the very cheap price of empty calories in the marketplace.

Joan Gussow: I have been particularly struck lately by the issue of inequality in this country. There was just a major piece in the Times showing that we were the worst of the worst in terms of the Gini coefficient, that we have the most inequality in terms of income. I do not really think, as Kate says, that we cannot not talk about exercise, we cannot not talk about money here. We are talking about the people who are most at risk, the people who can least afford the foods we want them to eat, and we really have to recognize that we all need to find ways of addressing the question of income inequality as services are cut and the rich are making off with more and more money. We have to have some kind of force coming from below saying, “This will not do.”

It has to do with whether people can exercise, if they live in neighborhoods where they cannot. We all know these things. They are all the reality. But the reality is, we just have this incredibly unjust society, and it is making the poorest people sick.

Mary Story: Building on what Joan said, turning this into a food justice issue of a lack of access to healthy food in many low-income neighborhoods.

Jennifer Wilkins: I would say that goes across the food system, starting with the people that produce our food, the people that work on farms, the people in processing industries. We have to think about justice throughout the food system, and really address the inequalities when it comes to food making, the money in the food system, and who has the influence on policy in the food system. Until those things are really addressed, I do not think we are going to be directing policy in a way that is at its core based on public health.

Angie Tagtow: That is actually a great segue into our next question, and Jennifer you can lead off because you have already touched on federal policy. When we think of food system legislation we often think of the Farm Bill and Child Nutrition Reauthorization. How do you see those pieces of federal legislation as impacting the availability, quality, quantity, and the safety of our food system?

Jennifer Wilkins: One of the things I would like to lay out first is a potential conflict or maybe contradiction, because we talk about making healthy food really affordable and accessible, and generally what that brings to mind for people is really inexpensive fresh fruits and vegetables. But then if you look at the production side of that, we have to consider, do we not want food producers who are essential to assuring food access and availability, to make a reasonable living? So we can talk about reducing food prices, but maybe where public policy can come in is subsidizing the price.

We have many policy mechanisms in place already that, if used differently, could really make a difference in terms of access, availability, and affordability of good food for low-income consumers. I am thinking of the biggest of the big food assistance programs—and Kate, you know what is coming, so we can have our little disagreement again. If we look to the largest title in the Farm Bill, the Nutrition Title, where SNAP is, the Supplemental Nutrition Assistance Program, we can find a largely untapped opportunity to improve public health while at the same time stimulate a more diversified sustainable agriculture. Currently, there are no nutrition standards in SNAP, formerly the Food Stamp Program (i.e., no restrictions on the type or quality of food that can be purchased), and the food system at the time that it started was a much different system. The food supply did not have the high proportion of empty calories that it does now, and it did not have the high proportion of shelf space devoted to foods that are very inexpensive but basically provide sugar and fat (i.e., processed, packaged foods).

Could we not take advantage of the fact that, as a nation we—and thank goodness we still do—make significant, though still inadequate, investment in feeding the poor and make a shift in SNAP policies so that it would push more of a healthful “dietary profile,” if you will? We have models for this already, especially with the WIC, Women, Infants, and Children Program, where participants can use their WIC vouchers only to buy foods that meet a nutrition standard that a few years ago (2007) was revised to meet the Dietary Guidelines. And more recently WIC has added special vouchers each month that can be used only to buy fruits and vegetables. In these ways, the investment of public money to nutrition assistance has a better chance of nourishing the poor, not just filling them up. And another likely outcome of placing a similar nutrition standard on SNAP would be that the benefit itself would become an effective nutrition education tool—by steering participants toward more nutrient dense options over nutrient poor calorie-packed junk food, their choices in the marketplace would be more in line with the Dietary Guidelines.

These mechanisms could spell positive shifts in the food system at the same time since more and more Americans are enrolled in food assistance programs. According to the USDA's latest Food Assistance Landscape report, about 15 percent of U.S. households are “food insecure” and therefore will need this kind of help. Actually, the report suggests nearly half of all U.S. kids will be on food stamps at some point during their childhood.

I'm not suggesting that developing a nutrition standard for SNAP would be easy. And food and nutrition professionals would certainly disagree. But it certainly is worth considering given the potential public health and food system benefits.

We also need to change our subsidy program, but I do not even know where you start to do that, given the very powerful interests, even though it is dwindling in number, that seem to have a grip on continuing the system of agricultural subsidies.

Joan Gussow: A lock. Not just a grip, a lock.

Kate Clancy: I want to bring up a couple of things and one is that food that is the healthiest is what is coming out of pretty much any farmer's field unless there have been too many pesticides or fertilizers on that field. So much of the problem is with manufacturing and with processing. I think we are giving the Farm Bill a lot more attention than it requires, and not putting enough attention on manufacturers in terms of what happens to perfectly healthy food after it goes out of the farmer's hands.

Another thing is that the USDA Economic Research Service has recently done some research, I think in reaction to the American Medical Association article that made such a big deal about saying that the cost of fresh fruits and vegetables had gone up so much over time and the cost of junk foods has gone down. When ERS disaggregated the data, they found there were 12 or 15 types of fruits and vegetables where the price, the real price, had not changed at all. I do not think a lot of people saw that analysis, and I think it is one of our jobs to pay attention to the fact that the price has not changed for many fruits and vegetables, and also to try and figure out how to make that message clearer to people.

The other thing I want to point out is that even Daryll Ray, who is one of the more radical agricultural economists we know, has argued that there is very little impact of subsidies on the extent of obesity or unhealthy diets in the country. You do not have to agree with that, but I think it is important that nutritionists and people who are arguing about this read all the studies and make some decisions about where we should put most of our energy in terms of trying to identify and address the right problem.

Mary Story: I would like to mention another area of food policy, and that is the Child Nutrition Reauthorization Bill. The Healthy, Hunger-Free Kids Act was just signed in December 2010. This is historic in that it makes the most significant investment in the national school lunch program in more than 30 years. It shows the positive effects of increasing the availability of foods that support good health for kids. This new bill gives USDA the authority to develop nutrition standards for all foods sold on school campuses throughout the school day. So the Child Nutrition Reauthorization Act that is, again, every five years, like the Farm Bill, is a place where we really can focus our efforts.

I wanted to mention one other area that is not covered by the Child Nutrition Act or the Farm Bill, but I think is absolutely critical if we want to reduce childhood obesity, and that is the regulation of food marketing to children. The Institute of Medicine (IOM) Food Marketing report, in 2005, found strong evidence that food and beverage marketing practices that target youth are out of balance with healthful diets and contribute to an environment that puts their health at risk. ² Unless we address marketing to children of unhealthy foods, I do not think we are going to really reduce childhood obesity.

I just wanted to add that I remember, Joan Gussow, that you had an article on advertising of unhealthy foods to children in the Journal of Nutrition Education years ago. ³

Joan Gussow: I remember being very scared when I published that article, because it broke all the rules and mentioned foods and said some of them were bad. I was saying to someone this morning that what gave me my courage was that I got about 50 letters after that article came out from people saying, “Thank God somebody said it.” So it was clear that people were feeling that way, and they felt rather helpless against this onslaught.

I am glad you brought this up, because I guess I feel a little like an old-timer in this whole thing. But it is appalling to me the degree to which we have not really done anything about excessive food marketing targeting children. I mean, what has happened is, it [food marketing] has gone off television, because children are not watching children's television, they are watching everybody's television now. It has gone on to the internet, so children are being marketed to all the time. It has gone into schools, onto school bags, into textbooks. It is everywhere. If you are learning to count, you count four pieces of Reese's Pieces—it is unbelievable how pervasive the marketing is.

We do not seem, as a culture, to be capable of saying our children ought to be protected from these kinds of exposures which are killing them. So I would be happy to hear from anybody who has any ideas about how we begin to change that. Interestingly enough, my article got reprinted at the time in the journal Clinical Pediatrics, and the title was, “It Makes Even Milk a Dessert” which was a great title for it. ⁴ It was not the title the Journal of Nutrition Education used.

Kate Clancy: I will just mention that I think 1974 or 1975 was the first year I published an article on the effects of television advertising on kids' food intake, and of course then we did the food advertising rule at the Federal Trade Commission. I think now we need some incredible legal brains to figure out how to not run into the First Amendment—which was the reason that it did not work the first time—with regard to television advertising, or advertising to kids. I have not seen anybody tackle that in a really long time. It does not mean that we cannot try to really get to the political will, but the manufacturing sector is always going to go back to the First Amendment.

Joan Gussow: Do you remember what happened the first time the Federal Trade Commission tried to regulate food advertising? They were shut down for two days because Congress did not appropriate the money to keep the agency open.

Kate Clancy: And we at the Federal Trade Commission were called the “national nanny.”

Joan Gussow: Yes, and the food marketers came to Washington on that and just shut down the Federal Trade Commission. So we are not in a particularly wonderful environment for doing any kind of regulation these days, but I think we all just have to keep trying.

Kate Clancy: Absolutely.

Angie Tagtow: Bridging the conversation from a federal-level activity down to a local or regional level—in 2009 the IOM released the publication “Local Government Actions to Prevent Childhood Obesity.” ⁵ Mary, you were on that committee. So my question is what can local governments really do in all of these areas to support more healthful nutrition and physical activity behaviors, especially for children?

Mary Story: The Institute of Medicine report, which is on the IOM website, came out in September of 2009, and has evidence-informed strategies that communities could use. They are focused both on actions for healthy eating and actions for increasing physical activity. Under the actions for healthy eating, there are two main goals: one is to improve access to and consumption of healthy, safe, affordable foods through strategies like retail outlets, restaurants, community food access, and also increasing breastfeeding; and two is to reduce access to and consumption of calorie-dense, nutrient-poor foods, through tax strategies or adopting land use and zoning policies.

Joan Gussow: Mary, has anybody used the idea of zoning so that you cannot have fast food places and places to pick up junk food near a school?

Mary Story: Yes, and the Robert Wood Johnson Foundation (RWJF) has devoted many resources to looking at environmental and policy approaches. For example, one excellent resource is the RWJF funded NPLAN (National Policy and Legal Analysis Network). NPLAN has developed local zoning templates that communities can use and these are on their website (www.nplanonline.org). Researchers are looking at corner stores located in close proximity to schools that sell unhealthy foods and zoning issues. There are data to show that fast food places often are located in close proximity to schools and that appears to be related to obesity risk.

Jennifer Wilkins: There is a really creative program that I think was proposed for New York City looking at the improvement in grocery stores in the city. The retailers were offered incentives to have a certain amount of shelf space in the store devoted to nutrient-dense foods to get the money to do the improvements. So I think incentives like that can be very useful.

Another example in the Child Nutrition Reauthorization Act supporting local action is support for farm-to-school programs, so that would be something that is also very useful at the federal level that can have a local impact.

Angie Tagtow: Your thoughts, Eduardo, on what local governments can do to support not only nutrition but physical activity behaviors?

Eduardo Sanchez: There are actually a couple of other reports that came out at around the same time as the IOM report, another RWJ-supported healthy communities report came out and the CDC issued a report.

So in the IOM report there are 58 what we called action steps. Roughly half of them are in the food system area, and roughly half of them deal with physical activity and the built environment. The IOM report focused on food and built environment strategies likely to directly affect children and that take place outside of the school day. Twelve were identified as “most promising.” Among the 12 are the following: Develop media campaigns to promote healthy eating and active living; Attract supermarkets and grocery stores to underserved neighborhoods; Require menu labeling in chain restaurants; Mandate and implement strong nutrition standards for foods and beverages in government-run or regulated after-school programs; Adopt building codes to require access to, and maintenance of water fountains; Build and maintain parks and playgrounds that are safe and attractive for playing, and close to residential areas; and Institute policies mandating minimum play space, physical equipment, and duration of play in preschool, after-school, and child-care programs. ⁵

Just the other day, I spoke at a school community garden event in Dallas, and there was discussion about policies and zoning ordinances to make it easier for folks who want to put community gardens in their communities to be able to do so. In some of the talks that I have done about local level actions to address healthy eating and childhood obesity, one issue that has come up that I do not think is addressed in the local government actions report is the idea of lower water rates for those organizations and individuals that are tending community gardens. If I understood correctly, the consumer rate is different than the corporate rate—and that having an exemption, a waiver for the lowest possible rate, that in some places may already exist but in other places may require an explicit policy, would also help community gardens.

Angie Tagtow: Does anyone else want to comment on what local governments can do?

Mary Story: I think that local governments are really important and a lot of innovation happens at the local level that can then go up to the state level and federal level. But I think having local governments involved is the best place to see what works and to come up with innovative things that often cannot be accomplished at a state level, or a federal policy level.

Angie Tagtow: So, Mary, how do practitioners get engaged? What can practitioners do at the local level to make food policy, systems, and environmental changes that support healthful food choices?

Mary Story: It is probably easier to get involved at the local level than it is at the state level. Also, in the local government, the IOM report, there are recommendations to have local food councils or healthy food, physical activity councils that really can bring people together, and this would enable more impact at the community level.

Jennifer Wilkins: In terms of what practitioners can do, just becoming aware of these different recommendations, these ideas, and these best practices is so important—getting food system policies on the agenda of different community group meetings, working through cooperative extensions if they exist in the community, and really becoming that local resource for ideas and working with groups to inspire their own versions of those strategies.

Joan Gussow: We cannot underestimate the effect—on the potential to change children's eating habits—of school gardens and community gardens. We know that they really change what people eat and that that is something practitioners can really promote.

Eduardo Sanchez: I would underscore the importance of (A) knowing what is going on in communities, (B) referring to the three previously cited reports and (C) meeting the community where it's at in terms of its awareness and readiness to take action.

Rather than thinking that they need to be where you are, it is more important to ask “where are they?” If it is about engaging food and food-related policies, we need to ask, “where are they with these issues?” Then, how do you sit together at the table and mutually put food system and health benefits on the table. Then perhaps create a bridge to even more health folks, nutritionists and health educators, for example, who sometimes are not thinking along the lines of a community garden or water fountains as strategies for health.

Kate Clancy: It seems to me that—and I am assuming dietitians are health practitioners, too—all of these people have different roles, and one is the professional role. But probably most of them are parents or they live in neighborhoods where they can use their positions and their knowledge by being inside PTAs and being on neighborhood councils to put together community gardens, et cetera. I could see them as separate forces that would be really useful inside local areas.

Jennifer Wilkins: Building further on that, I think that a lot of us in this movement who are interested in these areas do not look like a lot of the members of the communities that are really affected by the negative aspects of the food system. So part of the role of the practitioner, I think, is to engage different audiences from the community in being that spokesperson, so that if you are not really of the same culture or the same ethnicity, then building that capacity within those groups is, I think, critical to change, because you want them to be leaders and change makers.

Eduardo Sanchez: Agreed, Jennifer. I had an experience that I want to share with you. At a talk that I gave at the Dallas school with the school gardens program, I could not answer a question about why the vegetables grown in the school garden could not be served in the school cafeteria. But it turns out that there was a school board member in the audience who agreed to investigate what the barriers might be. Are they real? Are they perceived? And how would one go about changing those barriers? Practical considerations, such as consuming vegetables in the cafeteria, sometimes are not thought about and will not be thought about unless you put people around the table and start asking, “Okay, so you have gardens and you are growing food. Where do you want to go with that?” These are the kinds of questions and issues where health practitioners can help bring a perspective that may drive a point like that home.

Jennifer Wilkins: Again, that relates to policy. These barriers might be at the local level, state or federal, and may restrict the use of locally grown or garden-grown food to be used in the cafeteria. I am not undermining or not saying that the importance of food safety is not there, it really is, but sometimes policies can create barriers where they needn't.

Angie Tagtow: There was a new document released—a joint effort by the American Dietetic Association, the American Nurses Association, the American Planning Association, and the American Public Health Association—that framed quite concisely the principles of a healthy, sustainable food system. ⁶ How can communities or health practitioners use tools like that to perpetuate change?

Jennifer Wilkins: I took this document to my department chair who thought it was so amazing, so I think that is a good question. Disseminating through our networks is a first step. Then also operationalizing and taking that document and saying, “So, what does this mean on the ground to us in this community?”

Angie Tagtow: Do you have any other tools to share that would be very helpful for health practitioners?

Mary Story: One tool that I think is very helpful is the USDA Food Environment Atlas that you can find on the USDA Economic Research Service website (http://www.ers.usda.gov/foodatlas). From this website one can get a spatial overview of a community's ability to access healthy food. It includes factors related to food choices, health and well-being, community characteristics at both the county and state level, and you can map grocery stores and chronic disease rates such as diabetes, obesity rates.

The other resource that I think is helpful for childhood obesity is the Robert Wood Johnson Foundation Center to Prevent Childhood Obesity. It is www.reversechildhoodobesity.org. There is a lot of information there and resources for practitioners. Also, the letsmove.gov website has a lot of strategies for practitioners, both at the local and state level.

Kate Clancy: I will add a “tool”—a systems approach that encourages multiple simultaneous interventions, in local areas. I understand that more recently, foundations and other grantors have been more willing to think about these when they would not do that before, because they would not know what was actually working and what was not.

I cannot name a particular tool, but I think it is critical, especially with all these other issues coming along, for example this great increase in food prices that is going to continue, because you do not have world reserves of grains; and climate change, which, as we all know, is coming much faster than anybody thought. The tools that should be developed will help people think about feedback loops and systems analysis. We also need to develop tools for people in local areas, starting with practitioners, to make it easier for them to see the systems overlaps and the contradictions so that they can be asking the right questions about what should be done.

Eduardo Sanchez: The Food Trust has done work in some specific places. In December 2010, the Food Trust released a report, “Food for Every Child: The Need for More Supermarkets in Houston,” that focused on Houston to raise awareness about food system shortcomings in Texas and policy solutions. ⁷ The work of the Food Trust coupled with the USDA Food Environment Atlas can be a powerful catalyst for change.

Kaiser Permanente is obviously doing some work on a very different level and in a different way of thinking about this by taking steps to procure food locally for its facilities and the people in them. There are going to be discussions in communities across the United States in the post-health reform environment about accountable care organizations, ACOs. On the one hand, we need to understand how an ACO is defined, and, on the other hand, we will need to articulate clearly that the food system, because it can help or hinder health, should be considered part of an ACO.

To make this point more clearly, more than 50 million Americans have prediabetes. Healthy eating and physical activity can lower, by more than 50%, the conversion of prediabetes to full blown diabetes, a very serious disease. Food policy, food systems, and food environments that make healthy eating the easy and desired option are necessary to promote health and prevent and reverse obesity, prediabetes, diabetes, and a host of other chronic diseases.

Angie Tagtow: I want to thank each of you for taking time out today and participating in this roundtable discussion.