by Marion Nestle
Apr 30 2012

Will better access to healthier foods reduce obesity?

A question from a reader:

Q.  I was wondering if you could comment on the recent article in the New York Times which questions the link between food deserts and obesity.

A.  Sure.  Happy to.  The article talks about two recent studies finding no relationship between the types of foods children eat, what they weight, and the kinds of foods available within a mile and a half of their homes.

These finding seem counter-intuitive in light of current efforts to improve access to healthier foods in low-income communities.

Obesity is more common among the poor than among those who are better off.   Poor people must be eating more calories than they expend in physical activity.

Eating more calories means eating more of foods high in calories, especially fast food, snacks, and sodas.  Kids who are heavier have been found to eat more of those foods than those who are not.

I can think of several reasons why this might be the case:

  • Access: healthier foods are less available
  • Cost: healthier foods cost more
  • Skills: healthier foods require preparation and cooking
  • Equipment: cooking healthier foods requires kitchen facilities, pots, and pans
  • Transportation: even if stores are available, they might be too far away to walk to
  • Quality: even if stores sell fruits and vegetables, they might not be fresh
  • Marketing: fast foods, snacks, and sodas are heavily marketed in low-income areas
  • Peer pressure: eating high-calorie foods is considered the norm

I can think of ways we might try to improve any of these factors, but I’m guessing that cost is the critical factor for people with limited means.  The Department of Commerce reports that the indexed price of fresh fruits and vegetables has increased by 40% since 1980, whereas the indexed price of sodas has declined by about 30%.

Fast food, snacks, and sodas are cheap.  Fruits and vegetables are not.

Without access to healthful foods, people cannot eat healthfully.  But access alone cannot reverse obesity.

The real issue is poverty.  Unless we do something to reduce income inequality, and to make healthier foods more affordable, fixing the access problem is unlikely to produce measurable results on its own.

Posted from the World Public Health Association annual meeting, World Nutrition 2012, in Rio.

  • Marian.

    I’d also like to suggest another constraint and that is style of cooking, and oils used. Fried food vs. steamed food. Oil oil vs. CRISCO/ lard. Both of these would have an impact on the quality/ caloric count of food, and given the different costs, I think it would be easy enough to look at correlation between geographic areas and sales of “healthly” oils.


  • Steve Cronk

    I think you may have cause and effect backward. Soda gets cheaper because customers demand more soda; fruits and vegetables become more expensive because demand for these products has decreased.

    The solution has less to do with addressing income inequality than you suggest and more to do with persuading people that eating healthy foods is a good decision. If poor people WANT fruits and vegetables, entrepreneurs will find a way to make a profit by supplying them.

  • I just sat next to an 20-year-old, city dweller who works full-time. We somehow got on the topic of her budget. Her first monthly paycheck heads to rent, the second to her bills. What’s left is for food–a whopping $12 to hold her for the next two weeks.

    What’s more, she walks everywhere: to work, to school, to the movies and back home. Recognizing her small-city location with limited public transportation, she food shops at venues half mile away. I wish you could see the local corner store shelves of the prepackaged, but affordable “food” or the vast variety of fast food joints at her fingertips. But, no grocery store is in site. Well, she could hike 3 miles to the closest one, not to forget the heavy-handed trek back. Forget about those weighty, (easy-on-the-wallet) canned fruits and vegetables! Talk about a workout!

    This 20-year-old isn’t living the “bad-life” on the streets. Sure, she has lots of growing-up to do; but she’s working, living, paying bills, hoping to get by.

    Do you know many young gals who plan a weekly grocery store visit for fresh produce, especially when they have a 12 dollar food budget to top those barriers Marion mentioned above? Income inequality is real.

    Anyways, bring in those entrepreneurs because God knows we need ’em.

    Oh, I forgot. She exclaimed how much she LOVED apples and kiwi. Greens were on her list of likes too.

    Keep talking facts Marion. I applaud you.

  • I agree. I would also add:

    Marketing pressure. Junk food companies don’t pay out millions and millions of dollars unless they can get consumers to prefer their stuff.

    Education. The current messages about how to eat well are a) confusing and b) not as accessible as junk food marketing; adults are only educated about eating habits if they visit an educated doctor regularly or participate in WIC and most school districts don’t even have a nutrition education curriculum.

    Taste. Junk foods are specifically engineered to trigger “bliss points” in the people who eat them. Healthy foods don’t necessarily do that.

    I would also add that there are more factors to consider when it comes to access – for instance, you may be able to walk to the store with your three children under the age of five, but will you be able to walk home carrying milk, eggs, fruit and vegetables, or will you buy food your kids can carry themselves and eat on the way?

  • Viewing poverty as the primary cause is interesting, especially since world-wide, the wealthiest countries tend to be overweight, and poorer countries do not. Sadly, many poor Americans are actually wealthy by international standards, and many Americans were quite poor before the obesity epidemic. With the rates of obesity climbing rapidly among all income brackets in the US, it seems to me that there are other major causes. Perhaps our general prosperity has led to dependence on machines for virtually every activity that burns calories – including the farming and production of a heavy diet better suited to people involved in manual labor. With most of our health care expenditures now going towards behavior-related diseases, we need to attack the obesity problem quickly by changing both our diets and level of activity among all income levels.

  • Michael Bulger

    Soda prices and fresh fruit and vegetable prices do not respond to demand in the same manner. A few differences that affect prices: 1. Subsidized ingredients like high-fructose corn syrup. 2. Shipping (bottled soda is durable and can be shipped warm/fresh produce needs to be refrigerated, is fragile, and comes with food safety concerns). 3. Shelf-life (store managers include the cost of produce that spoils before it is sold when they set prices).

    These are just three of the reasons why consumer demand and price are not a simple matter of cause and effect.

  • Good points, Michael. It may be true that a soda will always be cheaper/more convenient than fresh produce, but we should think on the margin. Consumer demand explains much of why, despite improvements in technology and management, fruits and vegetables would become more expensive over time. Of course, removing distortions created by subsidies for foods like corn, soy, and wheat would also help bring fruit and vegetable prices toward their lower market price.

  • brad

    I also think there’s a fair amount of psychology wrapped up in this question. Poor people (even if they are wealthy by third world standards) have to live with a lot of inconveniences, and convenience food may help relieve some of the stress associated with that. When you’re a single mom with six kids and a tiny kitchen in an un-airconditioned eighth floor apartment, you’re probably going to welcome ready-made meals that can be tossed in the microwave. “Comfort foods” high in sugar and fat are likely to be favored for similar reasons.

    Back in the depths of the 1980s recession, I remember a guy in Boston who launched a highly successful chain of gourmet cookie stores. Most people couldn’t afford to buy a new car or new clothes, but almost anyone could afford to spend $3 on a cookie. It helped relieve the grind of austerity and provided a little thrill of luxury.

  • Micomyiza

    Michael’s post refers three important factors in the cost difference between soda and vegetables
    1. Subsidized ingredients
    2. Shipping
    3. Shelf-life

    Ignoring the first point, does anyone know of analyses done on vegetables for the other two? For example, fresh salad greens are very nutritious but fragile and spoil quickly so they are not a great starting point for a mini-mart trying to sell more vegetables. Sweet Potatoes, however, are great nutritionally, are tough as rocks, and last a long time if stored correctly.

    If the goal is gradually increasing the availablity of fresh vegetables in food deserts, a ranking of vegetables with the best nutrition for lowest risk (from a vendor perspective) might be useful.

  • Michael Bulger

    Fruit and vegetable prices have gone up due in part to the advent of bagged mixed greens, precut broccoli, pre-sliced fruits, etc. Food companies look to find ways to add value to food in order to grow profits. It could mean less store space for lower-cost produce. The result has been higher prices and lower affordability for low-income Americans.

  • Cathy Richards

    Poverty has varying effects on weight (population wise) depending on where you live. In developing countries poverty is generally associated with underweight, and ‘richness’ with overweight. In developed countries it tends to be the opposite.

    Marion’s comment about poverty and obesity being linked is true for North America.

    These are generalizations of course, for populations. There will be individual variances, as well as local variances (eg. urban vs rural). This may be why the study missed an association.

    Obesity always has a complex etiology. Although calorie imbalance is the ultimate determinant, there are multiple interconnected causes of this imbalance. Too much food, wrong kinds of food, too little activity, depression, happiness, neglect, poverty, genetics, no nearby grocery store, vending machines, sugary drinks, diet drinks, cars, phytoestrogens, lack of sleep, stress, sedentary work…etc etc etc.

    Which means multiple approached are needed, no scapegoating, no cherry picking, no pointing fingers, no excuses, no short term measures with long term expectations.

  • Angela

    quick comment–in your list of possible reasons why the working classes tend to be fatter than the upper middle class and upper classes, i would swap the word “skills” with the word “time.” poor people lack cooking skills? hmm, maybe, but i think it more likely that after working a 9 hour day that time is a bigger problem than not knowing how to cook.

  • Angela

    also, i agree with brad. there could be a huge psychological/emotional component to working class peoples’ decisions to eat more junk food. i mean, after working all day, who doesn’t feel like they deserve to relax or have a treat? for many people, other ways to treat yourself are unrealistic (like going out to a movie when you can’t afford a babysitter). however, junk food is cheap and can be eaten, well…whenever.

  • Angela: You have hit the nail on the head. Time and energy are indeed a huge problem. Cooking healthy is not only time consuming, but also highly complicated.

    Steve: And this is the reason why the demand side of the equation is so weak. People don’t have the time or energy to process all the complicated information about food, nutrition, user habits, etc. to make healthy decisions.

    ps: we are a early state startup working on this exact problem.

  • ..and our startup is called

  • brad

    The time issue is more a matter of perception than reality. I have entire cookbooks full of healthy recipes that take 20 minutes or less to prepare, and in some cases the 20 minutes includes cleanup afterward. Even when I’m working 70-hour weeks I don’t find it very challenging to cook all our meals; we eat out maybe twice a month. The biggest challenges for me are planning meals ahead and finding time to go to the supermarket to pick up ingredients. But the actual cooking itself is not time-consuming, and if you make big dishes like stews and soups you can have leftovers for several meals.

  • Brad: Agree 100%. Cooking itself if not that challenging. It is the planning, prep and groceries piece. This is what we are working on – an integrated solution that saves time across the cooking lifecycle.

  • Pelle Moulante

    The modern instant-gratification american lifestyle powered by accessible-anywhere junk food and the related full-on advertizing will block any efforts by the advocates of healthy food/eating to get people to slow down and eat real food.

    America’s top behavioural scientists work full time for coke and pepsi corporations to make this happen. We need behavioural scientists engaged in the “eat real food” side of the equation, along with an advertizing budget that will rival the defence dept appropriation or it just isn’t going to happen. (Get real)

    As well, it is sure easy to block out the scolding or highly self-righteous tone of the advocacy efforts to get america to eat real (non corporate-manufactured) foods. I might note that this tone can be frequently observed in these very comments, just sayin’ people. Nobody likes finger-wagging directed their way.

  • Michael Bulger

    This article might interest some of you:

    The basic gist of it is that Americans might not actually have less time than in the past, but that we certainly perceive time scarcity more than in the past. And that even the perception of time scarcity can be enough to make us alter our eating behaviors (especially when food companies incorporate our perceived time scarcity into marketing).

  • Min

    Cathy above mentions the urban/rural distinction which I think is one important factor. In the not too distant past, a much larger proportion of our poor population lived in rural areas where they could raise their own vegetables and scavenge for local berries or other fruit and even hunt for meat or raise chickens – all probably healthier, fresher and cheaper (but more labor intensive) than what they might find in urban food deserts.

  • Eating healthy food is a third or fourth order issue behind:

    *lack of opportunity to move forward in life
    *money problems
    *fear of local crime
    *lack of interest by those who have

    The biggest barrier to diet improvement is apathy, or ‘I just don’t care’, when there are so many other economic priority issues to deal with.

    It’s not being poor that causes one of the underlying problems, carrots are cheaper than fries, it’s being made to feel poor by a system focused on positional consumption.

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  • Angela

    brad–even if the cooking itself takes less than an hour, i can see people preferring to heat up packaged foods and spend that hour not chopping veggies. i think time and energy are still big factors.

  • Paula

    Interesting post and comments. I think that the reason why this is such a hard problem to solve is because there isn’t one “reason” for poor diets and obesity. Money, access, time and energy, interest, education are all part of the problem for low-income folks.

    However, I know plenty of people who have enough money to buy food, access to great food stores, kitchen gear for cooking it and interest in their waistline but are still overweight or even obese. (Maybe fewer than in the lower-income population, I don’t know the statistics.) The problem is that it’s not an easy problem to solve, because removing poverty doesn’t mean you remove weight issues. You remove some of the obstacles (like taking an hour and a half to get home from work on the bus) but you don’t remove the problem.

    I see loads of overweight people in my suburb loading up on crap in the high-end grocery store, so money and access aren’t the full story. Motivation and education are part of it, because even without much money you can eat a healthier diet if you know how and have the motivation to try. Time is part of it, but I know plenty of at-home moms who have time but are overweight and have overweight children.

    I think that government policy and the food industry do factor in for both low and not so low income people. Extensive subsidies make foods with lower nutritional value cheaper to buy than fresh, and food companies use subsidized food to manufacture convenience foods to have a great deal of appeal to the human appetite. A complex situation which will require a multi-faceted solution.

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  • Monica

    Hi Dr. Nestle,

    I am working on cooking education with children in Bayview Hunterspoint in SF- and actual federally designated food desert. My observation is that violence, trauma, and stress may also key factors in eating behaviors for the kids. I notice alot of compulsive eating, eating because of boredom/nothing else to do/too unsafe to leave your couch, eating whatever is around because food access is inconsitent, eating to soothe, and eating because junk food is a cheap pleasure.
    This, along with the other factors of lack of cooking skill and easy access to healthful stuff creates a perfect storm of obesity. Also, when you are in a ghettoized community, most people eat and look like you so the idea that your weight or diet is not okay is difficult to absorb.

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