Legal and policy approaches can be important tools for achieving healthier communities. The report, The Role of Law and Policy in Achieving the Healthy People 2020 Nutrition and Weight Status Goals of Increased Fruit and Vegetable Intake in the United States, provides evidence-based information and identifies priority areas that can help communities achieve Healthy People objectives.
This Bright Spot describes how the Navajo Nation helped their citizens access and consume more fruits and vegetables.
Challenge: Low availability and affordability of healthy foods
The Navajo Nation covers 27,000 square miles, an area bigger than West Virginia. However, a 2014 report by the Diné Policy Institute found only 10 full-service grocery stores operating on the Navajo reservation, meaning that many people living there are more than 100 miles from a grocery store. Given the distance, many residents rely on gas stations and convenience stores, which sell mostly high calorie, heavily processed foods.
Low access to healthy foods takes a significant health toll on the community. For example, according to the Centers for Disease Control and Prevention (CDC), American Indians and Alaska Natives have the highest prevalence of diabetes in the United States.1
It’s not only geography that impacts access to healthy foods—affordability is also a factor. “When we don’t have access to quality food and we’re forced to purchase non-quality foods, we’re really at a disadvantage,” says Gloria Begay of the Diné Community Advocacy Alliance (DCAA), a grassroots organization. Since 2011, DCAA has worked to change the Navajo Nation’s food environment and improve community health.
Strategy: Using tax policies and law to encourage healthier choices
In 2014, the Navajo Nation changed its tax policies to both encourage citizens to buy fresh fruits and vegetables (by reducing their relative cost) and discourage people from purchasing foods and beverages with “no-to-minimal nutritional value” (by increasing their relative cost).
Specifically, Navajo Nation Legislation No. 0290-13 removed the 5% sales tax from fresh fruits, fresh vegetables, water, nuts, seeds, and nut butters.2 At the same time, the Healthy Diné Nation Act (HDNA) applied a 2% additional tax on sugar-sweetened beverages and foods that have been “stripped of essential nutrients” and are high in salt, saturated fat, and sugar.3 The Act applies to all retail purchases on the reservation, from families shopping at local trading posts to restaurants buying from distributors.
Impact: Financial incentives may increase consumption of fruits and vegetables
Research on similar policy interventions points to the effectiveness of giving people a financial incentive to buy fruits and vegetables. For example, a study of 7,500 households receiving Supplemental Nutrition Assistance Program (SNAP) benefits found that adding a financial incentive to purchase fruits and vegetables led to a 26% increase in consumption of these foods.4
A 2017 systematic review of studies on the effect of food-pricing interventions on retail sales, consumer purchasing, and consumption of healthy foods also found that pricing interventions increased access to and consumption of these foods.5
Policies like HDNA need further study to measure the impact of pricing strategies on access to fruits and vegetables and on creating sustained changes to people’s fruits and vegetables intake. But what is known is how the revenues from the tax are being used. In June 2016, the Navajo Nation Council Budget and Finance Committee gave final approval to establish guidelines to distribute the HDNA revenues.6 Each local government chapter receives about $13,000 annually, which is being put toward initiatives including farming and vegetable gardens, fitness equipment purchases, and wellness instruction. In total, over $3.2 million was dispersed in 2016–2018.7
Lesson Learned: Maximize the impact
For advocates seeking to advance similar policies, patience for ongoing negotiations will be key. DCAA first proposed the tax changes to the Tribal Council in 2011, but it wasn’t until 3 years later that HDNA was approved. Begay also points out that emphasizing the purpose of the intervention is key to gaining public support for such a change.
“It’s not about the money,” she says, referring to the 2% tax. “It’s about raising awareness about health issues. People were asking why we want to tax the poor. But we’re trying to help them make better choices with what little money they have.”
At the same time, the authors of the HDNA evaluation study7 note that “obesity, diabetes, heart disease, and cancer are multifactorial health problems which cannot be affected solely by the elimination of a single food type in the diet.” They suggest that HDNA may help “communities to improve their health through physical activity, health education, and traditional knowledge, as well as improving access to these healthy resources.”
Taking an approach that simultaneously incentivizes healthy foods, de-incentivizes foods with no-to-minimal nutritional value, and funds public health programs certainly offers a multifaceted opportunity for significantly improving the health and well-being of a community over time. Collaborations like the one between the Navajo Nation government and DCAA may inspire advocates in other locations to promote and improve fruit and vegetable consumption in a similar way.
About the Law and Health Policy Project
The goal of the Healthy People Law and Health Policy project was to highlight how evidence-based legal and policy interventions and strategies can facilitate progress toward Healthy People 2020 targets by improving community health and well-being. In addition to reports and webinars, the project included "Bright Spots," or success stories, that highlighted successful policy interventions that led to improved health outcomes. The project was a collaboration between the HHS Office of Disease Prevention and Health Promotion (ODPHP), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, and the Robert Wood Johnson Foundation.
1 Centers for Disease Control and Prevention. CDC and Indian country working together. Atlanta (GA): Centers for Disease Control and Prevention, U.S. Dept of Health and Human Services; 2017. Available from: https://www.cdc.gov/chronicdisease/pdf/CDC-indian-country.pdf
2 Navajo Nation Legislation No. 0290-13. https://www.navajo-nsn.gov/News%20Releases/NNCouncil/2014/jan/NNC%20enacts%20the%20Healthy%20Dine%20Nation%20Act%20of%202013.pdf
3 Navajo Nation Code Ann. tit. 24, § 11 (2014) CN-54-14. Available from: http://www.navajonationcouncil.org/Code%20Page.html
4 Bartlett S, Klerman J, Olsho L, et al. Evaluation of the healthy incentives pilot (HIP): final report. U.S. Department of Agriculture, Food and Nutrition Service, 2014 Sep. Available from: https://www.fns.usda.gov/snap/healthy-incentives-pilot-final-evaluation-...
5 Gittelsohn J, Trude ACB, Kim H. Pricing strategies to encourage availability, purchase, and consumption of healthy foods and beverages: a systematic review. Prev Chronic Dis. 2017; 14: E107. doi: 10.5888/pcd14.170213
6 Native Health News Alliance. Advocates call for proposals for Navajo community wellness projects. 2016 Jun 30. Available from: https://voicesforhealthykids.org/news/advocates-call-for-proposals-for-navajo-community-wellness-projects
7 a. b. Navajo Department of Health, Navajo Epidemiology Center. Our voice: implementation results of Healthy Diné Nation Act 2016 - 2018. Available from: http://www.nec.navajo-nsn.gov/Portals/0/Reports/HDNA%20Report%20July%202...
Related Healthy People 2030 objectives:
- Increase fruit consumption by people aged 2 years and over — NWS‑06
- Increase vegetable consumption by people aged 2 years and older — NWS‑07
- Increase consumption of dark green vegetables, red and orange vegetables, and beans and peas by people aged 2 years and over — NWS‑08
- Reduce consumption of added sugars by people aged 2 years and over — NWS‑10
- Reduce consumption of saturated fat by people aged 2 years and over — NWS‑11
- Reduce consumption of sodium by people aged 2 years and over — NWS‑12