March 7, 2022

Food is closely linked to health, yet federal nutrition research is underfunded, even as the costs of diet-related diseases are skyrocketing. Does Washington hold the key to solving the obesity crisis?

What Americans eat is making us sick on a staggering scale, but judging by federal investment in nutrition research, Washington doesn’t seem to care.

Diet-related illnesses like obesity, Type 2 diabetes and high blood pressure are on the rise while heart disease remains the leading cause of death. Treating these intertwined epidemics is a top driver of ballooning U.S. health care costs.

But even in an increasingly health-conscious America, the federal government has devoted only a tiny fraction of its research dollars to nutrition, a level that has not kept pace with the worsening crisis of diet-related diseases. Studying the relationship between diet and health is such an afterthought that Washington doesn’t even bother tracking the total amount spent each year.

A POLITICO review of federal budget documents reveals that at the National Institutes of Health and the Agriculture Department — the two agencies that fund the majority of government-backed nutrition science — the share of research dollars devoted to nutrition has stayed largely flat for at least three decades, and pales in comparison to many other areas of research.

Take NIH. In 2018, the agency invested $1.8 billion in nutrition research, or just under 5 percent of its total budget. USDA’s Agricultural Research Service spends significantly less; last year, the agency devoted $88 million, or a little more than 7 percent of its overall budget, to human nutrition, virtually the same level as in 1983 when adjusted for inflation. That means USDA last year spent roughly 13 times more studying how to make agriculture more productive than it did trying to improve Americans’ health or answer questions about what we should be eating.

Nutrition science has become such a low priority at NIH that the agency earlier this year proposed closing the only facility on its campus for highly controlled nutrition studies — a plan that is on hold after pushback from outside groups.

“In so many areas [of health], things get better over time,” said Jerold Mande, a professor at Tufts University’s Friedman School of Nutrition Science and Policy, who worked at USDA and the Food and Drug Administration during Democratic administrations. “But nutrition has gotten so much worse.”

Dozens of interviews with current and former NIH and USDA officials and nutrition researchers indicated that a leadership failure across multiple administrations, Republican and Democratic, has led to no national strategy for nutrition research and little coordination among federal agencies.

NIH in a statement said that funding for nutrition research has steadily increased over the past several years. (POLITICO’s analysis shows it is declining as a percentage of the overall research budget, however.) Three years ago, NIH also established a task force “to coordinate and accelerate progress in nutrition research” across the agency and develop the first ever NIH-wide strategic plan for the topic, the agency said. That report has not yet been released. USDA did not return a request for comment.

At the highest level, nutrition research has never regained the prominence it had during the 19th and 20th centuries, when vitamin deficiencies like pellagra, rickets and scurvy were largely eradicated. By contrast, today’s diet crisis is one of excess, and it is costing us dearly: obesity alone costs about $147 billion annually; hypertension costs an estimated $131 billion a year; and diabetes, the vast majority of which is Type 2, costs $237 billion. Yet, there is no major lobbying force behind boosting nutrition research funding. This has allowed it to be quietly sidelined while more attention is paid to specific illnesses, rather than the root cause of so many of them: poor diet.

The lack of federal investment has left plenty of room for consumer confusion. Food industry-funded studies often fill the vacuum, but are criticized for being more about marketing than unbiased science. The nutrition science community also finds itself in turmoil, fighting over whether public health enemy No. 1 is processed carbs or fat or sodium or sugar.

Last month, a major peer-reviewed study questioned advice that most people should eat less red and processed meats, concluding that the evidence backing such long-standing recommendations is weak. The study, published in the Annals of Internal Medicine, sparked an international media frenzy and yet another round of consumer whiplash.

It highlighted why diet studies are the frequent butt of jokes: One day coffee is healthy, the next it’s not; red wine is good for your heart, or maybe not; cheese is either a healthy source of protein and calcium, or a dangerous overdose of fat and salt.

“People ask me if they should drink milk. How do we not know that?” Dariush Mozaffarian, dean of Tufts University’s nutrition school and a cardiologist, said in an interview with POLITICO. ”They ask me: Is cheese good for you or bad for you? ... We don’t know if cheese is good for you! We should know whether cheese is good for you.”

A major reason why the nutrition science field is in turmoil is because the science itself is so complicated. Researchers can’t feasibly lock up people for decades and meticulously track their diets. Even if they could, people eat so many different foods in different combinations that isolating the impact of one variable is incredibly difficult.

There are a couple of ways for scientists to sort this out. The gold standard for most medical research is randomized controlled trials. Researchers assign people to two or more groups: One that will get the intervention, in this case a particular type of food or diet, and another that will not, known as a control group.

This approach works well for determining whether a drug is effective, but is not as straightforward in nutrition studies. Humans don’t tend to stick to specific diets over the course of weeks, months or even years, making it difficult to parse out how eating oatmeal for breakfast — or any other food — affects our health.

To get around these expensive clinical trials, the field for decades has relied on observational data. These so-called epidemiological studies use self-reported surveys across large populations and then try to find associations with health outcomes. This research is cheaper but less rigorous, in part because people often forget or lie about what they eat. It tends to drive the conflicting headlines on everything from chocolate to eggs.

Most nutrition researchers contend these epidemiological studies are important, despite their flaws. The idea that we don’t know anything about what to eat is greatly exaggerated, they argue.

“We know a lot, but the more we know, the more we know how much we don’t know,” said Mozaffarian, a leading voice in the field who is now pressing Congress to create a new nutrition science arm at NIH.

But a growing number of critics are convinced the field is so flawed it requires a complete reboot. They include John Ioannidis, a physician at Stanford University who specializes in data science and clinical research, and is among the best-known critics of scientific methodology.

“I’ve worked in many different fields, and it’s hard to find another field that seems to be performing so poorly,” Ioannidis said in an interview, noting that he believes the epidemiological studies are particularly problematic. “It does draw amazing attention in the news, but nothing seems to be validated. I can’t think of any other field that has that constellation of failure.”

THE LARGEST SOURCE of federal funding for nutrition research comes from NIH, which today spends nearly $40 billion a year exploring how to better prevent, detect, diagnose and treat diseases.

This work has led to dramatic improvements in cancer treatments, for example, with the overall death rate for the disease on the decline since the early 1990s. The agency also led an international genome project that helped identify hundreds of disease-causing genes that continues to spur biotechnology innovations. NIH has 27 institutes with their own jurisdictions, including heart, lung and blood, mental health, alcohol abuse and eye diseases. The National Cancer Institute remains the biggest and best-funded.

The research the federal government prioritizes can seem out of whack, however, when put in context with the prevalence of diseases. In 2018, NIH funding for cancer, which affects just under 9 percent of the population, was $6.3 billion. Funding for obesity, which affects about 30 percent of the country, was about $1 billion.

NIH in a statement said diseases affecting fewer people are often devastating and costly for patients and the country. The agency has a legislative mandate to fund rare disease research, for instance, although it may appear disproportionate to its posted burden.

Within NIH, the fall of nutrition research goes beyond funding, which at $1.8 billion doesn’t come close to matching the scale of America’s epidemic of diet-related diseases. There also is no institute dedicated to the topic, no central leadership and few staff. Nutrition science has been falling as a priority within America’s medical research powerhouse for nearly 50 years, losing political clout with every bureaucratic reorganization, according to interviews with nearly a dozen former and current officials and researchers who work with NIH.

The last time NIH saw nutrition research as a high priority was during the Carter administration, when Donald Fredrickson, a renowned expert in lipid metabolism, was the director. At that time, nutrition research coordination was housed within the director's office, the nerve center of NIH.

“We were working at a very high level,” said Artemis Simopoulos, who coordinated nutrition research at NIH at the time, adding that there was high-level political interest on Capitol Hill following media reports of widespread hunger in America. After seeing subsequent leaders lose interest in the topic, Simopoulos left NIH in 1985.

In the early years of the Clinton administration, NIH moved its nutrition coordinating office from the director’s office to the National Institute of Diabetes and Digestive and Kidney Diseases, a branch that supports research on a range of common chronic illnesses.

No one POLITICO interviewed could recall exactly what prompted the move in 1993. Other research areas have been reorganized over the years, but typically to create a new institute or center. Sidelining the leadership of a cross-cutting issue like nutrition made little sense to those working on the issue inside and outside NIH, especially now when diet is known to help prevent so many of the chronic diseases ailing the country.

“It’s a hell of a lot easier to coordinate from the position of the office of the director than from within an institute,” said Paul Coates, former director of the Office of Dietary Supplements at NIH.

NIH contends that many agency-wide areas of research are “successfully coordinated” by its institutes and centers without oversight from the Office of the Director. One example is a brain research initiative, the agency said.

Today, the size of the NIH office coordinating nutrition research is dwarfed by those overseeing narrower topics: just four staff work in the nutrition coordinating office (two are part-time), while 26 work in the dietary supplements office, which is responsible for studying the effects of vitamins, minerals and herbal remedies. The nutrition office is now located off-campus, requiring employees to take a shuttle to get to important meetings — a geographical symbol of its status.

“It’s been whittled down to almost nothing,” said Mande, the Tufts professor who worked at USDA during the Obama administration on food safety and nutrition programs. “Things are heading in the wrong direction.”

Several years ago, amid first lady Michelle Obama’s public fight against childhood obesity, NIH also quietly completed a long-planned transition away from supporting the nearly 80 general clinical research centers across the country, where many groundbreaking human studies on nutrition, physiology, metabolism and other fields have been conducted.

For decades, NIH had awarded special grants to teaching hospitals and academic institutions so these research centers could hire trained staff like nurses and dieticians, and maintain beds for participants in clinical trials. These centers conducted rigorous, highly controlled feeding studies and other research that profit-driven industries like drug or food manufacturing wouldn’t benefit from funding. They also attracted young researchers who didn’t have enough resources to recruit and pay staff or rent out a facility.

“There are certain kinds of research that is done nowhere else, like nutritional research,” said David Nathan, director of the clinical research and diabetes centers at Massachusetts General Hospital and a professor at Harvard Medical School. “Pharma doesn’t support that because there is no drug to be sold.”

Before the elimination of these clinical research center grants, Mario Kratz, an associate professor in epidemiology and medicine at the University of Washington, said he could conduct a well-controlled dietary intervention study in which all food was provided to participants over four months for about $12 a day per person. Now, because he has to pay for the facility and research staff salaries, the cost has shot up tenfold.

Theoretically, investigators could request this higher amount from NIH directly to pay for a specific research project. However, most NIH grants are effectively capped at $500,000 — a threshold that has not increased in a decade — and are no longer sufficient to cover the costs of most clinical feeding studies.

“It has made it impossible for me and my colleagues to propose these types of studies,” said Kratz, who also works at the Fred Hutchinson Cancer Research Center in Seattle, where he studies dietary interventions and cancer prevention. “It’s now cost-prohibitive. I think nutrition feeding studies were an unintended casualty.”

Clinical nutrition research faced another potential blow earlier this year. NIH leadership in May proposed closing the only metabolic research unit at NIH headquarters in Bethesda, Md. The unit that was on the chopping block has a kitchen for preparing and measuring meals, private rooms where people can stay overnight for extended periods of time and be observed, as well as specially trained research staff, including nurses who prevent people from smuggling food in or out of patient’s rooms — a crucial role, considering high-calorie contraband could throw off a study’s results.

It housed a recent high-profile clinical trial that was the first to demonstrate a cause-and-effect relationship between ultraprocessed foods and weight gain. For the study, published in the journal Cell Metabolism in May, researchers designed two diets that had the same levels of calories, carbs, fat and protein. The only significant difference was whether the foods were unprocessed or considered ultraprocessed: spinach salads with chicken, apples, bulgur and homemade dressing were designated the former; foods like canned ravioli and white bread were the latter.

The participants had no underlying health problems and were randomly assigned to one of the diets for the first half of the study, and to the other for the second half. The study was a month long and levels of exercise were held constant.

The results were a breakthrough: Those on the ultraprocessed foods diet on average ate 500 more calories each day, causing weight gain, compared with those eating unprocessed food, who lost weight on average. Previous research looking at this question had shown that processed food was associated with weight gain, but this study showed definitely that processed food caused weight gain.

Around the same time the landmark study was published, NIH proposed closing its metabolic research unit, sparking pushback from the scientific community. In a letter to the agency’s leadership in June, the American Society for Nutrition and The Obesity Society argued the closure would imperil important research. The proposal “indicates that nutrition research is not considered a prominent area of scientific pursuit at NIH,” ASN wrote.

NIH said there is no “current plan” to close the research unit.

“There has been discussion about relocating the capabilities of this unit,” the agency said in a statement. “This would require a great deal of additional planning, communication, and coordination to ensure that the important research done there would not be adversely affected.”

Kevin Hall, an intramural researcher at NIH focused on nutrition and obesity — and the lead author of the ultraprocessed food study — said in an interview that the agency in 2017 also shrunk the number of beds in the metabolic ward from 10 to seven to make room for other research.

NIH has just one other similar metabolic facility at a branch in Phoenix, which studies determinants for obesity and diabetes. That facility has 15 beds.

Having fewer beds means it takes researchers much longer to run such highly controlled trials, because they have to stagger their overnight patients. Hall’s processed food trial, for example, took roughly eight months to complete, even though it included only 20 participants.

Hall thinks the nutrition field needs more of these in-patient trials to settle some of the thorniest debates over nutrition. Otherwise, researchers don’t know with certainty what people actually ate, he said.

"You're not studying the diet at all,” Hall said. “You're studying the effect of the advice.”

BY THE TURN of the 20th century, the Department of Agriculture had begun exploring how proper nourishment could help both farmers and an increasingly urban population. Nutritionists identified milk and fruits and vegetables — at the time luxury products — as “protective foods” for good health. They made great strides in understanding vitamin deficiencies, helping to largely eliminate diseases like rickets, scurvy and pellagra in the United States by World War II.

Still, by 1940, with the looming possibility of America’s entry into the war, 40 percent of recruits were deemed unfit to serve because they were underweight or malnourished. President Franklin D. Roosevelt convened an emergency conference that led to the first federal diet recommendations and an expansion of USDA’s school lunch program and food stamps, now known as the Supplemental Nutrition Assistance Program.

Nutrition wasn’t thrust into the national spotlight again until the late 1960s and 1970s, after a CBS News special on hunger in America raised alarm. Sen. George McGovern, a Democrat from South Dakota, formed a special committee to respond to the large number of poor people who were malnourished. The Nixon administration exactly 50 years ago this winter also organized a White House conference to “lay the foundation of national nutrition policy based on need, not agricultural subsidies,” wrote one organizer.

That focus on nutrition decades ago presented Catherine Woteki, who would later become USDA’s chief scientist during the Obama administration, with her first job in Washington. An office that advised Congress on science policy hired her as part of a team tasked with compiling a sweeping assessment on the government’s nutrition research.

Her report, published in 1978, determined that agencies had “failed to deal with the changing health problems of the American people.” It said the most important area of research will be identifying dietary links to chronic diseases and ways to prevent them. Humans’ quality of life would be seriously affected if the government didn’t shift its focus, the report warned. It also recommended that Congress consider designating a lead agency because federal nutrition research was so poorly coordinated.

Woteki, now a professor at Iowa State University, told POLITICO in an interview that it is frustrating how many of the same problems highlighted by her team decades ago persist today. There still is no national strategy, and nutrition research continues to be scattered across the government.

“It’s been everybody’s and then it’s nobody’s,” she said.

In the years after the report came out, there was a turf battle between USDA and NIH over nutrition science, Woteki said. As a result, the agencies agreed that NIH would take the lead on research related to the biomedical aspects of nutrition, like diagnosing and treating diseases, while USDA would be responsible for defining healthy diets.

“The result has been unfortunate,” Woteki said. “USDA’s research budget has not increased. In constant dollars, it’s less than what it was in the 1980s.”

Today, there are six USDA nutrition centers across the country overseen by the department’s Agricultural Research Service. Half are completely funded by the agency, while the others operate under cooperative agreements with universities and medical centers. Their work helps inform federal dietary advice that is updated every five years by tracking people’s eating patterns, monitoring the composition of food and studying how to maintain health while preventing obesity and chronic disease.

Just 7 percent of ARS’ funding is set aside for nutrition, dwarfed by other priorities like improving crop yields, managing natural resources and ensuring food safety, even though USDA spends 75 percent of its $144 billion budget on feeding Americans through programs like school meals and SNAP.

“I used to tell my students at Cornell [University] that we know more about the nutrition of a chicken than we do a human,” said Gerald Combs, who for 14 years led the agency’s human nutrition center in Grand Forks, N.D. before retiring in 2015.

“I think it is clear that ARS sees itself as working for the farmer,” he said, adding that the status quo is sustained because agribusiness spends a lot of time lobbying Congress.

Nutrition funding at ARS has been on rocky footing over the past decade, even during the Obama administration when Michelle Obama made combating childhood obesity a top priority. The administration during its early years requested modest increases to ARS’ human nutrition research budget, only to call for rolling back funding in fiscal 2016 and 2017.

Today, nutrition science at USDA is under constant threat. The Trump administration has repeatedly proposed slashing the ARS human nutrition budget in half. Congress has rebuffed these requests and kept funding largely flat.

The Agriculture Department did not respond to requests for comment.

Many researchers, policymakers and public health advocates interviewed by POLITICO said that the complexity of nutrition research factors into its low priority in Washington, which isn’t exactly known for having a long attention span.

“You don’t get quick or definite answers,” said Nancy Chapman, who owns a consulting firm that works with the food industry, nutrition organizations and agricultural trade associations in Washington. “It’s not like you’re testing one drug, where there is a measurable intervention and outcome. When you talk about diet, it is not just the complexity of the foods, but also life habits, exercise, whether your neighborhood has clean air and water, how much money you make. There are all these things that may be associated with your overall health.”

AS NIH, USDA and Congress let nutrition research languish, Americans are grappling with the very problem that Woteki’s report predicted 41 years ago. People have been getting sick from having too much to eat.

In the 1970s, America’s obesity rate started to surge for reasons researchers still can’t fully explain. At the time, 14 percent of adults were obese. By the early 2000s, the rate had climbed to more than 30 percent. Today, it is nearly 40 percent, putting the population at risk of a host of other ailments, including certain types of cancer. Even those who aren’t obese are likely heavier than they should be: More than 70 percent of American adults are now overweight.

Researchers and policymakers are increasingly convinced that without a boost to public funding for nutrition research, there will be little progress against this health epidemic. Food company-backed studies can’t do the job because they often are rife with conflicts of interest, fueling mistrust among consumers and medical professionals.

Nonprofit organizations have also shown limitations in sponsoring nutrition research. In 2012, for example, two Texas philanthropists launched a $40 million “Manhattan Project” for nutrition and obesity, only for it to unravel amid fights over questions about scientific independence, as Wired reported last year. One of the studies set out to test whether a low-carb diet helps people burn calories faster, but researchers who conducted the study — including Kevin Hall of NIH — quickly ran into disagreements with the leaders of the nonprofit over methodology.

By contrast, the federal government is uniquely positioned to do long-term nutrition research; done right, it could provide a more reliable funding stream and infrastructure for nutrition science, said Sean Adams, director of the Arkansas Children’s Nutrition Center, which is part of the USDA-ARS network and has a mission to improve maternal and child health.

“Human nutrition is central to the entire farming and food production system,” Adams said, adding that as an example, the facility in Little Rock is doing cutting edge research on the relationship between diet and the gut microbiome — bacteria and fungi that naturally live inside the intestines of both humans and livestock. (Adams declined to comment on budgetary politics, even though the Trump administration proposed zeroing out support for his center.)

There have been several attempts to draw attention to the federal government’s lackluster support and coordination of nutrition research over the years, including another effort led by Woteki during her time as USDA’s chief scientist during the Obama administration. She said that around 2010, nutrition researchers at the department and NIH told her they needed a high-level forum to meet.

So Woteki rebooted an obscure interagency committee on human nutrition research that she said had been disbanded years earlier, although she was unable to convince White House officials that it should be housed under Obama’s main science advisory council. The committee published a 176-page road map in 2016 identifying key research gaps, but stated that “the role of current or future federal funding for human nutrition research was not within” its charge.

Woteki said the next step would have been for the participating agencies to develop a budget initiative, but it didn’t materialize after Trump won the White House.

Three years ago, NIH established its own nutrition task force to develop the first 10-year, agency-wide strategic plan, soliciting input from the broader research community. A draft released last fall does not discuss funding. It only points out seven research gaps, such as the relationship between the diet and the gut microbiome and optimal nutrition during pregnancy and infancy to prevent chronic disease. The NIH plan still hasn’t been finalized, and a number of current and former NIH employees described it as not much more than a futile political exercise.

In light of the funding woes, a Silicon Valley hedge fund manager and a small group of nutrition advocates are now trying to build momentum to establish a new institute at NIH, one that would be focused on nutrition. In June, the three men leading this effort tested their pitch to a room full of nutrition researchers and doctors at an annual conference on nutrition science in Baltimore.

“I think medicine is waking up to what you all have known,” said David Kessler, who led the FDA during the George H.W. Bush and Clinton administrations. “We need to be able to focus on what is at the center of these diseases.”

The audience was intrigued, but skeptical. They raised concerns about the feasibility of creating a new agency at a time of extreme dysfunction in Washington, as well as whether other research areas would suffer if money was diverted within NIH.

“We haven’t been willing to admit it as a country, but this is dire,” Kessler told the audience. “We have to figure it out because the current status quo is not acceptable.”

Published in Politico

By Helena Bottemiller Evich and Catherine Boudreau

November 4, 2019