Levers for Preventing Chronic Disease That Intersect with Key MAHA Report Themes

August 06, 2025 | Susan Kansagra, Jessica Baggett, Kelly Williams

The Make America Healthy Again (MAHA) Commission was established on February 13 with an initial mission to “advise and assist the President on how best to exercise his authority to address the childhood chronic disease crisis.” Its preliminary report focuses on drivers of chronic disease in children and includes several overarching themes: 1) increased consumption of ultra-processed foods and decreased consumption of whole foods, 2) physical inactivity, and 3) environmental exposures.

State and territorial health departments have a long-standing commitment to chronic disease prevention. This blog post explores public health actions at the state and federal levels that both conceptually align with the MAHA Commission’s goals and form part of the broader framework of evidence-based public health practice, related to:

• Supporting nutrition.
• Promoting physical activity.
• Reducing and mitigating exposure to environmental contaminants.

In addition to existing local programs, services, and policies, we cover other opportunities at the federal level to influence the drivers of chronic disease.

How to Prevent Chronic Disease: Public Health Actions

Supporting Nutrition

Food Procurement Standards

Establishing food procurement standards for government agencies and other facilities such as public hospitals, early childcare, and schools is one policy tool available at all levels of governments that supports healthy eating. Many government agencies and jurisdictions have implemented nutrition standards for food served on government property, which help ensure that meals served in publicly funded institutions with taxpayer dollars align with the broader goal of supporting health. These standards can also help promote local agriculture and sustainability. For example, in 2016, Vermont created 29 V.S.A. § 160c, which requires that all foods and beverages sold or served by the state meet the minimum nutrition procurement standards established by the Commissioner of Health.

SNAP Policy Changes

Several states have moved toward restricting purchase of candy and sugar-sweetened beverages (SSB) through SNAP. A USDA report states that as much as 20% of SNAP dollars are spent on sweetened drinks, desserts, salty snacks, candy, and sugar. As a result, several states have proposed legislation to instruct states to seek waivers that would prohibit the purchase of these items with SNAP funds (e.g., Texas’ SB 379 which will take effect in September 2025).

States can also implement fruit and vegetable (F&V) incentive programs through SNAP, which can improve the fruit and vegetable consumption of SNAP participants, increase revenue for farmers, and may reduce health care costs.

Sugar-Sweetened Beverage Taxes

SSB are responsible for nearly 25% of all added sugar consumption in the average American diet, surpassing even dessert on the list of top contributors. Jurisdictions such as Philadelphia, San Francisco, and Boulder have implemented a tax to reduce SSB consumption. Multiple studies demonstrate the effectiveness of this strategy, with a 10% increase in the price of SSB estimated to reduce consumption by 7%. Furthermore, the revenue generated by these taxes can fund additional efforts to address chronic disease. In 2008, the Congressional Budget Office created revenue estimates for a federal SSB tax, estimating that a federal tax of $0.03 per 12 ounces would generate $50 billion from 2009-2018.

Breastfeeding

Breastfeeding extends health benefits to infants, as it can protect against lower respiratory tract infections, severe diarrhea, ear infection, and obesity. In addition, mothers receive health benefits such as decreased risk of diabetes mellitus, hypertension, breast cancer, and ovarian cancer. To gain their respective benefits, infants must be breastfed for six months and mothers must breastfeed for 12 months. However, only 59.8% of women are still breastfeeding at 6 months, and only 39.5% are breastfeeding at 12 months.

State and local governments have supported breastfeeding through breastfeeding support hotlines, promoting breastfeeding friendly worksites, engaging hospitals to increase breastfeeding friendly designation, and supporting policy changes to increase coverage of peer counseling and lactation consultants. Peer counseling for breastfeeding is highly effective, and some hospitals have implemented their own programs. States can require health insurance coverage for breastfeeding services and equipment (e.g., Nevada, NRS § 695G.1717).

Sodium and Sugar in Processed Foods

Sodium is a major contributor to heart disease in the United States. The American Heart Association recommends a 1,500 mg per day or less as the ideal standard which is significantly lower than the USDA’s dietary guidelines for Americans of 2,300 mg per day or less, the average American adult’s intake of 3,400 mg per day, and children’s average intake of 3,330 mg per day. Most of this sodium intake is due to commercial food processing and preparation, including foods prepared at restaurants. CDC compiled evidence-based laws that states and local governments can implement to reduce sodium consumption and suggests lowering sodium in government provided foods (such as in schools), increasing menu labeling, and requiring stores to sell a higher proportion of low-sodium foods. Based on the high impact of salt alongside its prevalence in the American diet, the Center for Science in the Public Interest petitioned the government to revise the regulatory status of salt and revoke its Generally Recognized as Safe (GRAS) status.

Additionally, added sugar can contribute to health problems, such as heart disease, obesity, and tooth decay. In 2017, children on average consumed 17 teaspoons of sugar daily — well above the recommended guidelines. The Center for Science in the Public Interest urged FDA to lower the sugar amount threshold in beverages considered to be GRAS. Although GRAS status is determined at the federal level, some local governments have also called for FDA action. The New York City Department of Health and Mental Hygiene petitioned FDA to act by setting multi-year targets for added sugar in food, creating an online database for consumers to compare added-sugar levels, and requiring restaurant chains to disclose added sugar in menu items. The Department also convened public health organizations to set voluntary salt and sodium reduction targets for food and beverage companies.

Promoting Physical Activity

Complete Streets

Building complete streets enables pedestrians, bicyclists, motorists, and transit riders to increase connectedness and physical activity. Furthermore, creating Safe Routes to School enables students to increase their physical activity and reduce the risk of pedestrian injury as well as transportation costs for families and school systems. The recent bill H.R.3931, which encourages safe routes to and from school, has bipartisan support. Although state and territorial health officials do not have direct authority over transportation or parks and recreation, they can collaborate with other agency leaders and community organizations to create safer and more effective transportation routes.

For example, the Minnesota Department of Health (MDH) and the Minnesota Department of Transportation collaborated to create “Minnesota Walks,” the first statewide pedestrian planning framework. MDH provided expertise to reach shared goals such as creating healthier communities and safer places to walk, and minimizing pollution. Minnesota Walks engaged over 6,000 residents to identify key routes and aspects of optimal sidewalks, barriers, and priority populations. The project concluded in 2021, and Minnesota now ranks high nationally for being suitable for both cyclists and pedestrians.

Other Built Environment Opportunities

In addition to active modes of transportation, residents benefit from recreation activities which necessitate facilities like gymnasiums, playgrounds, fields, courts, and running tracks. While government property, such as schools, often have one or more of these facilities, they close their property to the public after hours. By creating joint use agreements (JUAs), government and nonprofit properties allow the community to use their facilities after hours. JUAs may be informal, but a formal, written agreement can address possible concerns (e.g., liability, additional costs for maintenance, insurance, and staffing).

Arkansas implemented the Arkansas JUA Grant, supported by the governor and the Tobacco Excise Tax, to increase physical activity in communities which would otherwise be unable to enjoy such facilities. The Arkansas Department of Education primarily oversees and administers the initiative, as health and educational outcomes are related. In addition, the Arkansas Department of Health, Arkansas Center for Obesity Prevention, and the Arkansas Center for Health Improvement all provide support. Creating a JUA does not necessitate creating a state-level grant. Instead, the facilities and community can calculate the potential costs for use and agree on methods for funding allocation by writing a formal agreement.

Physical Activity in Schools

Enhanced physical education focuses on implementing strategies to increase moderate to vigorous activity to at least 50% of class time and is an effective method for increasing physical activity in youth. Substituting sedentary games with active games or including lessons that incorporate fitness and circuit training activities can help achieve this. In addition, active lessons in classrooms throughout the day effectively increase physical activity.

Public health departments do not have direct authority over schools and their curricula, but they can support and partner with education departments. This support may include providing expertise in internal policies, providing feedback on physical education curriculum, and including school-based physical activity in community health assessments and community health improvement plans. Education departments can also benefit from enhanced physical education as physical activity correlates to improved academic performance and cognitive functioning. Virginia’s Department of Health has collaborated with the Virginia Department of Education since 2017 through its chief movement officers. The collaboration integrates physical activities throughout the day in each classroom. The initiative has improved student concentration, academic achievement, and behavior.

Reducing and Mitigating Exposure to Environmental Contaminants

Radon

Radon exposure is the leading cause of lung cancer deaths for non-smokers, killing an estimated 21,000 people annually. Radon is an invisible but radioactive gas released from water, soil, and some building materials. Over time it can build up in homes, leading to lung damage and cancer in residents. Children are at higher risk for radiation from radon exposure because they breathe at faster rates. While radon levels vary significantly across regions, 1 in 15 homes is exposed to radon levels that meet the threshold for mitigation.

Health departments can work with a wide variety of partners to raise awareness of radon exposure and the benefits of radon testing and mitigation. For example, the North Carolina Department of Health and Human Services partners with a wide range of professionals, from universities to the real estate commission. The state also produced educational videos for the public in multiple languages, so residents can take action against radon exposure.

PFAS

Per- and polyfluoroalkyl substances (PFAS), are man-made chemicals that are pervasive environmental contaminants. PFAS are now present in low levels in both the environment and food, and studies have found that most Americans have PFAS in their body. While research is still ongoing about the health impacts of PFAS, research shows negative effects on the body including impaired immune response, decreased fertility, increased cholesterol, and increased risk for certain cancers. Children are especially at risk, as they consume more water, food, and air per pound of body weight than adults. Additionally, children often put items such as toys in their mouths, increasing the likelihood of PFAS exposure.

State governments have engaged in a number of actions to decrease PFAS exposure including establishing drinking water regulations. PFAS exposure occurs in both private well water and public water systems. Starting in 2031, cities must act when PFAS are detected at dangerously high levels for public water. However, private residential wells are not subject to the same frequent tests as city water. States can raise awareness for well owners and encourage testing. For example, the South Carolina Department of Environmental Services provides free well water testing to residents. While health departments nationwide continue to reduce PFAS exposure in drinking water, some states are also exploring innovative legislation to reduce PFAS use in a wide variety of consumer products.

Lead

There is no safe level of lead exposure, which has been linked to many impacts including cognitive impairment, brain damage, difficulty in learning, and speech and hearing impairment. CDC’s Childhood Lead Poisoning Prevention Program funded state and local health departments to address childhood lead exposure. For example, it supported Alaska's efforts to improve testing in children in 2018, which resulted in the number of children tested for lead quadrupling and identifying additional cases of lead poisoning. Health departments have addressed lead poisoning through several interventions including:

• Educating the public and providers.
• Conducting screening tests for elevated blood lead levels.
• Tracking trends and the epidemiology of lead poisoning in their jurisdiction.
• Performing case management for children with lead poisoning.
• Conducting home and environmental inspections to identify sources of lead.

A recent example of the impact of these federally funded state programs includes North Carolina identifying a contaminated food product that led to elevated lead in over 500 children across 44 states. In 2021, the Bipartisan Infrastructure Law provided $50 billion to strengthen the nation’s drinking water and wastewater systems, which included $15 billion for lead service line replacement projects or similar activities that identified and replaced lead lines. In 2024, the Bipartisan Infrastructure Law provided an additional $2.6 billion in drinking water infrastructure funding to support lead pipe replacement and inventory projects. As a result, Erie Pennsylvania Water Works received $49 million to replace all lead pipes within five years, instead of their original 25-year timeline. Continued federal investment in health department home and environmental investigations for children with elevated lead, coupled with policies designed to replace lead water lines and abate lead paint hazards, can reduce the number of children exposed to this neurotoxin.

Looking Ahead

Federal support (including funding and technical assistance) helped move many of these initiatives forward, and continued investment is important. State and territorial health departments’ knowledge and partnerships can improve nutrition standards, promote physical activity, and reduce exposure to environmental toxins — goals outlined in the MAHA Commission report on chronic disease. However, public health departments need stable, long-term federal investments to sustain this work.

Special thanks to ASTHO’s State Health Policy, Environmental Health, and Chronic Disease Prevention and Health Improvement teams for contributing to this Chief Medical Officer series blog post.