One in five deaths worldwide stem from unhealthy diets, according to a large-scale study published last week in The Lancet. Deaths stemming from poor diets total 11 million each year, including deaths from heart disease, cancer, and diabetes. In total, more people die as a result of their diet than from cigarettes or high blood pressure.

“Poor dietary habits, which is a combination of high intake of unhealthy foods, such as red meat, processed meat, and sugar-sweetened beverages and a low intake of healthy foods such as fruits, vegetables, nuts, whole grains, and seeds, overall causes more deaths than any other risk factors globally,” according to Dr. Ashkan Afshin, a University of Washington assistant professor of Health Metrics Sciences, and an author of the study.

If the world is having a nutritional crisis that eclipses the death toll from cigarettes, it needs to be treated as a crisis in the same way. This means going beyond encouraging healthier choices, and passing legislation to save lives. Since the health effects of smoking first became clear, governments have passed laws requiring clear labeling of the risks, regulating advertising by tobacco companies, putting taxes in place to lower consumption, offering treatment programs to help quit, and limiting access to cigarettes for young people. Studies have shown that these policies have reduced smoking rates.

Studies have also increasingly shown that taxes on sugary drinks, for example, are effective. Similar taxes could also be applied to other harmful food components, like high sodium and trans fats. But, among the many arguments opposing such taxes, is the accurate criticism that these taxes disproportionately affect the poor. Eating unhealthy food is simply less expensive than a healthy diet.

And while there are certainly problematic government policies in the US, like subsidies that promote cheap production of the ingredients that make up junk food, this isn’t the whole picture either. The idea that the poor are simply tempted to eat junk food by its artificially low price misses the way access and price prevent them from eating healthy foods that they would already rather be eating, according to researchers.

According to a 2015 study, the “high price of healthful food, inadequate geographical access to healthful food, poor quality of available healthful food, and lack of overall quality of the proximate retail stores” all play a role in preventing low income populations from improving their diets. The participants in the study “reported high levels of knowledge and preference for healthful foods” but access issues prevented them from eating a diet based on those preferences.

And it’s not just about cutting down on junk food, either.

“While historically the conversation around diet and nutrition has been focused on a high intake of unhealthy foods, mainly salt, sugar and fats and reducing their consumption, our study shows that in many countries, the main problem is low intake of healthy foods,” according to Afshin.

All of this research points to the idea that it’s not only a matter of making junk food harder to access or encouraging better diet choices, it’s a matter of increasing access to healthy alternatives. As of 2014, almost 24 million Americans were living in places without access to sources of healthy and nutritious food. These areas are called food deserts, and the low-income residents that live there face greater risk of obesity and related diseases. Bringing supermarkets to these areas is a good step, but it’s not likely to solve the problem without further measures.

For one thing, the authors of the 2015 study suggest community gardens and farmers markets lead to better results than strategies that use chain supermarkets or convenience stores. But structural changes are necessary too.

A paper published in 2016, in the journal Preventative Medicine, suggests that efforts to tweak the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to offer vouchers specifically for fruits and vegetables, whole-grain bread, and lower-fat dairy were successful in changing diets. The diets of low-income people on the program improved, while low-income households without assistance saw no changes in the same period. They found that healthier program was not more costly to the government, and suggested tweaking broader food assistance programs in the same way.

A 2016 report from the Union of Concerned Scientists, looking specifically at the relationship between food access and diabetes, makes several recommendations for federal policy. They support recommendations to improve food assistance programs and to encourage retailers to set up shops in food deserts. But they also suggest comprehensive nutritional education programs and food and farm policies. They emphasize the need to coordinate these various policies instead of relying on limited, piecemeal solutions. This is exactly the kind of broad-based approach that has been lacking in public food policy thus far.

Many may not be aware that bad dietary habits can be as deadly as smoking. Others may view diet as a personal choice with no regard for structural factors. Some acknowledge the problem, but only consider local, piecemeal solutions often based on nutrition education or measures like food taxes alone. But only when we approach poor diet as the global and national epidemic it is will we make progress, saving lives and reducing healthcare costs.

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