When it comes to discussing poverty in the U.S., few topics seem as counter-intuitive — on the surface at least — as poor Americans’ struggles with obesity. Using the Center for Disease Control (CDC) definition of having a BMI of 30 or greater, obesity is more prevalent among people earning minimum wage than their better off counterparts. In states where the minimum wage is lower, across the South, minimum wage earners are even more likely to be obese.
It would be easy to simply blame poor people either for not knowing enough to choose healthier foods or, worse, for being too lazy to implement the smarter choices.
Like many of you, I’ve worked at spending less on food for the last couple years, but my own experience in trying to cut costs has largely involved substituting in healthier choices, such as buying fresh fruits and vegetables rather than more expensive processed foods, or by eating less meat that might spoil before I get a chance to cook them and instead opting for beans, nuts, lentils, tofu, and so forth. Moreover, even if fast food restaurants did sell cheaper food than grocery stores, wouldn’t it be even cheaper to just eat less of it?
Finding answers for the causes of obesity isn’t just an academic question; it’s a growing public health crisis. A 2009 report published in Health Affairs estimated that medical spending related to obesity amounted to $147 billion in 2008.
Here are some of my thoughts on the topic.
If you’ve looked into this topic at all, you’ve no doubt heard of the term, “food desert.” The CDC defines food deserts loosely, as such:
Food deserts are areas that lack access to affordable fruits, vegetables, whole grains, lowfat milk, and other foods that make up the full range of a healthy diet.
In practice, a food desert has two commonly used quantitative measures, which are both laid out on the USDA map below. The areas in green are either urban areas where for many people, the nearest grocery store is at least one mile away or rural areas where the nearest grocery store is at least 10 miles away. The areas in yellow are low-income areas where many people don’t have access to vehicles or are 20 or more miles from the nearest supermarket.
Think about it this way: food shopping is tough enough when you’ve got a car or easy access to the subway. If you’re working two minimum-wage jobs, walking your kids to and from school, and spending time dealing with all the stressors that a life in poverty throws at you, then you may become more likely to buy something easy and unhealthy at a convenience store or fast food place rather than walking a mile to a grocery store to carry home a week’s worth of groceries — or else make multiple weekly trips — particularly if you’ll be walking through unsafe neighborhoods.
It goes back to the issue of bandwidth that I’ve previously discussed; with so many other things fighting for attention of the working poor, if they can cross food off the list in a way that doesn’t take very much money, time, or effort, then so be it.
Compare the map above with this one, which shows the prevalence of obesity by county.
It should be clear that better access to healthy food is at least a part of the puzzle.
The concept of access may not end with supermarkets either. The other side of the equation in maintaining a sensible weight is staying active. It should not be too much of a logical leap to suspect that the same factors that could prevent someone from making trips to a far away grocery store — lack of spare time and unsafe neighborhoods — could also make it tough to get outside for a hike around town or a game of catch in the park.
It starts early
Here’s a counter-theory: obesity tied to poverty is a deeply seated inter-generational problem and food deserts, at best, tell only part of the story.
The CDC itself claims that “many consumers [who live in food deserts] continue to make unhealthy choices based on personal preferences” even after healthier options are made available. Professor Adam Drewnowski of the University of Washington — a leading researcher in the field — found physical distance to supermarkets unrelated to obesity risk, finding instead that it was more consistently associated with lower education, lower income, lower neighborhood property values, and shopping at lower-cost stores.
Both of these results suggest that behavior that could lead to obesity is deeply ingrained among those with lower socioeconomic status — and perhaps that obesity risk has less to do with what we do about it and more to do with who we are.
I imagine that this may not sit well with normal readers of my blog, in which personal agency and personal responsibility are all but assumed, what with all the goal-setting and constant drive toward self-improvement.
I think that while every adult may be responsible for his or her current choices, many of the decisions that shaped their attitudes about food were made long before they had any say in the matter. In this case, it starts long before high school home ec classes and learning about the food pyramid in middle school; a study shows that 35% of 3-year-olds from low-income households were already overweight or obese — a number double the rate for all 3-year-olds.
Say what you will; it’s pretty tough to shake habits developed before you stopped wetting the bed.
Bad food is cheap and a conclusion
In the end, maybe the answer isn’t even that hard. Maybe poor people choose fast food for the same reason anyone does (on occasion at least).
— because they like how it tastes. That you don’t have to expend a lot of energy, use up much time, or give away a lot of money to get a lot of food may also help (The Freakonomics podcast once posited that the McDonald’s McDouble, a 390-calorie sandwich with 23 grams of protein, might be a modern miracle).
And maybe that’s part of the problem. Advances in farming and food manufacturing have succeeded in making empty calories extremely cheap, while nutrient-dense foods have remained more expensive — and the gap between prices of the two is growing.
Another study led by Drewnowski showed that the gap in price between 1000 calories of the most nutrient-dense foods (including red peppers, raw oysters, and the healthiest greens) and 1000 calories of the least nutrient-dense foods (including white sugar, hard candy, jelly beans) grew by 31% from 2004 to 2008.
By 2008 those more nutritious foods were more than nine times the price of the least nutritious foods.
I would start my conclusion by saying that I’d like to do lots more research and analysis on the topic. I’m hesitant to suggest policy implications for such inconclusive correlative relationships, but see the benefit in current efforts by both government and the food industry to increase access to food. All stakeholders should shift from a focus on measures of calories toward a focus on measures of nutrients.
And that’s that. Have a good day everyone.
Centers for Disease Control and Prevention. “Defining Overweight and Obesity.” Retrieved Aug. 19, 2014. http://www.cdc.gov/obesity/adult/defining.html
DaeHwan Kim, John Paul Leigh. “Estimating the Effects of Wages on Obesity.” Journal of Occupational and Environmental Medicine, 2010; 52 (5): 495 DOI: 10.1097/JOM.0b013e3181dbc867. http://www.sciencedaily.com/releases/2010/05/100511092151.htm
Eric A. Finkelstein, Justin G. Trogdon, Joel W. Cohen, William Dietz. “Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates.” Health Affairs, September/October 2009. http://content.healthaffairs.org/content/28/5/w822.full.html
Centers for Disease Control and Prevention. “A Look Inside Food Deserts.” Retrieved Aug. 19, 2014. http://www.cdc.gov/Features/FoodDeserts/
United States Department of Agriculture. “Food Access Research Atlas.” Retrieved Aug. 19, 2014. http://www.ers.usda.gov/data-products/food-access-research-atlas/go-to-the-atlas.aspx#.U_MEg8kXuT0
Centers for Disease Control and Prevention. “Estimated County-Level Prevalence of Diabetes and Obesity — United States, 2007.” Nov. 20, 2009. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5845a2.htm
Adam Drewnowski, Anne Vernez Moudon, Junfeng Jiao, Anju Aggarwal, Helene Charreire, Basile Chaix. “Food environment and socioeconomic status influence obesity rates in Seattle and in Paris.” Int J Obes (Lond). Feb 2014; 38(2): 306–314. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3955164/
Stephen Smith. “Obesity battle starts young for urban poor.” Boston Globe. Dec 29, 2006. A.1, Health & Science. http://pqasb.pqarchiver.com/boston-sub/doc/405046605.html
Freakonomics Radio. “Freakonomics: Can the McDouble save humanity?” July 3, 2013. http://www.marketplace.org/topics/sustainability/freakonomics-radio/freakonomics-can-mcdouble-save-humanity
Pablo Monsivais, Julia Mclain, Adam Drewnowski. “The rising disparity in the price of healthful foods: 2004–2008.” Food Policy. Volume 35, Issue 6, December 2010, Pages 514–520. DOI: 10.1016/j.foodpol.2010.06.004. http://www.sciencedirect.com/science/article/pii/S030691921000076X