America’s record rates of income inequality may be to blame for the nation’s largest ongoing public health crisis. According to the Alternate Healthy Eating Index in 2010, a metric that assigns foods values based on their relative nutritional merit, the nutrition gap between the wealthiest Americans and the poorest doubled between 2000 and 2010 alone. While overall U.S. dietary practices have improved since the turn of the century—a trend frequently attributed to widespread nutrition education efforts—these improvements are concentrated in the high- and medium-socioeconomic brackets, leaving low-income Americans behind.
This phenomenon presents a serious challenge to society as a whole. Nationally, rates of chronic diet-related diseases have been on the rise for several years—117 million Americans have a preventable chronic disease, and many of these diseases, including cardiovascular disease, high blood pressure, Type 2 diabetes, and several types of cancer, are linked to poor dietary quality. More than two-thirds of adults —and one-third of children—are overweight or obese. In 2008, obesity-related health problems were estimated to cost $147 billion nationally, while by 2012, diabetes costs had reached $245 billion, including $69 billion in decreased productivity.
While diet-related disease is a massive public health issue nationwide, the burden disproportionately affects the poorest Americans. Chronic diet-related diseases can cause further financial struggles, producing extensive medical bills and making work difficult. In 2006, people with obesity paid an average of $1,429 more in medical expenses than other people. Obesity is least prevalent among adults in the highest economic bracket.
Adam Drewnowski is a leading epidemiologist at the University of Washington whose research explores the pronounced relationship between socioeconomic conditions and health outcomes. In a conversation with the HPR, he explained that “not only obesity rates but also soda and salad consumption patterns can be readily predicted from residential property values.” In Seattle-King County’s census tracts, for instance, he found that every additional $100,000 in median home values was associated with a 2.3 percent decrease in obesity rates, and that the “obesogenic areas,” where high obesity rates are perpetuated by dominant cultural and social practices, were mainly those with low property values.
Food Deserts and the Problem of Access
One of the most basic barriers for people of low socioeconomic status pursuing a healthy diet is a lack of access to high-quality, nutritious food. Many low-income neighborhoods can be classified as food deserts, areas characterized by a limited availability of healthy food. Individuals who can’t access full-service grocery stores are more likely to purchase food from convenience stores, where fresh produce and other healthy foods may be of limited quantity and low quality, if not entirely absent. In Massachusetts alone, 2.8 million residents of low-income areas lack access to grocery stores, and diet-related diseases are responsible for an additional $3.5 billion in health care expenses each year.
Over the last few years, companies like Whole Foods have been opening in these food deserts with the aim of improving community health outcomes; Cambridge’s own Clover Food Labs has made plans to open new locations in areas with limited access to healthy food options. Although some critics have raised concerns that corporate interests, including brand maintenance and an eye on profit, may prevent upscale food retailers from bringing their best wares into food deserts, examples have been promising. In Boston’s Jamaica Plain, for instance, Whole Foods, which has been a feature of the famously diverse neighborhood since 2011, boasts an expanded bulk department, complemented by location-specific sales.
The long-term impact of these supply-side interventions remains to be seen, but the deeply entrenched relationship between socioeconomic status and health outcomes suggests the need for complementary demand-side solutions. As of now, no study has been able to demonstrate that neighborhood residents become significantly healthier when a health food store sets up shop. Indeed, social and demographic markers are much better predictors of individuals’ food consumption patterns than where they shop and eat. The availability of healthy food is still secondary to factors like budget, culture, and dietary knowledge in shaping shoppers’ food choice.
Kristina St. Cyr Kimani, who leads the Massachusetts Public Health Association’s healthy and affordable food access work, is quick to point this out during an interview with the HPR. “You may have physical access to healthy food, but if it’s not affordable, you don’t really have access,” she said. Her definition of access also considers the effects of public transport: Long routes, bus-switching, and a limit on the number of grocery bags riders can bring onboard may all contribute to a hassled shopper’s decision to pick up food at the nearby corner store instead. That’s one reason why the Massachusetts Food Trust Program, established in 2014, focuses on providing loans and technical assistance to support the health-driven expansion of local corner stores and food distribution hubs, as well as community-driven enterprises like farmers’ markets and food co-ops.
Issues Beyond Access
If access isn’t the only problem, other factors must be driving consumers’ suboptimal food choices. The first and most significant barrier is likely to be price-related: healthy foods tend to cost more than unhealthy ones. Although health foods have become more popular in recent decades, even staples like lean meats, fish, fruits, and vegetables remain much more expensive per calorie than foods high in refined grains and added sugar. For a shopper on a lean budget, it is easier to choose filling, energy-dense but nutrient-poor foods every time. As Drewnowski points out, “the narrow dietary focus on good versus bad foods ignores the basic economics of food choice. There is a social divide separating regular consumers of sugary soda from consumers of salad.”
As the income gap continues to grow, high-priced health food stores and restaurants can make a profit by targeting middle- and upper-class consumers, while the shrinking food budgets of low-income families drive them to choose low-cost empty calories. Even with access to stores like Whole Foods, most families with highly restricted food budgets will choose foods that provide maximum calories for minimum cost instead of stocking up on fresh produce. After all, Whole Foods, a middle-class favorite, is well-known for its nickname, “Whole Paycheck.”
The Supplemental Nutrition Assistance Program is a federal program that provides food-purchasing assistance to roughly 45.6 million Americans. As the largest program in the domestic hunger safety net, SNAP has repeatedly been shown to reduce food insecurity for low-income families. However, the evidence as to whether SNAP promotes a healthier diet is inconclusive. In contrast to other federal subsidy programs like the Supplemental Nutrition Assistance Program for Women, Infants and Children, SNAP does not require food purchases to meet any nutritional requirements. Numerous proposals have been made to institute basic nutritional requirements as part of SNAP, but each has been rejected by Congress and the Department of Agriculture, with many opposing the proposal as an infringement on recipients’ freedom to make their own dietary choices. In its current form, SNAP may help with price-related barriers to healthy food selection, but other factors still cause SNAP beneficiaries to choose low-quality foods.
Varying levels of nutritional knowledge may be another such factor to blame for the food gap between the rich and the poor. While national levels of nutritional science knowledge are steadily increasing, not everyone has the same access to up-to-date nutritional guidelines. Instead, low-income individuals are more likely to be exposed to advertising for products that encourage sedentary lifestyles and the consumption of unhealthy foods and sedentary lifestyles. This is especially troubling because so many of these ads target children, on whom food choice ads exert a particularly strong influence.
The good news is that each of these issues suggests possible areas for intervention. Improving access to healthy foods via the introduction of health chains or community-driven efforts and increasing nutritional awareness are both worthy goals. Indeed, some combination of nutrition education, financial incentives, and improvements to the regional food landscape will be necessary to fundamentally reshape attitudes and behaviors born of an obesogenic environment.
However, in order to truly correct the yawning nutrition gap and subvert our national public health crisis, it is likely that more structural economic changes are also required. Nutrition inequality is largely a consequence of income inequality, and not just because of the high cost of healthy foods.
A Vicious Cycle
Unhealthy eating behaviors and the negative health outcomes associated with them are part of a vicious and deeply-entrenched cycle for families in the lowest socioeconomic brackets. Its causes include the logistics of access and price, as well as the more insidious psychological and biological consequences of food insecurity.
Basic food insecurity—along with low-wage work, limited access to health care, poor housing, and other factors—is a significant daily stressor for low-income families. Stress is known to produce weight gain through metabolic and hormonal changes, as well as less healthy eating patterns. Several recent studies have also linked food insecurity to psychological stress and mental disorders like depression, which can have negative health consequences independent of dietary practices. Thus food insecurity has effects that are long-lasting and permeate seemingly separate aspects of an individual’s life.
Food consumption patterns among low-income families add another concern: the metabolic changes associated with irregular food availability. Highly food-insecure individuals are often subject to repeated periods of food restriction or deprivation. When food does become available, they are much more likely to overeat. This problem is especially severe given the cheapness and convenience of fast food in many food deserts, which traffic in high-calorie, low-nutrient foods that allow for overconsumption even on an extremely limited budget. These individuals are liable to experience worse health outcomes due to the metabolic changes that result from chronic or repeated food deprivation, as the body adapts to store more fat. Irregular access to food is also associated with an increased likelihood of developing an unhealthy preoccupation with food, spurring even greater overconsumption when food is available.
Solving the Nutrition Gap
David Ludwig, a professor of nutrition at the Harvard T.H. Chan School of Public Health and director of the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, is the first to acknowledge that nutrition science has provided conflicting messages in the past. He emphasizes, however, that we can craft the outlines of a much healthier diet based on existing knowledge—the goal now is to design public policies that will encourage that way of eating. In an interview with the HPR, he maintained that we cannot neglect the overarching societal challenges faced by low-income communities. “Until we make systematic changes, it’s going to be easy to point the finger at the individual and expect personal responsibility to solve the problem.” While some low-income families might be able to maintain healthy diets, Ludwig adds, “the risk is expecting that [personal responsibility] to be a public health solution, when such massive social forces are arrayed against the community, making it very difficult to sustain a healthful lifestyle.”
The kind of systemic changes that Ludwig is advocating for—including establishing subsidies for healthy foods funded by a tax on all processed foods—will not come easily. Implementation of this kind of solution, furthermore, will likely require campaign finance reform. As long as politicians are more accountable to special interests than public health, we are unlikely to be able to address the national nutrition gap. Ludwig’s advice? “Vote with the fork, and vote with the ballot.”
As it stands, a dangerous and damaging cycle, in which patterns of unhealthy food consumption are worsened by budgetary restraints, poor food access, psychological distress, and metabolic changes, among myriad other factors, is the reality for a large percentage of the U.S. population. With so many structural factors perpetuating individuals’ suboptimal food choices, it should be clear that the onus to improve our country’s nutritional report card cannot rest on the low-income families whose diets are lagging. We need to focus on collective solutions: promoting widespread nutrition education, and supporting policies that improve the food environment and advance public health.
Image Source: Flickr/lyzadanger