Cardiovascular disease (CVD) remains the leading cause of disability and death in the US and globally [1], with associated economic costs projected to increase substantially along with population aging [2]. Additionally, the risk of type 2 diabetes is steadily increasing, with tremendous associated health and economic consequences [3]. Large disparities in these burdens are also evident, with a much higher risk among those of lower socioeconomic status (SES) [4, 5] and disparities growing over time [6]. Based on health burdens, economic costs, and corresponding inequities, the identification of effective population interventions to reduce cardiovascular disease and diabetes (cardiometabolic diseases, CMD), as well as disparities, is crucial.

A suboptimal diet is a major cause of CMD [7]. Among strategies to improve dietary behaviors, fiscal interventions to alter food prices are promising [8]. Such approaches may not only improve population health, but also potentially reduce disparities in diet quality and diet-related health burdens [9]. Several fiscal strategies, such as taxation of sugar-sweetened beverages (SSB) and/or unhealthy snacks [10–12] and subsidization of fruits and vegetables [13], have been already implemented. Yet, while such measures significantly improve diet, neither the potential impact of such interventions on CMD in the US, nor the potential impact on disparities, has been quantified. In addition, other foods beyond fruits and vegetables or SSBs represent appealing targets for fiscal interventions, but the separate and joint benefits of such approaches have not been assessed. To address these knowledge gaps and inform policy-makers, we quantified the impact of altering the intakes of seven key food groups through economic incentives on coronary heart disease (CHD), stroke, and type 2-diabetes mortality in the US, as well as the impact on corresponding disparities.

By combining nationally representative datasets, we report, to our knowledge for the first time, the potential impact of strategies to alter food prices on CMD deaths in the US. A joint 10% price change was estimated to prevent 3.4% of all CMD deaths, while a larger price change (30%) was estimated to prevent 9.2% of all CMD deaths. None of the pricing scenarios significantly increased disparities; all would reduce disparities in diabetes deaths and, given a higher SES price-responsiveness, each would also reduce disparities in CHD, and stroke mortality. The largest impact was observed for decreasing prices of fruits and vegetables, and increasing the price of SSBs. By cause of death, reductions in stroke mortality were most effectively achieved by subsidies for vegetables and fruits, and in diabetes mortality by taxes on SSBs. These results are in line with previous modeling studies in South Africa and India, where a 20% SSB tax was estimated to reduce diabetes prevalence by 4% over 20 years [33, 34].

Many governments have already implemented fiscal measures to increase the price of unhealthy foods. One of the earliest was a 2011 Danish tax on saturated fat, later rescinded in 2013 due to controversy but estimated to have reduced national saturated fat intake by 4% [35]. Taxes exist in Hungary (on fat, sugar and energy drinks), Finland (sugar, expanding to soft drinks), Portugal (high salt products), and Mexico, France, and Latvia (SSBs) [36]. In Mexico, after the implementation of an 8% excise tax on non-essential foods (energy density > 275 kcal/100 g) and SSBs, the demand of these products decreased by approximately 5% from the predicted trend. Moreover, whereas no change was observed among high SES households, a 10% decrease was reported for those households of low SES [37]. South Africa and the UK also announced taxes on SSBs, effective in 2017 and 2018, respectively [38]. These efforts demonstrate the legal, practical, and political feasibility of food taxes. In the US, the cities of Berkeley and Philadelphia have passed excise taxes on SSBs [39], and state and national efforts have been deemed legally feasible [40]. Our findings suggest that the benefits of taxes for both health and disparities would be strongly complemented by accompanying strategies to reduce the price of fruits, vegetables, nuts, and whole grains. Subsidies are an essential component of a balanced pricing strategy to effectively improve diets, as well as to minimize the regressive nature of taxation alone [41]. Evidence from natural experiments and national interventions support this approach. In Finland, a combined strategy of agricultural, subsidy, and taxation policies resulted in an increased consumption of berries and a decreased consumption of animal fats versus increased consumption of vegetable oils, and a significant reduction of CVD risk factors and incidence [41, 42].

Given the growing inequities in diet and CMD in the US [16], our findings for disparities are particularly relevant. Since those with a lower SES have a lower intake of healthy foods, an intervention with a uniform proportional impact by SES would increase disparities; while higher intakes of healthy foods among those with a lower SES could lead to reduced disparities by uniformly effective interventions. Many types of interventions, such as education campaigns or food labeling, often have smaller effects among those with lower SES, potentially further exacerbating existing disparities [43]. In fact, most national efforts in the US focused on dietary education and guidelines/labeling improved overall dietary habits in all population subgroups, but much less among those with lower SES [16], finally resulting in increased dietary disparities over time.

Both nutrient- and food-specific taxes could be implemented by policy-makers. A recent report estimated that a sugar (nutrient) tax would have a larger impact on nutrition than a product-specific (SSB) tax, based on the broader base of products influenced by the former [44]. We focused this investigation on food-specific pricing changes based on the growing nutritional science, as highlighted by the 2015–2020 Dietary Guidelines for Americans [17], on the relevance of foods and overall diet patterns for health. Future studies should consider other pricing strategies, such as taxes on additives including added sugar and sodium.

We modeled final retail price changes of foods, which could be achieved by a range of potential strategies. Lower prices could be achieved by subsidies for agricultural practices, research and development or tax incentives for food manufacturers, retailers, and restaurants, or direct subsidies to wholesalers, retailers, or consumers [40]. In parallel, higher prices on certain foods could be achieved by changes in agricultural policies, tax disincentives or, most simply, by excise taxes [40]. Certain national US feeding programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children, already utilize such an approach by providing federal grants to states aiming to subsidize (by reducing the price through direct funding) nutritious foods for low-income, nutritionally at-risk populations [45]. At a broader scale, incentives for purchasing fruits and vegetables through rebates in the Supplemental Nutrition Assistance Program (SNAP) has proven successful to increase fruit and vegetable consumption and overall dietary quality in this population [46, 47]. Our findings suggest that a combination of financial incentives for fruits, vegetables, nuts, and whole grains (e.g., direct rebates, or increased relative purchasing power via the Electronic benefit transfer card), together with financial disincentives for SSBs and processed meats (e.g., via relative reductions in the purchasing power of the Electronic benefit transfer card for these food groups) would meaningfully reduce CMD and reduce disparities among SNAP participants. Given the large and growing inequities in dietary quality and CMD risk in the US [16], our findings for disparities are particularly relevant.

Our study has a number of strengths. We used nationally representative datasets on demographics, education, dietary habits, CVD risk factors (blood pressure and BMI), and cause-specific deaths, making our results generalizable to the US adult population. We limited our estimates of etiologic effects to a small number of specific dietary factors with the greatest evidence from meta-analyses, supported by consistency, dose-response, and plausible biology. Our model incorporates stratum-specific heterogeneity in underlying characteristics and intervention effects by age, sex, and education, increasing the validity of our results. We quantified uncertainty using Monte Carlo simulations, increasing interpretability and identifying the range of plausible effects.

Potential limitations should be considered. Dietary estimates were based on self-report, which could introduce errors into our estimates. We minimized this by using the average of two 24-h recalls per person and adjusting for both energy intake and within-person variation. The etiologic effect of each dietary factor on CMD was obtained from meta-analysis of mostly prospective observational data, which may be impacted by residual confounding (causing overestimation of effects) and by measurement error and regression dilution bias (causing underestimation of effects). However, these effects are supported by mechanistic evidence as well as a large randomized clinical trial that demonstrated reductions in CVD and diabetes highly comparable to the predicted effects from observational studies [4, 48]. While considerable evidence demonstrates the existence of differential price-responsiveness by SES, the precise magnitude of this gradient and how it might vary by underlying population characteristics are not perfectly characterized. We accounted for this by modeling both low and high gradients, providing findings for a range of plausible scenarios, and recognize that our results might modestly vary selecting alternative scenarios. In choosing our inputs for these scenarios, we favored estimates from meta-analyses and empirical national evidence over individual cross-sectional studies in the US, which show great variation in their estimates, to avoid favoring one particular study. We recognize that the efficacy of taxes on harmful foods will largely depend on what products consumers choose as an alternative. We did not incorporate specific substitution or complement effects (cross-price elasticity), which could potentially alter our results. This is especially relevant for price subsidies that have been found to be potentially counterproductive as they increase overall income to purchase food, including unhealthy products, when not applied in combination with unhealthy food taxes [49]; this supports our approach of combining subsidies and taxes. Additionally, we used meta-analysis of observed effects, incorporating average substitute and complement effects, as inputs to our model and the results most likely represent an average effect, which could be further augmented beyond our estimates by specifically encouraging or advocating for more healthful substitutes and complements. Furthermore, while approximately 80% of studies in our meta-analysis of interventional and prospective food pricing studies were from the US, the price elasticity estimates in the remaining countries were (non-statistically significantly) smaller. Thus, our findings may modestly underestimate the true health benefits of these food pricing strategies, compared to results based on US studies alone. Finally, given that effects of price changes on intake and of dietary changes on CMD are evident within 1 year [11, 48], we did not model lag-effects nor decay or acceleration of effects over time. Further research is needed to address how competing risks affect our mortality estimations and to incorporate the calculation of life years gained and reduction in disparities in life expectancy.

Strategies introducing modest price changes on key dietary factors could reduce cardiovascular disease and diabetes burdens and disparities in the US. Policy-based strategies targeting disparities will require considering both baseline dietary habits as well as price responsiveness in specific population subgroups. The findings of our study have broad implications for policy-makers targeting fiscal measures to reduce CMD burden.