"Food Systems and Public Health,"by Mary Story, Michael W. Hamm & David Wallinga March/April 2010 issue of Poverty & Race
In the United States, obesity and diet-related chronic disease are major contributors to preventable morbidity and mortality. Today, more than 1 in 3 American children and adolescents, as well as two-thirds of adults, are overweight or obese. The rising rates of obesity among children and youth are of particular concern. Actions need to be taken today to improve food and physical activity environments and help reverse the obesity epidemic. The alternative is to witness today’s generation of young children growing and developing, unable to realize their individual potential, in part due to obesity and chronic diseases, while the country’s health care system becomes increasingly overwhelmed by their health and medical needs.
Few American children or adults consume diets that meet the Dietary Guidelines for Americans. Average intake of healthy foods, such as fruits, vegetables, whole grains and calcium-rich foods, is inadequate, with overconsumption of calories, total fats, saturated and trans-fats, sodium and added sugars. For the entire U.S. population, daily caloric intake has increased on average by 300 calories since 1980, with no accompanying increase in physical activity.
Though most Americans have diets that need improvement, those living in lower-income households are even less likely to have healthy diets compared to higher-income households. Income inequalities underlie many health disparities in the United States; in general, those who have the highest poverty rates suffer the worst health status. Differential availability and affordability of healthy foods in low-income communities have been suggested as important contributors to health disparities in diet-related chronic diseases and obesity rates. An exodus of grocery stores and an influx of fast food outlets in low-income urban areas contribute to the income and racial/ethnic disparities in access to affordable and healthy foods. Currently, many low-income neighborhoods lack access to fresh, healthy, affordable foods, and residents often pay a higher percentage of their income for food.
Over the past several decades, technological, economic, social and lifestyle changes, as well as changes in U.S. farm and agricultural policies, have combined to transform our food systems. These changes have had numerous ramifications. Highly-processed and convenience foods, often high-calorie, low-nutrition foods, are widely available in larger portion sizes and at relatively low prices. Collectively, these environmental changes have influenced what, where and how much we eat and are thought to have played a substantial role in diet-related diseases and the current obesity epidemic.
National attention has been placed on improving the health and nutrition of Americans through a broad-based approach related to behavior change efforts, public health action, and social change involving multiple sectors and stakeholders. However, often in health and nutrition efforts the focus is on the end result—improving the diet and food consumption of individuals— and not on the food system or environmental context in which this food exists. Issues such as where the food comes from, how it is produced, what is produced, how it is priced, whether or not it is subsidized, how it is distributed, or how labor is treated are typically not addressed. The public health community has been primarily concerned with an adequate, diverse food supply for all individuals to meet the dietary guidelines within a Food Guide Pyramid framework. However, it is increasingly clear that public health dietary guidelines and obesity prevention cannot be met without a focus on the food system, from field to fork.
The severity of the obesity crisis has focused attention on the role of agriculture policies on the U.S. food supply and how current farm policies and practices may impact public health and diet-related chronic diseases, such as obesity. Agriculture policies determine the crops for which the government provides support through direct farm payments, price supports or research. Government support influences which crops farmers produce, the wholesale prices of those crops, and, subsequently, which products food producers, distributors and retailers make available to consumers and at what retail price. U.S. farm policy for commodity crops has helped make sweeteners and fats that are added to many processed foods some of the most inexpensive food substances available today. Fruits and vegetables receive little government support, and their cost has risen relative to inflation, whereas the cost of sweeteners and other commodity crop products has actually declined in real terms.
The bottom line is that current agriculture policies have helped to make food environments less healthy for Americans. There is a need for food systems reform. Agriculture and farm policies need to be aligned with national public health and nutrition goals. Currently, there is a great disconnect between public health diet-related diseases and agriculture policy issues, but they are intimately connected. A systemic strategy that simultaneously focuses on developing the sustainability of food systems, community food justice and public health success would have multiple benefits and allow for rich partnerships.
The Need for a Food Systems ApproachIn addition to obesity and diet-related chronic diseases and disparities in access to affordable healthy foods, other concerns of our food supply include antibiotic resistance, foodborne pathogens, chemical and pesticide contamination, and depletion of natural resources. These issues are all related to food—what we eat and how it is produced and distributed. Further, many contend that though the U.S. food system provides plentiful, inexpensive food, much of it is not as healthy as it should be and the agricultural system that underlies it is resource-intensive and not sustainable. The American Public Health Association and American Medical Association have both passed resolutions concerning the linkage of a sustainable agriculture and food system to the public health of our nation (http://www. ama-assn.org/ama1/pub/upload/mm/475/refcomd.pdf, http://www.apha. org/advocacy/policy/policysearch/default.htm?id=1361). In their framing, a sustainable food system has been defined as one that provides healthy food to meet current food needs while maintaining healthy ecosystems that can also provide food for generations to come, with minimal negative impact to the environment; encourages local production and distribution infrastructures; makes nutritious food available, accessible and affordable to all; is humane and just—protecting farmers and other workers, consumers and communities.
This leads to the need for a systems approach to food and health. A food systems approach enables consideration of the many intricately related factors involved in getting food from farm to consumer, including the inputs, mechanisms and structures for food production, processing, distribution, acquisition, preparation and consumption, as well as the farmers, fishers, workers, governments, institutional purchasers, communities and consumers who participate in that system—and the contribution of these various factors and participants to overall health. A systems approach is one that takes the complexity of this food system into account. It is an approach that recognizes that in complex systems, parts have not single but many inputs and outputs, and therefore health and other outcomes must emerge from the system as a whole and not from a focus on any single component of that food system. In a systems-based model, interacting parts work synergistically, each as complement to the other and each supporting the system as a whole. Problems arising from complex systems are challenging and likely will require interventions that have multiple components and an appropriate level of complexity. Thinking about systems, in other words, is not consistent with easy or “magic bullet” solutions.
We must address the inadequacies of our food system if we want to successfully reduce the increasing costs of health care as affected by dietary patterns. Policies and programs to ensure a healthier food system need to be a part of health care reform efforts. Further, the U.S. Farm Bill, renewed every 5 to 6 years, is a vehicle for addressing food system changes because it has such sizable and important impacts on agriculture production, rural development, food and nutrition assistance, conservation policies and research.
Moving Toward a Healthier and More Sustainable Food SystemThe objectives of the Airlie Conference (see note on p. 3) were to:
Mary Story is Professor in the Div. of Epidemiology & Community Health, Univ. of Minn. School of Public Health. email@example.com
Michael W. Hamm is Professor at the College of Agriculture & Natural Resources, Michigan State Univ. mhamm@anr. msu.edu
David Wallinga is Food and Health Program Director at the Institute for Agriculture and Trade Policy in Minneapolis. dwallinga@iatp. org
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