Have NIH Priorities Led to Sickcare aka Healthcare?

Investment Priorities and Outcomes

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Apr 18, 2025

We usually publish data for the weekend as the Saturday morning theme. While today might look different, missing the succinct bullets, it is still very much data for the weekend in regards to the priorities of the National Institutes of Health. There is much controversy and concern about cuts, resignations and more, so we decided to dive into where the money has been spent historically in relation to nutrition. Given that it is such a core component to the root of human health. What we found was quite disappointing and it is yet another example of why our healthcare industry/system has evolved into a sickcare system.

NIH’s Investment in Nutrition vs. Other Research Domains

The NIH allocates only a small fraction of its ~$42 billion annual budget to nutrition science. In recent years, about 4–5% of NIH funding (roughly $1.9 billion per year) has gone toward nutrition research. This share has remained largely flat for decades, despite the explosion of diet-related diseases over the same period.

NIH Nutrition Research 2023

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2023 list of Nutrition related research

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By comparison, other fields like cancer research receive far larger dedicated budgets (for example, the National Cancer Institute alone accounts for about 17% of NIH spending) - over $7 billion.

And now here we sit with nutrition as one of the top causes of poor health in the U.S., yet NIH dedicates a “pales in comparison” level of funding to it. To add insult to injury, NIH analysis of funding relative to health burdens found the largest gap for nutrition. This means diet-related factors cause enormous death and disability but receive disproportionately low research investment. Even within NIH’s nutrition portfolio, only about 1.3% of NIH funds (around $500 million, or one-quarter of that 5%) focus specifically on diet in the prevention or treatment of disease in humans (the rest includes basic research on nutrients, animal studies, etc.). This underscores that applied nutrition research – the kind most likely to directly improve public health – is a sliver of NIH’s activities.

Fragmentation

Historically, NIH nutrition research has been fragmented across institutes rather than centralized. Multiple NIH institutes fund nutrition-related work (e.g. NIDDK for diabetes/obesity, NHLBI for heart disease, NCI for diet and cancer, etc.), but until recently there was no single institute devoted to nutrition. This distributed structure led to a lack of coordination and strategic priority.

Recognizing these issues, NIH created an Office of Nutrition Research (ONR) and in 2021 elevated it to the NIH Director’s Office to coordinate nutrition science across all institutes. NIH also released its first agency-wide Strategic Plan for NIH Nutrition Research (2020–2030) to guide a more unified approach.

However, the ONR’s budget remains very modest – the FY2024 request was $121 million (just 0.25% of NIH’s budget). We are spending $1.7 trillion on poor nutrition that is yielding $1.9 trilion in diet-related chronic illness healthcare expense and $4 trillion in healthcare expense for chronic disease. The latest data points 90%+ of our healthcare spend is related to chronic disease, primarily related to lifestyle, of which diet is the primary driver.

To put that in perspective, we are investing somewhere between 0.002% - 0.007% of NIH dollars to research something that represents up to 90% of our healthcare expense. A mismatch that many have criticized as inadequate and shortsighted. Let that sink in.

Clinical Impact of NIH Nutrition Research on Chronic Disease

An overarching question is whether NIH’s nutrition research investment has paid off in better health outcomes – for example, measurable reductions in chronic diseases like obesity, diabetes, and cardiovascular disease (CVD). To date, the impact has been limited at the population level. Diet-related conditions (obesity, type 2 diabetes, etc.) have continued to rise over the past two decades, with roughly 73% of U.S. adults now overweight or obese and 1 in 2 having diabetes or prediabetes. Diet remains the leading risk factor for premature death and disability in America. This suggests that, despite many research findings, we have not yet translated nutrition science into broad, effective prevention of chronic disease.

That said, NIH-funded nutrition research has yielded some important scientific discoveries and interventions, though implementing them at scale is an ongoing challenge. It points back to the systemic disconnect between the food industry and public health and the lack of “health”care vs. our current healthcare (sickcare) system.

For example, the NIH-sponsored Diabetes Prevention Program (DPP) was a landmark randomized trial in the early 2000s that demonstrated a 58% reduction in progression to type 2 diabetes among high-risk individuals through intensive diet and lifestyle changes. This was a remarkable proof of concept that lifestyle modification can prevent disease; it eventually led to community-based prevention programs and even a Medicare-covered Diabetes Prevention Program, aiming to reduce healthcare costs by averting diabetes.

Another success was the NIH-funded DASH diet trials, which showed that specific dietary patterns (rich in fruits, vegetables, and low-fat dairy) can substantially lower blood pressure – findings that informed hypertension treatment guidelines.

Nutrition research also contributed to policies like trans fat elimination in foods (after studies linked trans fats to heart disease) and improved understanding of salt, sugar, and other dietary components in chronic disease.

These examples underscore that NIH research has generated valuable knowledge and even influenced some public health measures.

However, many large NIH nutrition studies have struggled to show clear clinical benefits, highlighting the difficulty of producing decisive outcomes in this field. A case in point is the massive Women’s Health Initiative (WHI) Dietary Modification Trial, which followed nearly 49,000 women for 8 years on a low-fat diet intervention. The WHI diet trial – one of the most expensive nutrition RCTs ever – ultimately found no significant reduction in heart disease, cancer, or overall mortality from the low-fat diet strategy. In other words, a decade-long NIH nutrition intervention did not yield the hoped-for drop in chronic disease risk.

Similarly, the NIH-funded Look AHEAD trial tested intensive weight-loss counseling in people with type 2 diabetes to see if it would cut cardiovascular events; it achieved weight loss, but failed to reduce heart attacks or strokes, leading to an early halt of the study. These mixed results indicate that identifying effective diet interventions – and sustaining adherence to them – is challenging, and even well-designed trials may show only modest effects on hard outcomes. It shows the complexity of behavioral modification.

Moreover, despite extensive research, some fundamental nutrition debates remain unresolved, limiting clinical impact. For instance, there has been a long-running controversy over the drivers of obesity: the traditional “energy balance” model (excess calories in vs. out) versus the “carbohydrate-insulin model” (CIM), which posits that high-carb diets drive fat storage and hunger via hormonal effects.

NIH has funded studies on both sides of this debate (including tightly-controlled feeding studies). Yet consensus is elusive – researchers continue to publish competing theories, and the obesity epidemic rages on. The persistence of the energy balance vs. CIM dispute suggests that nutrition science has not yet provided a definitive answer on optimal diet composition for weight control, which in turn hampers clear clinical or public health guidance.

In summary, while NIH-supported nutrition research has deepened scientific understanding (e.g. the role of ultra-processed foods, sugar-sweetened beverages, various diet patterns), its translation into large-scale disease prevention has been limited. Unlike some medical research areas where NIH investments led to dramatic drops in disease (for example, HIV or cardiovascular drug breakthroughs), nutrition research outcomes have been more incremental and harder to implement broadly. Rates of obesity and diabetes are higher today than 20 years ago, indicating that knowledge gains have not yet converted into significant population-level health improvements.

It’s essential to recognize that this is not solely a failure of research – many findings, such as the importance of consuming whole foods over ultra-processed foods, are well-established. However, changing human behavior and food systems is a challenging task. Nonetheless, critics argue that NIH’s nutrition research agenda has often been too narrow or methodologically weak to drive major clinical impact. Studies have frequently been short-term or small-scale, showing what we already suspect (e.g. that junk food leads to weight gain) without delivering the robust evidence needed to change policy or medical practice. As discussed next, these critiques have spurred calls to reform how nutrition science is conducted and translated.

All of this leads to the unfortunate conclusion for many that food doesn’t really make that much a difference in human health. Yet we know from evolution that it is indeed the most primitive of root elements driving human health. As a result, the healthcare system was developed and evolved completely detached from the human bodies primary input other than water.

Criticisms of NIH Nutrition Science: Rigor and Relevance

NIH-funded nutrition science has faced a number of pointed criticisms from experts regarding its depth and rigor, especially when contrasted with other areas of medical research:

Limited sample sizes and short durations: A common critique is that many nutrition studies (particularly randomized trials) are too small and too brief to detect meaningful effects on chronic disease endpoints. Feeding studies in metabolic wards, for example, often include only dozens of participants for a few weeks due to cost and logistical constraints. This raises questions about statistical power and whether short-term biomarkers truly predict long-term outcomes. As one analysis noted, “small sample size [and] short length of follow-up” have traditionally plagued nutrition trials, making it hard to draw firm conclusions. In contrast, other fields (like cardiology) routinely conduct trials with thousands of patients over years to assess hard outcomes. The lack of equivalent “mega-trials” in nutrition means we often rely on weaker evidence.
Over-reliance on observational studies: Much of nutrition research has been epidemiological – using cohort studies and food questionnaires – which can only establish associations, not causation. Critics like John Ioannidis have highlighted that observational nutrition findings are often unreliable, prone to confounding and measurement errors, and frequently report tiny effect sizes that may not be real. For instance, one tongue-in-cheek review found that almost every food has been linked to cancer in observational studies, illustrating implausible results due to multiple comparisons. While NIH has funded some large observational cohorts (yielding important correlations between diet and health), skeptics argue that too much money went into repeating association studies “proving” known links (e.g. that fruits and vegetables are healthy) instead of investing in rigorous trials or mechanistic research.
“Discovering” the obvious and duplicating known results: Another criticism is that NIH nutrition research often ends up confirming common-sense knowledge with high expenditure. A frequently cited example is the 2019 NIH metabolic ward study on ultra-processed foods, which was the first randomized trial showing that ultra-processed diets cause overeating and weight gain. While scientifically valuable (it provided causal evidence), many joked that we paid scientists to tell us potato chips make you fat, something that seemed intuitively clear. Similar critiques have been made about studies re-confirming that sugary drinks contribute to weight gain or that eating more vegetables improves health – important to quantify, but hardly paradigm-shifting. The underlying issue is that nutrition science has not yielded enough surprising, actionable discoveries, and often lags behind public health intuitions. In comparison, other NIH-funded fields (like genomics or oncology) have produced more novel breakthroughs (e.g. immunotherapy, gene editing) in the same timeframe.
Failure to resolve key debates or provide clear guidance: Despite decades of research, nutrition science remains rife with unsettled controversies – low-fat vs. low-carb, salt restrictions, the role of red meat, supplements, and so on. As mentioned, the energy-balance vs. insulin-carb model debate is a prime example. NIH has funded prominent researchers on both sides (e.g. Dr. Kevin Hall’s trials favoring energy balance, and Dr. David Ludwig’s work exploring the CIM) yet no consensus has emerged, in part because each study can be critiqued for design limitations or short follow-up. This lack of resolution on major questions frustrates clinicians and the public, who still receive conflicting dietary advice. It contrasts with fields like lipid research, where NIH-funded trials conclusively proved that lowering LDL cholesterol prevents heart attacks – ending debate and leading to unified guidelines. In nutrition, by contrast, we still debate the merits of different weight-loss diets or optimal macronutrient mix, which dilutes the clinical impact of research. Policymakers also lament that nutrition science hasn’t definitively answered “big” questions needed for policy, such as how to most effectively reduce obesity at a population level.
Weak translation and implementation: Critics also point out that even when solid findings exist (e.g. the DPP trial on preventing diabetes), NIH and the broader research enterprise have struggled to implement them widely. There is a gap between discovery and real-world application. For instance, the lifestyle interventions proven to work in controlled trials are difficult to scale up in community settings with fidelity. NIH has not traditionally emphasized implementation science in nutrition to the degree needed to turn clinical trials into nationwide programs. This stands in contrast to other areas like vaccine research, where an NIH-funded discovery (e.g. an HPV vaccine) quickly led to public immunization campaigns. In nutrition, effective interventions (diet counseling, Food-as-Medicine programs, etc.) have seen only patchy adoption. Some observers fault NIH for not investing enough in pragmatic trials or policy-focused research that could directly inform regulations (like soda taxes or food subsidy experiments).

In summary, the depth and rigor of nutrition research has often lagged other biomedical fields, according to its skeptics. As two leading nutrition epidemiologists put it, the field is sometimes accused of “unable to present a consensus on what constitutes a healthy diet,” and is criticized for relying on weak methodologies.

On the flip side, nutrition scientists argue that their work is inherently challenging – you cannot double-blind a diet, people’s eating behavior is hard to control, and long-term diet trials are expensive and logistically complex. All of these are true, but they point to the need for innovation in how we approach nutrition science. The criticisms have sparked calls for NIH to re-think its strategy and adopt new models that ensure nutritional research is as rigorous, large-scale, and impactful as the magnitude of the nutrition-related health crisis demands.

A Strategy for High-Impact Nutrition Research

To better leverage NIH’s $42 billion budget against the $1+ trillion diet-related disease burden, experts propose a more impact-focused nutrition research strategy. Key elements of such a strategy include:

1. DARPA-Style Leadership and Bold Initiatives: Adopting a management approach akin to DARPA (Defense Advanced Research Projects Agency) could inject much-needed dynamism into nutrition R&D. In the defense arena, DARPA achieves breakthroughs by rotating top external experts in as program managers, giving them autonomy to launch high-risk, high-reward projects with specific goals, and holding them accountable to milestones. Similarly, NIH could empower a nutrition “SWAT team” – perhaps via the new ARPA-H (Advanced Research Projects Agency for Health) – to pursue ambitious, mission-driven research programs rather than just funding investigator-initiated R01 grants. ARPA-H, launched in 2022, is explicitly modeled after DARPA’s philosophy of “big bucks for big results”. Its project managers “establish focus areas and actively recruit the best minds… ensuring they meet demanding checkpoints” . A nutrition-focused effort under ARPA-H or ONR could similarly set bold targets (for example, a “moonshot” to cut national diabetes incidence in half within 10 years) and fund multi-disciplinary teams to achieve them. Crucially, this would involve bringing in outside experts – eminent nutrition scientists, but also systems engineers, behavioral scientists, etc. – on term-limited stints to lead initiatives, which injects fresh thinking and avoids the inertia of status quo. Such leaders could commission strategic projects directly: e.g. a nationwide trial of food prescription for diabetes, or development of a novel wearable that accurately tracks diet. This proactive model contrasts with NIH’s usual passive grantmaking and could accelerate innovation. As one commentary noted, “rigorous nutrition research can achieve the same public good [as DARPA tech]… ARPA-H’s mission to create ‘high-impact solutions to society’s most challenging health problems’ is a useful guide”. In practical terms, NIH should fund a Nutrition ARPA-like program that operates with flexible hiring, milestone-driven contracts, and the mandate to cut through bureaucratic delays in pursuit of game-changing results.

2. A Clear Sequence of Studies – from Cohorts to Mega-Trials to Implementation: To maximize impact, nutrition research must be planned as a logical sequence of evidence-building, rather than scattered small studies. This means prioritizing large-scale and long-term studies at a level commensurate with the questions being asked. First, NIH should launch or expand longitudinal cohort studies with big sample sizes (tens of thousands) to map relationships between diet, biomarkers (e.g. gut microbiome composition, metabolomics), and health outcomes over time. Modern technology – wearable diet sensors, continuous glucose monitors, AI analysis of diet logs – can be leveraged in these cohorts to get more objective and granular dietary data than traditional food-frequency questionnaires. These massive observational studies (potentially integrated with the All of Us precision medicine cohort) would help identify critical dietary factors and high-risk populations, and generate hypotheses (for example, specific diet-microbiome patterns linked to obesity or dementia).

Next, armed with hypotheses, NIH needs to fund mechanistic and clinical trials at an unprecedented scale for nutrition. This includes mechanistic feeding studies in metabolic units to understand causal pathways (e.g. how certain diets affect hormones, gene expression, or gut microbes), and more importantly, “mega-trials” in humans – large, simple outcome trials akin to those in cardiology. Thought leaders have suggested that “pivotal megatrials with tens of thousands of participants and lifelong follow-up are possible in nutrition science” if we streamline the process. For instance, one could envision a 10-year trial across multiple cities randomizing thousands of people to different dietary interventions (Mediterranean diet, low-carb diet, intermittent fasting, etc.) with hard endpoints like the development of diabetes or heart attacks. These kinds of trials are expensive, but so are the stakes – and the return on investment could be huge if they finally settle debates and inform guidelines. NIH’s budget could support at least a few such large nutrition trials (for context, the Women’s Health Initiative diet trial cost around $415 million – a fraction of annual NIH spending). By sequencing from cohort discovery -> smaller pilot trials -> large definitive trials, nutrition research can move toward the level of evidence that drives clinical practice (analogous to large trials for drugs).

Additionally, the research sequence should encompass microbiome and genetics (“precision nutrition”) studies. Because responses to diet vary between individuals, NIH is already pursuing the Nutrition for Precision Health initiative, which will analyze how factors like genetics and gut microbiota affect dietary response. Mapping the human microbiome’s interaction with diet could yield new interventions (e.g. personalized probiotics or fiber supplements to improve metabolism). Thus, the strategic plan would include dedicated mechanistic studies on microbiome, metabolite profiling, and other cutting-edge science to understand why certain diets work better for certain people. Finally, the sequence must conclude with implementation research: testing how to deliver proven dietary interventions in the real world (through healthcare, community programs, policy changes). This might involve cluster-randomized trials of interventions in schools or workplaces, evaluations of Food is Medicine programs (like produce prescription projects for low-income patients), or partnerships with government agencies to pilot nutrition policy interventions. By following a continuum from discovery to implementation, NIH can ensure that findings don’t languish in journals but actually reach populations.

3. Performance-Based Adaptation and Focus on Outcomes: A revamped strategy should include clear metrics of success and adaptability. Instead of judging nutrition research programs solely by publications or academic metrics, NIH should track tangible health outcomes and cost savings attributable to its research. For example, goals could be set for reducing national obesity or diabetes rates, or for lowering Medicare/Medicaid expenditures on diet-related diseases, over a decade. As research progresses, NIH can measure intermediate markers (like improved diet quality in certain pilot communities, or number of patients served by effective nutrition programs) that tie back to eventual disease reduction. If some line of research is not showing promise in moving these needles, the strategy should be agile enough to redirect funds to other approaches (hence “performance-based adaptation”). This is akin to a venture capital or DARPA mindset – fund outcomes, not just ideas.

Concretely, NIH could implement milestone reviews for large nutrition projects: are they on track to demonstrate a reduction in risk factors or disease incidence? If not, adjust the approach or pivot resources. The agency can also foster collaborations with payers like CMS (Centers for Medicare & Medicaid Services) to test how research findings might save healthcare dollars. One successful example of this was the Medicare Diabetes Prevention Program: after the NIH’s DPP trial proved lifestyle coaching could cut diabetes by 58%, a demonstration showed it saved enough in medical costs that Medicare began covering it. This kind of research-to-policy pipeline should become standard. NIH might even tie a portion of funding to whether a project leads to a viable policy or intervention within a certain time frame. In addition, placing greater emphasis on health disparities is crucial – tracking metrics of equity (such as reducing the gap in diet-related diseases between populations) and adjusting programs to ensure that high-risk groups benefit. The new ONR has noted the need to reduce nutrition-related health disparities and costs as part of its mission (). Making those outcomes an explicit yardstick will keep the research enterprise oriented toward real-world impact.

In summary, a more logical and impact-driven NIH nutrition strategy would combine visionary leadership with methodical science. By borrowing the DARPA ethos of aggressive, goal-oriented projects, outlining a sequential research roadmap from basic discovery through large trials to implementation, and holding programs accountable to health impact metrics, NIH could vastly increase the returns on its nutrition research investment. Importantly, this isn’t just about spending more money, but spending smartly and boldly. Currently, nutrition-related illness costs America on the order of $1–2 trillion every year in healthcare and lost productivity () () – an untenable drain on the economy and a source of immense suffering. Yet only a few percent of NIH funds are aimed at this problem. Aligning research funding with disease burden is a strategic imperative. As one analysis put it, we need to treat nutrition as a true “moonshot” priority, on par with cancer or other initiatives.

This proposed strategy would likely require increasing nutrition research funding (e.g. doubling it from 5% to 10% of NIH’s budget over time) – but even that would be a tiny fraction of diet-disease costs and could yield enormous dividends if it leads to effective prevention. The payoff of improved nutrition is not only longer, healthier lives for millions, but also potentially hundreds of billions in saved healthcare costs and a more robust workforce. By reorienting nutrition science to be better funded, more rigorous, and laser-focused on reducing chronic disease, NIH can help translate decades of nutritional knowledge into a healthier population and significantly lower the financial burden of preventable diseases. The challenge is great, but with strategic planning and leadership, nutrition research can finally be put on a path to deliver the kind of clinical and policy impact that Americans urgently need.

4. The importance of personalized approaches

Although this is hotly contested, talk to any close group of friends or family about nutrition and diet amongst the cohort and you will find just how differently people respond to the same diet. If you want some extra fun, wear a continuous glucose monitor at the same time as your spouse and start to compare the impact of the same foods on each of you. While we need to know the core basis of nutrition, it’s one place where personalized approaches can’t be ignored and clearly has made things a great deal muddier.

5. And let’s not forget about AI…

Clearly we need more research and the right kind of research but can we harness AI to look for answers we might already have from all of the disparate research done to date?

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