By Sarah Blenner, JD, MPH

As the saying goes, you are what eat.  If that’s the case, what are we? Fat and sweet.  The American diet derives approximately 40% of its daily energy from added sugars and fats.  In 2000, low cost potatoes (i.e. potato chips), canned tomatoes, and lettuce constituted 48% of the average American’s total vegetable intake.  It has been well established that poor diet directly correlates with chronic health conditions, such as diabetes and cardiovascular disease.  A disproportionate amount of individuals who are obese or have diabetes and other chronic health conditions are of lower socioeconomic status. Thus, financial constraints coupled with the availability of healthy food options in certain communities play a major role in determining a person’s diet.  In combating what many have termed “the obesity epidemic” and the skyrocketing rates of diabetes (which is estimated to double or triple in the next 40 years), we must cater food policies towards at-risk populations.  Specifically, it will be important to look at food policies geared towards programs which have a significant impact on these populations, such as food stamps, food pantries, and school lunch programs. 

Recently, while sitting in a food pantry, I overheard several women talking about their strategies for getting food.  The women were complaining about the insufficient amount of money they received on food stamps and discussed strategies for stretching food stamps to bring home the most amount of food.  One woman expressed her preference for purchasing hotdogs over healthier options, exclaiming that she makes her decisions based on the maximum quantity of filling foods for the lowest possible cost.

It turns out that individuals like the women I overheard talking in the food pantry are making logical decisions about feeding themselves and their families.  Better to eat unhealthy foods than eat healthy and suffer the consequences of hunger.  Studies have shown that individuals who receive assistance from food pantries, meals on wheels, food stamps, or other forms of food assistance are more likely to face “food insufficiency” (not having enough food to eat because of financial constraints) than other populations.  This can have a serious impact on the health and well-being of individuals with chronic health conditions, such as diabetes.  For example, one study that analyzed hospitalizations at a particular urban hospital found that about 30% of the hospitalizations for individuals with Type 1 diabetes that were due to low blood sugar levels occurred because the individual could not afford to eat.  Another study conducted in Georgia found that elderly individuals who receive or are on the wait list to receive meals delivered to their home are significantly less likely to properly manage medications, which can have a devastating effect on the management of chronic health conditions like diabetes.

Because many individuals who frequent food pantries are at risk for diabetes, targeting this population has been proposed as a primary intervention.  In January 2010, the Canadian Diabetes Association formed a partnership with several local food banks to encourage screening and educational programs for patrons who were identified as being the most at risk for developing diabetes.  While educating the public about healthy food choices is a lofty goal, its practical implications might not be as great as one would hope. This is because of both health disparities and the availability of and access to healthy food choices. For example, many food pantries don’t have the resources to regularly offer fresh fruits and vegetables and often white bread, not whole grain bread, is the typical bread option.  

In Illinois, an individual on public aid may receive a therapeutic diet allowance.  Under Illinois policy, an individual with diabetes, an ulcer, or other select medical conditions may qualify to get extra money to spend on his or her food.  But should individuals who have diabetes, for example, really require more money to eat?  Unfortunately, the answer for many in impoverished areas or with serious financial constraints is yes.  The American Diabetes Association recommends a diet compromised of a lower carbohydrate and calorie intake, which can be accomplished by making adjustments in food choices such as eating whole-grain bread instead of white bread.  One study concluded that in a New York neighborhood where diabetes rates were 4 times higher than in New York City at large, “disparities in healthy-food availability may be a barrier to diabetes self-management.”  Another study showed that in some stores whole milk actually costs less than nonfat or low-fat milk.  Thus, getting the most for your money leads to diets that contain a larger amount of cereal, added sugars and fats, and a smaller amount of lean meat, fish, cheese, vegetables, and fruit. The implications for an individual with diabetes: a more difficult time controlling blood glucose levels and managing his or her health condition.  The implications for public spending: possibly higher Medicare costs and health care utilization.

There have been efforts to make food bank distributions healthier.  The Greater Chicago Food Depository has a program called Nourish for Knowledge, which provides bags filled with ready to eat food for children to take home over the weekend.  Recognizing that diet plays an important role in the prevention of chronic health conditions, such as diabetes, high blood pressure, and heart disease, the Greater Chicago Food Depository consulted with a nutritionist and increased the nutritional value of the food that went home to children.  Steps like those taken by the Greater Chicago Food Depository are critical for the community that is accessing the resources of the food depository and is even more important for children and adults suffering from chronic health conditions where diet and meal planning plays an imperative role in disease management and prevention.

Another significant source of nutrition for children, especially minority children and those who come from homes with a lower income, are school breakfast and lunch programs.  It is well established that children who eat well perform better in school and have healthier body weights.  Soon to celebrate its 65th birthday, the U.S. Department of Agriculture’s (USDA) federally subsidized school lunch program is being both applauded and criticized: some go as far as saying that the school lunch program is one of the most successful social programs implemented in the U.S., while others believe the program needs revamping because of issues such as conflict of interest and low health standards.  In January of this year, USDA issued proposed guidelines for improving the nutritional content of school lunch programs.  Over the course of time, schools who accept federal funds to administer the school lunch program will place a ceiling on the calories served, limit the number of times that starchy vegetables, such as French fries, are served per week, increase the amount of fiber and whole grains, lower sodium and sugar quantities, and provide nonfat and low-fat milk options.  

While many would applaud schools for encouraging the prevention of chronic diseases and obesity, some political figures, such as Sarah Palin vehemently oppose such efforts.  Sarah Palin views the regulation of school lunch programs and the encouragement of healthy food options as another example of the government overreaching and infringing on individual rights.  What Palin fails to mention is that these guidelines would allow children, many of whom rely on school breakfast for a meal which they would otherwise not be able to eat, to consume healthier foods and lower their risk for developing diabetes and other chronic health conditions associated with poor diet.  Some schools are already taking action to encourage healthy eating by providing healthier school lunches.  In Philadelphia, for example, a local bakery changed the recipe for muffins by lowering the amount of sugar to comply with the school district’s effort to lower the calories in school breakfasts. According to bakery representatives, the treats are still very tasty. 

With the USDA’s school lunch program guidelines pending, Michelle Obama’s Let’s Move Campaign in full gear, and obesity and obesity-related chronic diseases on the rise, policy makers and community leaders should implement policies that will not only encourage healthy eating, but that will also give vulnerable populations and at-risk communities the opportunity to access healthier foods.  Healthy diets are imperative for both disease prevention and disease management.