Good Food for All
Sometimes, even if you do everything right, it's still not enough. That's how Taché Figueroa feels whenever she goes to the grocery store. Both she and her husband—her high school sweetheart—were forced to leave their jobs when the coronavirus hit last March, and with their four kids at home for breakfast, lunch and dinner, they have just $680 a month in federal food assistance to feed the family.
Making it harder is that Figueroa doesn't want to buy just any food. She wants healthy food. Several years ago, the 31-year-old from Brockton, Massachusetts, was diagnosed with a rare brain disease and it was imperative, her doctor said, that she lose weight. High blood pressure and diabetes run in her family, though so far she has avoided them. And she also worries that one of her daughters—the one with a vicious sweet tooth—is becoming overweight.
The family has long been on a tight budget. Figueroa clips coupons, visits multiple stores to get the best deals, and took a class on making healthy budget recipes that would please the kids. But even before the pandemic—when she worked full time as a personal care assistant and her husband had a job with the local waste management company—she'd run low on money before the end of the month. "I can't tell you how it feels when I go into a store and I only have $50 and 14 more days' worth of food to buy," she says. "I think, 'How am I ever going to make it work?'"
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It's a heartbreaking story, and all the more so because Figueroa's situation is anything but unusual. Despite being one of the richest countries in the world, the United States also has one of the largest wealth gaps. The highest-earning 20% of households take in more than 50% of all income, while 34 million live below the poverty line. (And because the federal government defines that as $26,200 a year for a family of four—a benchmark considered too low by some experts—many more families who aren't technically poor still have difficulty getting by.) Black Americans are at a particular disadvantage, with a median household income that is nearly 40% below that of white households. And that was before COVID-19 upended the economy.
In 2020, the number of Americans with food insecurity jumped from an already-whopping 35 million—nearly the entire population of Canada—to a projected 50.4 million, a level not seen since the Great Depression. And again, that dramatic spike did not hit everyone equally. Nearly 4 in 10 Black and Hispanic families struggled to put food on the table when the country shut down last spring—a rate more than double that of white families.
This stark divide fuels disturbing health disparities. A U.S. Department of Agriculture report found that the most food-insecure adults—who tend to have less-balanced, nutrient-poor diets—are 40% more likely to have a chronic health issue, such as diabetes, obesity, heart disease or cancer, than those who are most food-secure. As a result, the families that can least afford them face significant additional health care costs. The average annual expenditure on health care for adults facing hunger is $1,834 higher than that of food-secure adults.
Conditions like obesity and diabetes have proved especially dangerous during the pandemic. They're among the underlying issues estimated to increase the chances of dying from COVID-19 from 1.6% (the risk for healthy individuals) to 20%, according to an early surveillance report from the Centers for Disease Control and Prevention. "We thought that a virus doesn't discriminate. Yes it does," says Adam Drewnowski, Ph.D., a professor of epidemiology at the University of Washington and one of the country's leading researchers on social disparities and their impact on diet and health. "It is quite possible that we come out of this pandemic with a gap between the rich and the poor that may not be bridged again."
The Barriers to a Healthy Diet
That socioeconomic status is intricately linked to health seems intuitive. Less money, less education and limited access to medical care translates to less stability and worse outcomes. But in America, where belief in the power of individual choice is paramount, eating an unhealthy diet has long been viewed as a moral failure.
This is true of both the left and the right, who have used the argument to serve their political agendas. As far back as the 1970s, conservatives argued that federal food assistance, such as food stamps—now known as the Supplemental Nutrition Assistance Program, or SNAP—should only be used to purchase certain foods due to rising rates of obesity among the poor. In 2011, cook and progressive writer Mark Bittman argued, in a still much-cited New York Times opinion piece, that junk food is not cheaper than the healthy stuff, as is widely believed. By his calculations, the ingredients for a homemade chicken dinner totaled half of the $28 it cost to buy a family of four dinner at McDonald's. "Taking the long route to putting food on the table may not be easy, but for almost all Americans it remains a choice," he concluded in a plea to embrace cooking at home. "If you can drive to McDonald's you can drive to Safeway."
Yet, the fact is that healthy food is empirically more expensive. A recent global study by the United Nations Food and Agriculture Organization shows that, in North America and Europe, a balanced diet that includes both adequate calories and nutrients costs nearly six times more than one that provides just the basic calorie requirements. Meanwhile, there are mountains of studies demonstrating that healthy foods, such as fruits and vegetables and lean meats, are not as available in low-income neighborhoods as affluent ones. Even when they are, they tend to be counterintuitively more expensive than in places where the customers can afford them. What is abundant in economically disadvantaged neighborhoods, according to a study published in the American Journal of Public Health: fast-food restaurants and convenience stores selling high-calorie, nutrient-poor foods.
Figueroa and her family experience this every day. Fruits and vegetables—the foods you are "supposed" to fill your plate with—are flat-out too expensive. "My kids love grapes," she says. "But at $2.99 a pound, a bag costs $10. It's like, 'Oh my god, not this week, guys.' Fruit is a luxury thing."
She has tried myriad strategies to stretch her budget. For a while, she shopped once a month so she could, in theory, carefully plan out where to spend every penny. But that limited her ability to buy fresh produce, which wouldn't last four weeks in the fridge. Then she started shopping weekly. But the occasional splurge on, say, strawberries, meant she'd end up short on funds and have to rely on frozen pizzas or corn dogs to make it through the end of the month. Figueroa tried buying food at the local dollar store, too, but found that the only items she could afford were exactly the kind she was trying to avoid. "The junk food is what is cheap in those stores," she says. "You will find a $1 box of crackers, but it's filled with sodium. You will find your kid a meal, but it's full of sodium. Meanwhile, the only vegetables are these individually portioned frozen ones that cost $5."
These frenzied efforts to provide sustenance are what Feeding America, the nation's largest network of food banks, calls "coping strategies." More than half of its clients use three or more of these strategies at any one time: 40% water down food or drinks to make them last longer; 53% receive help from friends; and 35% sell or pawn personal property. But the No. 1 coping mechanism, at 79%, is purchasing inexpensive or unhealthy foods.
Beyond the high sticker price of nutritious foods, there are other, hidden costs.
Time is one. The ingredients for Mark Bittman's chicken dinner may indeed cost less than a meal at McDonald's, but you also have to shop, cook—and know how to cook—and clean up too. A Tulane University analysis concluded that it would take at least 16 hours a week to prepare a menu of the thrifty, healthy meals recommended by the USDA (not including shopping or cleanup)—up to three times as many hours as the average working woman spends in the kitchen. (And yes, it's still women who do most of the cooking.) In other words, Drewnowski says, if you're poor, you can either cook healthy food or have a paying job outside the home, but not both: "Perhaps the time has come to acknowledge that most people eat the foods affordable to them; that is, they make the best of the options available."
Another obstacle is the fear of waste. Or to put it another way: What if you spend your budget on healthy food and the kids won't eat it? That is the dilemma that Autumn O'Brien, a single, 44-year-old mom in Minneapolis, faces on a regular basis. O'Brien works in human services, and her salary is too high for her to qualify for federal food assistance. But by the time she pays her mortgage, child care and other bills, there's not much left over. She often visits food pantries to close the gap.
O'Brien's 4-year-old, Brycen, is a picky eater, the kind of kid who will not eat chicken that isn't breaded. (Though when he does, he removes the breading from the chicken and eats them separately.) A plate with vegetables on it—with the exception of potatoes in fry or tot form only—is all but a declaration of war. "I don't waste $3 or $4 on something he might not eat when I could spend it on something else," she says.
The Food Desert Myth
For struggling families who do qualify for assistance, increasing the money provided through SNAP is one way to help. But it's also politically fraught. And so over the last decade, public health officials have championed the idea—palatable on both sides of the aisle—of improving access to healthy food by incentivizing supermarkets to put new locations in disadvantaged areas, and getting bodegas and convenience stores to carry more than just a few browning bananas. Ending so-called food deserts was one of the pillars of First Lady Michelle Obama's "Let's Move" campaign to end childhood obesity. "If you build it, they will come" was the rallying cry.
But a growing body of research suggests that there is actually little to no relationship between the proximity of stores that sell healthy food and improved health outcomes. A 2017 study published in the American Journal of Health Promotion found that a year after the opening of a new supermarket in an underserved South Bronx neighborhood, residents did not report a significant change in fruit or vegetable consumption or overall dietary quality; a Minnesota analysis of that state's food sales concluded that poor health outcomes were more strongly linked to poverty than to the distance of a well-stocked grocery store. In other words, affordability was the primary barrier to nutritious foods, not availability. A stinging critique of food-desert policies in the Fordham Urban Law Journal—titled "Let Them Eat Kale"—determined that despite their failures, "Support for these interventions has nonetheless continued to grow—obscuring underlying issues and detracting from more effective strategies."
Janet Poppendieck, Ph.D., a professor emerita at Hunter College and the author of several books on hunger, agrees. "Fundamentally, food insecurity is an income problem, not a food problem," she says. "People go hungry because they cannot afford to purchase adequate food. And even when they can buy sufficient calories, many cannot afford the foods that promote health."
Drewnowski set out to prove exactly that five years ago with a series of studies that mapped, block by block, what Seattle residents ate and how it affected their health. The first study tracked the consumption of salad versus soda—proxies for a healthy or unhealthy diet. Next, he looked at overall diet quality, and then obesity rates, which were as much as 600% higher in poor neighborhoods than wealthy ones. In every case, the greatest predictor of health—more than age, gender or race—was the value of someone's home. "People are very uncomfortable with that," Drewnowski admits. "It all comes back to socioeconomic status." Or, as Alexandria Ocasio-Cortez, the Democratic congresswoman for New York City's 14th District, tweeted during the early days of the COVID-19 pandemic last spring: "The chronic toll of redlining, environmental racism, wealth gap, etc. ARE underlying health conditions. Inequality is a comorbidity."
Providing Better Food for All
It was a cool, sunny October morning, just after 9 a.m., when Rose arrived at the Storehouse food pantry in downtown Albuquerque. She had never been to one before. She had never needed one, until the pandemic.
As a public school teacher, Rose, who requested a pseudonym for privacy, hadn't lost her job. But she felt compelled to leave. Her own children, 8 and 6, required supervision while learning at home—and in September both of her elderly parents contracted the virus and also needed care. Downtown that morning, many of the shops were closed, but there was already a line of some 30 people, all standing 6 feet apart, at the Storehouse. When a worker rolled up a shopping cart full of 100 pounds of food—quick oats, lentils, spaghetti, chicken breasts, burger patties and several bags of fruit—Rose began to cry. "I used to judge others who got free food," she says. "Now I'm one of them. This isn't a place where I ever thought I would be."
Forty percent of Americans who visited a food bank or pantry since last March were first-timers, according to Feeding America. The skyrocketing need has added urgency to longtime calls to provide greater resources and flexibility for existing programs, such as SNAP. In December, Congress temporarily raised SNAP benefits by 15% as part of the latest relief package. The pandemic has also encouraged a slew of retailers to allow shoppers to use SNAP benefits online (in some cases with free delivery), a move that could make it easier to find affordable healthy foods that may not be available in their neighborhoods. But the pandemic has also pushed policymakers as well as doctors and farmers to consider new, and in some cases more radical, plans to tackle economic inequality.
Take universal basic income—touted by Andrew Yang during his run for the 2020 Democratic presidential nomination—a concept that is gaining ground. Last April, a University of Chicago nationwide survey reported that a majority of young adults of all races, ethnicities and political parties supported a universal basic income that would give every American a monthly stipend no matter their income or employment status. In the fall, a majority of Democrats in both houses of Congress endorsed a monthly child allowance—an expansion of the tax credit families can take—as part of a COVID relief package. Columbia University researchers estimated that the plan would have lowered overall child poverty by 49%. (It did not pass.)
Still, there's increasing evidence that such measures work. A landmark report from the National Academy of Sciences concluded that subsidizing the incomes of poor U.S. families, on average, leads to better health among their children—along with more schooling and higher earnings as adults. Basic income pilots are underway in Stockton, California; St. Paul, Minnesota; and Jackson, Mississippi. "When you have economic security and a consistent amount of income coming in that allows you to support yourself, your well-being improves. There is increasing evidence that shows this," says Sarah Berger Gonzalez, program manager for the Basic Income Lab at Stanford University.
Programs focused on health care are also making nutritional assistance a more central part of their efforts. Kaiser Permanente's Food for Life program, for example, is studying the benefits of offering free medically tailored meal deliveries to recently discharged patients and their families in California, Colorado and Oregon. Meanwhile, a program called Produce Prescriptions, created by the nonprofit Wholesome Wave in 2010, enables doctors to prescribe fresh fruits and vegetables to their patients along with the money to pay for them. And the program's results are clear: a 14-month study in New York City showed that more than 80% of participants increased their fruit and vegetable consumption and 28% lost a significant amount of weight during the program. Even more important, says Michel Nischan, Wholesome Wave's founder, the idea of incentivizing healthy eating is becoming normalized: since 2014, the Farm Bill has allocated $20 million a year to boost SNAP dollars spent on fruits and vegetables at farmers' markets and retail stores.
One of the most impressive demonstrations of how health outcomes can improve when fresh food is affordable and accessible is health care provider Geisinger's Fresh Food Farmacy program, designed for patients with diabetes and other diet-responsive conditions. Patients who enroll receive clinical treatment and educational support for their diabetes, plus free healthy food for themselves and their family. In 2016, Rita Perkins, now 55, was one of the first to sign up. She was overweight, hovering near 200 pounds at just 5-foot-3, and had long struggled with diabetes. "I'd get real tired, and I'd get the shakes really bad when my sugar was low," Perkins, who lives in Kulpmont, Pennsylvania, remembers.
Within two years, her weight dropped to 140 pounds and her A1C, a key measure of glucose in the bloodstream, had gone from a dangerous 13.8% to a healthy 5.9%. For comparison, a diabetes drug is considered successful if it reduces a patient's A1C by 1 percentage point.
Fresh Food Farmacy now serves nearly 1,200 patients a week in western Pennsylvania and plans to expand the model in partnership with community-based organizations, according to Allison Hess, vice president for health at Geisinger's Steele Institute for Health Innovation. Not only does it improve health and alleviate food insecurity, it makes economic sense, she says, for patients and for the company's bottom line. Research indicates that for every one-point reduction in A1C levels, hospitals could save between $8,000 and $12,000 per patient annually. On average, program participants see their A1C levels fall by two points.
It's an obvious win-win. If food-is-medicine programs like Fresh Food Farmacy are widely embraced, they might begin to move the needle on socioeconomic health disparities. But closing the divide requires a more fundamental philosophical shift: a shrugging off of the national myth of equal opportunity and an acceptance that inequality, and its dire health consequences, cannot be solved by individuals alone. There must be systemic change too.
Such a transformation will not come easily. But if there's any silver lining to the tragedy of the coronavirus pandemic, it may be that today many more Americans understand what it's like to experience food insecurity—or know someone who has. After all, familiarity breeds compassion. It could, over time, help build a movement for change. "Prior to COVID, it was 'they' and 'we.' 'They need it. We don't,'" says Swarupa Watlington, executive director of Albuquerque's Storehouse food shelf. "Now the 'they' might be a business owner who was forced to shut down, or your neighbor who needs food. There's more empathy that you could be in that situation. And you think: 'Why not have access to the healthiest food possible?'"
Jane Black is a Washington, D.C.-based writer who covers food politics and sustainability.
Writers: Jane Black, Maya Feller, Vanessa Rissetto, Christine Byrne, Andrea Mathis
Photography: John Stanmeyer, Leslie Grow
Visuals: Tyrel Stendahl, James Van Fleteren
Coordinating Digital Editor: Lisa Valente
Special Thanks: Anne Treadwell, Shaun Dreisbach, Jessie Price and the staff of EatingWell.