Why Community Engagement Must Be Matched by Structural Food Policy

Am J Manag Care. 2026;32(Spec. No. 3):SP154-SP155. https://doi.org/10.37765/ajmc.2026.89905

The case study of the Go for Bold initiative, published in the March 2026 issue of Population Health, Equity & Outcomes, powerfully illustrates how community-driven campaigns can yield measurable health improvements.¹ In Washington County, Maryland, this bold challenge—collectively losing 1 million lb by 2030—has already mobilized more than 7700 participants across 55 organizations, resulting in more than 160,000 lb shed by December 2024 and a 6.05% uptick in endocrinology patients achieving a body mass index under 27. These outcomes underscore the potential of local partnerships, social accountability, and motivation to drive health behavior change.¹

Yet, as I argue in asSALTed: Saving Lives and Money by Adopting the Finnish Salt Laws, effective behavior-change efforts like Go for Bold cannot stand alone.² They operate within a food system whose economic incentives often frustrate health-oriented goals. High-salt, processed products remain cheap and ubiquitous, effectively opposing individual efforts to eat better.

In asSALTed, I highlight the dramatic health and economic benefits of national sodium reduction policies. A 40% reduction in population salt intake—from 3700 mg/d to 2300 mg/d—was associated with a 50% drop in osteoporosis-
induced hip fractures. It also led to a 75% drop in heart attacks and an 80% drop in strokes, while saving billions in health care costs.² These “salt laws,” inspired by Finland’s decades-long regulation, illustrate how a single, well-conceived policy can deliver systemic impact without relying on ongoing personal vigilance. Similar results are obtained in Argentina.³

The literature confirms what Go for Bold has begun to show: Voluntary efforts work—but paired with structural policy, they work exponentially better. For instance, a crossover trial found that just 1 week on a low-sodium diet produced a mean reduction of approximately 8 mm Hg in systolic blood pressure (BP)compared with a high-sodium diet—even among individuals with normal BP—underscoring the direct biological efficacy of sodium reduction.⁴ Complementing this, a recent meta-analysis revealed that behavioral salt-reduction interventions yield only modest benefits—a systolic BP decrease of approximately 1.2 mm Hg—suggesting that voluntary efforts, although effective, are markedly constrained without policy reinforcement.^5,6 A Cochrane review of global, government-led sodium reduction initiatives found that multicomponent, structurally oriented policies—such as reformulation, procurement standards, and labeling—yielded significantly larger reductions in salt intake than behavior-only efforts, suggesting both enhanced effectiveness and potential for greater equity, particularly when socioeconomic mechanisms are embedded.⁷ A good example is the UK’s Soft Drinks Industry Levy, a policy change that shifted those incentives at scale. Within a year of its implementation, children’s daily free sugar intake fell by 4.8 g and adults’ by 10.9 g. The sugar content of many taxed beverages was reduced as manufacturers reformulated to avoid the levy. These reductions were population-wide and achieved without requiring ongoing individual motivation—an effect more powerful, and far more scalable, than what any voluntary campaign could produce.⁸ Importantly, Eykelenboom et al showed that in the Netherlands, public acceptability for such a tax rose from 40% to 55% when revenue was earmarked for health initiatives.⁹ Similar results were obtained in Mexico with a sugar-sweetened beverage tax.¹⁰

Policies—including taxes, reformulation mandates, and labeling—are not just useful but also essential because of the following:

• They shift the environment so that healthier choices are easier, cheaper, and normative.
• They ensure equitable reach, particularly in communities with lower capacity for sustained behavior change.
• They require less ongoing effort from individuals, reducing “behavioral burden” and improving long-term adherence.

Let us be clear: Obesity, diabetes, and cardiovascular disease do not arise from moral failing or lack of willpower. They are predictable outcomes of an economic system that subsidizes corn syrup and ultraprocessed grains, floods neighborhoods with fast food, and makes nutrient-rich foods prohibitively expensive. A burger can be had for a dollar; an apple, ironically, may cost more.¹¹ At the same time, the proportion of processed food consumption increased further from 53.5% to 57.0% of calories, whereas the proportion of minimally processed foods decreased from 32.7% to 27.4% from 2001 to 2018.¹²

To amplify Go for Bold’s achievements, we should advocate for several complementary, evidence-informed policy actions, including the following:

• Redirect agricultural subsidies away from ultraprocessed, sodium-heavy
  commodities toward minimally processed, nutrient-dense crops.
• Implement excise taxes on high-sodium, high-sugar products, with revenues earmarked to subsidize healthy foods and support local growers.
• Mandate front-of-pack warnings or interpretive labels (eg, color-coded
  or traffic-light systems) for high-sodium content.
• Incentivize zoning and licensing policies that limit fast-food density and promote access to fresh food retailers in underserved areas.

Without such structural measures, we risk the “policy responsibility paradox” described in asSALTed: expecting individuals to overcome systems that policy itself permits to persist.

Yet, Go for Bold offers a strong foundation for these efforts. Its success demonstrates that communities rally effectively around shared, quantifiable health goals. Equipped with this momentum, local leaders can make a convincing case: “Look what we—and people—are already doing. Now, please give us a supportive policy.”

Ultimately, pairing bold goals with bold laws is how we transform transient wins into sustainable public health progress. Complementary efforts of the population in conjunction with policy muscle offer our best path to lasting change.

Author Affiliation: Departments of Pediatrics and Medicine, Western University, Children’s Hospital, London Health Sciences Centre, London, Ontario, Canada.

Source of Funding: None.

Author Disclosures: The author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.

Send Correspondence to: Guido Filler, MD, PhD, Departments of Pediatrics and Medicine, Western University, Children’s Hospital, London Health Sciences Centre, 800 Commissioners Rd E, Rm E3-26, London, Ontario, Canada, N6A 5W9.

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