Eating healthfully may be a luxury many cannot afford.
By Neil Osterweil
WebMD Weight Loss Clinic - Feature
Reviewed By Brunilda Nazario, MD
You can never be too rich or too thin. In fact, if you're not rich, you may not be able to afford to be thin.
According to the CDC, poor diet and lack of physical activity are closing in on tobacco as leading causes of death in the U.S. Or as Secretary of Health and Human Services Tommy G. Thompson put it in a recent news conference announcing a "Healthy Lifestyles" initiative, "We're just too darned fat."
To prove its point about the weighty problems facing our nation, the HHS, using data from the CDC, has produced a map showing a steady increase in the percentage of obese adults in all states from 1991 to 2000. In 1991, more than 20% of the adults in five different states were obese. A decade later, the problem had spread -- literally -- to 17 additional states.
But while the data show an unequivocal gain in excess poundage throughout the country, the map also reveals a surprising inverse relationship between income and waistline. In other words, the more income grows, the lower obesity goes.
"The states that are becoming obese are the states that are low income," says Adam Drenowski, PhD, director of the Center for Public Health Nutrition at the University of Washington in Seattle. States that rank among the lowest in household incomes -- Mississippi, Louisiana, Alabama, and West Virginia -- are those with the highest percentages of obesity. Conversely, Connecticut and Massachusetts, which are among the wealthiest states, have among the lowest obesity rates, Drenowski contends.
You Get What You Pay For
At a recent symposium on the science of obesity, presented at the Harvard School of Public Health in Boston, Drenowski argued that many Americans are obese not by choice, but because they can't afford the luxury of being thin. The economics of food production, he says, are balanced heavily in favor of cheap foods that pack a big caloric wallop.
"Refined grain, added sugars, and added fats remain the cheapest elements of our diet," Drenowski says. "Just how cheap is something not many people appreciate. At global market rates, sugar -- refined sugar, sucrose -- costs nine cents per pound. In other words, sugar provides you with 20,000 calories for one dollar. If you look at fat at world market prices, you will be getting one pound of fat for 20 cents, which means another 20,000 calories for one dollar."
Fats, refined grains, and sugars are among the foods highest in what nutritionists call "energy density," which means that they contribute more calories pound-for-pound to the diet than, say, lean fish, vegetables, or fruits. But many foods with low energy density are full of nutrients, such as whole grains and vegetables.
"Basically, the two variables are fat and water. If things are higher in fat, they're higher energy density generally, and fat is relatively cheap. Using corn oil, or soybean oil, or safflower oil is relatively inexpensive. The cuts of meat on an animal that are high in fat are the least desirable generally," explains Victoria H. Castellanos, PhD, RD, founding Director of the Long Term Care Institute at the National Policy and Resource Center on Nutrition and Aging at Florida International University in Miami, in an interview with WebMD.
Small portions of high energy density foods such as chocolate chip cookies will have the same calorie content as a much larger serving of strawberries, and the cookies will leave you wanting more. Fruits and vegetables, on the other hand, are high in water content and in fiber, both of which are filling, meaning that you can eat a much larger portion of strawberries and still satisfy your hunger.
The catch is that the foods nutrition experts consider to be "healthy" in addition to fruits and vegetables -- lean meats, nuts, and whole grains -- are out of the financial reach of many Americans.
"It's very difficult to argue on the basis of health and variety for consumers to make different food choices, because food choices, like everything else, are determined by economics," Drenowski says.
"Bread, potatoes, rice, and pasta are relatively inexpensive; it's pretty cheap to grow a grain or a potato," says Castellanos. "It's much more expensive to grow a vegetable and get it to market in good shape. If you're growing broccoli, it takes good soil, it takes a lot of water, you have to have refrigerate it and it can spoil so you have wastage. So produce is a lot more expensive than a grain or an oil."
Times Have Changed
A century ago, excess poundage was considered to be a sign of prosperity and success. Railroad tycoon James "Diamond Jim" Brady, for example, was a famously voracious eater with the gut to prove it. He was renowned for packing away several dozen oysters for an appetizer, followed by as many as eight steaks at one sitting.
In 1904, being fat meant that you had the wherewithal to buy plenty of food and didn't need to burn calories in hard labor to earn your daily bread. In 2004, being fat is often an unwanted byproduct of being poor.
"We've known that very rich people are almost always thin, rarely fat, and that the lower you go down the socioeconomic status ladder, people tend to be fat," Castellanos tells WebMD.
It isn't laziness, either. According to the Greater Boston Food Bank, nearly half of all people who receive assistance from food pantries nationwide live in households with at least one working adult, and of the 23 million who receive food assistance in the U.S., 9 million are under age 18.
Workers earning the federal minimum wage of $5.15/hour (the standard in 29 states) gross $206 in a 40-hour week, or at best $412 if they can manage to hold down two full-time jobs. Out of that pay they have to subtract the costs of housing, transportation, utilities, child care, clothing, and food. So how does a family of four at or near the poverty level spend their food budget -- on spaghetti at 3 lbs. for a dollar for a bargain brand, or on 1/6 of a pound of salmon at $6.00 a pound?
"High-fat, energy-dense foods are often the cheapest options for the consumer. As long as a meal of grilled chicken, broccoli, and fresh fruit costs more, and is less convenient, than a burger and fries or a peanut butter sandwich, then the battle against obesity will be lost," write the editors of the UK medical journal The Lancet in the January 31, 2004 issue, in an editorial titled "Who Pays in the Obesity War."
The same editorial notes that the estimated $75 billion dollars spent in the U.S. on medical costs linked to obesity "equates to $175 each year for every U.S. taxpayer, who pays for obesity-related illness including heart disease, cancer, diabetes, and gallbladder disease, via Medicare and Medicaid programs."
"I would love to see more subsidies for fruits and vegetables, making fruits and vegetables more readily available, particularly amongst poor people," says Barbara J. Rolls, PhD, professor of nutrition at Pennsylvania State University in University Park, Pa., in an interview with WebMD. "The produce that's available in poor communities is shocking -- non-existent, or really bad. A lot of poor kids never taste fresh vegetables. A kid in our graduate program went and worked in a poor community in Philadelphia; the children in that community had never even seen a banana."
Rolls, who also presented data at the Harvard School of Public Health symposium, studies how the size of food portions and the content of dishes can contribute to weight gain. She advocates small dietary changes that can be made by people on limited budgets and can help to modestly decrease the energy density of inexpensive common dishes such as macaroni and cheese.
"I'm not thinking dramatic: I'm thinking building toward goals with smaller changes. Take out some fat, and add in some water-rich vegetables, such as celery and onion, and try to do it in a way that isn't going to cost an arm and a leg but is going to have some significant impact," Rolls tells WebMD.
Castellanos tells WebMD that federal agricultural subsidies "have not kept up with the nutritional problems of modern-day America. I think when we started school lunch programs, commodities and a lot of these price supports, we were worried about people getting enough calories. I think we haven't kept up with the science and the current health problems of Americans and made adjustments."
Ultimately, both food producers and their customers need to play a role in changing attitudes about food choices, says Rolls.
"In the end, the problem is that the food industry is giving people what they want. They're very good at figuring out what we want and providing it, and trying to provide it cheaply, because they know that brings people in. So we really have to work on consumers, too. Consumers have to demand better food. If they demanded smaller portions, they would get them. So I think what we need to demand is more choices of portions, and not jacking up the price so much."
Published March 19, 2004.
Adam Drenowski, PhD, Center for Public Health Nutrition, University of Washington, Seattle. Victoria H. Castellanos, PhD, RD, National Policy and Resource Center on Nutrition and Aging, Florida International University, Miami. Barbara J. Rolls, PhD, Pennsylvania State University, University Park, Pa. Greater Boston Food Bank. U.S. Census data. Dept. of Health and Human Services. The Lancet, January 31, 2004, p 339. U.S. Department of Labor Employment Standards Administration Wage and Hour Division.
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