Diet-related health problems have been worsening in the U.S., and obesity rates have skyrocketed in recent decades.
The search for an explanation in recent years has often zeroed in on “food deserts,” generally defined as places where many residents don’t have access to a full-service grocery store within a mile of home in urban areas or 10 miles in rural ones.
From first lady Michelle Obama to Wal-Mart Stores Inc., many people and organizations have pledged to help eliminate such zones.
Yet the question of whether food deserts are critical factors in the disproportionately poor health of people with low incomes remains hotly debated.
The Wall Street Journal invited three people to join in an email discussion of the issue: Mari Gallagher, founder of Mari Gallagher Research & Consulting Group, which has studied food deserts across the country; Helen Lee, a senior associate at MDRC, a social-policy research organization that studies ways to improve health; and Brian Lang, director of the Food Trust’s National Campaign for Healthy Food Access. Here are edited excerpts:
Does access matter?
WSJ: Do low-income people in the U.S. have trouble getting access to healthy food?
MS. GALLAGHER: Many people of all income levels in urban and rural locations have difficulty accessing healthy food, but poor families and communities suffer most. The relationship between the food environment and health outcomes is complicated. Many additional factors besides access and income are in play: cost, transportation, time, education, exercise and motivation are only a few.
We have stressed throughout the course of our work that simply plopping down a grocery store doesn’t mean that these problems are instantly solved. Yet all the knowledge and willpower in the world won’t allow food-desert residents to choose healthy food unless they also have access. Access is foundational. So is understanding the local marketplace and crafting solutions that are economically viable and sustainable.
WSJ: Helen, do you think people in low-income areas often struggle to find healthy food? And if it is readily available, should we be considering strategies to nudge consumers into choosing it—or is that simply unrealistic?
DR. LEE: All Americans, rich and poor, have more access to healthy—and unhealthy—food choices than ever. There are more fast-food restaurants, but there are also more grocery stores with fresh vegetables. At the same time, obesity rates have risen, with the poorest Americans suffering the worst health consequences. Why do people, including the poor, eat too much, and unhealthy foods?
Surveys of low-income households find that taste and convenience rank as top factors. Price is another. Also consider the evidence that the poor and the rich shop at grocery stores outside of their neighborhoods.
Sure, policy makers can tax unhealthier foods to nudge purchasing toward healthier options, but what counts as “healthy?” There is, in fact, ever-changing science and large disagreement about this among nutrition experts. Such “sin” taxes can’t address the energy imbalance of calories in versus calories out. The fundamental causes of health disparities—including but not limited to obesity—are chronic socioeconomic disadvantage, and, in turn, chronic stress. For the poor, the problem has less to do with food deserts and more to do with income deserts, education deserts and quality-health-care deserts.
MR. LANG: A large body of research finds that the food environment in lower-income communities is notably different than in more affluent areas. While low-income neighborhoods may have some small markets that are classified as “grocery stores,” they stock mostly snacks, and the fresh food on their shelves is low-quality and expensive. For folks without a lot of time or money, it’s easier to find a grape soda than a bunch of grapes.
The 2 miles that a higher-income suburbanite might travel to access healthy food isn’t the same as the 2 miles that a lower-income resident might travel. That fact isn’t only borne out by research, but by my experiences on the ground in distressed communities like North Philadelphia and Treme [in New Orleans]. Helen is right that there’s a complex set of factors that drive people’s food choices. But in Philadelphia where my organization, the Food Trust, has been involved for more than 20 years in a comprehensive approach to improve people’s health that includes nutrition education, increasing access to healthy food and a range of other measures, we’ve seen obesity rates decline in some of our most vulnerable youth.
Cure or bandage?
WSJ: What are the key factors your group has identified that led to the decrease in obesity rates?
MR. LANG: In Philadelphia, the city has embarked on a comprehensive approach to improve health led by Mayor Michael Nutter. It’s multifaceted, but some of the food-related work has involved growing a network of over 600 bodegas that now offer healthier options, passing a menu-labeling law for fast-food restaurants, banning soda in the schools, offering strong nutrition-education programs, opening 10 new farmers’ markets in low-income neighborhoods and working in partnership with the state to invest in grocery-store development. We don’t think any of these interventions on their own are a silver bullet, but taken together they’ve had an impact. And researchers in the field seem to be gravitating toward this idea, too—that for these things to improve health, they need to be done in coordination with one another.
MS. GALLAGHER: Brian raised a number of good points. So let’s talk about some of the research that underscores them. Neutral evidence confirms that the food environment matters. In our block-level study of our nation’s capital, for example, we found that pregnant women were 10% more likely to give birth to an overweight child when the closest mainstream food store was a half-mile to a mile away. A half-mile is a fairly decent distance, so this was a surprise. At a mile or more, the risk of being born overweight went up to 20%. The food environment matters in different ways in different places, so we have to be careful not to generalize or make assumptions. But it does matter. And it’s probably easier to improve the food environment than to instantly give each poor person a great job, a college education and a car so that they can travel out of their neighborhood to the healthy food store.
We are working right now on a statewide project in Florida under the leadership of Agriculture Commissioner Adam Putnam. Most people don’t realize that—aside from oranges and tomatoes—Florida produces over 300 commodity crops each year. The state has 47,000 farms; 90% of them are family-owned, and 70% are 50 acres or smaller. In many respects, Florida is the land of plenty. Yet hunger and healthy food access are serious issues, partially because of a few broken links in the food system. We found that improving healthy-food access in poor-food environments by a single percentage point could prevent 650 deaths in Florida over a seven-year period. The commissioner’s team has been conducting listening sessions with some of the leaders of these communities to identify and support locally driven solutions.
WSJ: Helen, you seemed to indicate earlier that scarce income, education and quality health care is a bigger factor in the relatively poorer health of people in low-income communities than healthy food access. What do you see as potential solutions for relatively unhealthful diets among poor people?
DR. LEE: There are surely poor neighborhoods in certain pockets of cities with lower access to grocery stores than wealthier ones. But the evidence that has looked systematically at this issue finds that, on average, low-income neighborhoods aren’t lacking in grocery stores. Does this mean that grocery stores in poor areas offer comparable quality and variety to those in wealthier areas? No. But again, the poor, like many of us, choose their foods primarily for how good they taste. This means that building more grocery stores is, at best, a bandage and, at worst, may actually increase consumption of unhealthy food because, let’s face it: Potato chips are way tastier than rice cakes.
Correlations don’t prove causation. If I showed that brown-eyed people or people who had Android phones were more likely to be obese than blue-eyed folks or iPhone users, would we make policy or targeting decisions based on those findings?
What matters most for good health, as has been documented again and again and for outcomes beyond obesity, is education, higher incomes and access to quality care. No one policy or program can address these things entirely. But investing in evidence-based early preschool programs or initiatives that help low-income young adults attend and complete college or promising work-development strategies might do more for improving the health status of the most vulnerable than building farmers’ markets or grocery stores.