Key to Solving the Obesity Crisis: Ending Food Deserts and Increasing Education
Introduction
The Centers for Disease Control and Prevention (CDC) estimates that 36.5% of adults and 17% of children in the United States population are obese (CDC 2016). from 2004 to 2006. asy access to fresh produce have lower obesity rates than those that do not have access (10). n up in these Obesity is defined by the World Health Organization for adults as having a body mass index greater than 30, and for children who are 2 standard deviations over the Child Growth Standards median (WHO 2016). It has been observed that obese children are more likely to become obese adults (Deshmukh-Taskar P. et al., 2006). Obesity, like any other disease, has both short and long term consequences. Short term effects include elevated blood pressure, difficulty breathing, and physical pain. Over time, these issues take their toll on the body, and can lead to cardiovascular disease, type 2 diabetes, and an overall low quality of living (CDC 2015). Excess food consumption with a lack of physical activity could be considered the main cause of obesity, but often it is this combined with biological, genetic, and/or environmental factors that lead a person to develop obesity (Wyatt SB, Winters KP, Dubbert PM, 2006).
Obesity can be detrimental to the health of an individual no matter their personal demographics, such as age and socioeconomic status. Many of those who are living in a state of low socioeconomic status are obese. According to the most recent data collected by the U.S. Census Bureau in 2016 (Proctor, B. D., Semega, J. L., Kollar, M. A., 2016), 13.5% of the population, or 43.1 million people, were living in poverty in 2015. Of these people, the United States Department of Agriculture estimates that 11.5 million are living in low income areas, with the nearest grocery store more than one mile away (USDA 2009) These people are said to be living in food deserts, where the access to fast food restaurants and liquor stores is greater and easier than grocery stores that sell fresh produce and healthy foods. People are at risk for obesity when they are living off of low-cost, high-calorie foods, especially when that is all they can afford.
Every ten years, the Office of Disease Prevention and Health Promotion puts forth a list of national objectives set to improve the health and wellbeing of the nation, called Healthy People (ODPHP 2010). Launched in 2010, one objective set in Healthy People 2020 is to reduce the number of adults and children who are obese from 33.9% to 30.5%, and 16.1% to 14.5% respectively (ODPHP 2010). One solution to this problem of obesity among the lower classes living in food deserts is helping those living in food deserts gain access to healthy foods. Studies have shown that neighborhoods with easy access to fresh produce have lower obesity rates among adolescents than those that do not have access (Powell LM, Auld MC, Chaloupka FJ, O’Malley PM, Johnston LD, 2007). The Obama Administration created the Healthy Food Financing Initiative in 2010, which was set to add 400 million dollars in the 2011 national budget to help stores that carry fresh produce and other items essential to a proper diet open up in these food deserts (Holzman DC, 2010). This program was modeled after a similar initiative that took place in Philadelphia (Giang, T., Karpyn, A., Laurison H. B., Hillier, A., Perry R. D., 2008). The Fresh Food Financing Initiative was launched in response to research by The Food Trust, a nonprofit community organization in Philadelphia. This research included grocery store locations relative to low income neighborhoods, and deaths related to poor diet, and concluded that many people had to travel long distances if they wanted fresh food from a grocery store due to unequal distribution of stores, and that many people were affected by this unequal distribution (Perry D., Sherman, S., Stone M., Hillier A., Pozoukidou, G.). The published research was geared towards bringing awareness of the issue to Philadelphia policymakers in an attempt to allocate funds to help bring more grocery stores to areas that were lacking. The initiative helped gain enough funding for 32 stores to open across Pennsylvania, and it was estimated at the time that more than 320,000 residents would benefit from the opening of these stores (Giang, T., Karpyn, A., Laurison H. B., Hillier, A., Perry R. D., 2008, p 278). The Healthy Food Financing Initiative has helped to open 1,000 stores that offer healthy food choices across 35 states since 2011 (CHFA 2017).
While this initiative has been successful in helping get the government and policymakers on board with helping those living in low income areas gain more access to healthy foods, research has shown that this may not be enough to help solve the obesity crisis. One study found that many of their respondents travelled distances of 4.3 kilometers on average to shop at a grocery store, and that this distance was not correlated to body mass index or purchasing habits, suggesting that there may be other factors involved (Dubowitz T, Zenk SN, Ghosh-Dastidar B, et al., 2015). Another study found that a program set to bring fresh and healthy food availability to a Bronx, New York neighborhood had no significant effect on consumption habits (Elbel, B. et al., 2014 p 2887). If making access to healthier food options easier for those who live in low income food deserts does not change purchasing and consumption habits, then what will?
Health Belief Model, Social Cognitive Theory in Health Education
To address the issue of obesity among the lower classes, the option to purchase healthy foods must be coupled with education. For an intervention initiative such as the Healthy Food Financing Initiative to be successful in all aspects—easier access to healthy food, but also an increase in consumption of this food—the target population must not only be supplied with the physical tools needed, but they must also be supplied with the knowledge to make a change. The health belief model can be used to predict and explain how and why a person will or will not change their behaviors. According to the health belief model, a person will be more willing to change their behaviors if: they believe that they are suffering from obesity or are at risk of developing obesity; they believe that the consequences or health outcomes of obesity are severe; they believe that taking action to lose weight and change their diet and lifestyle will benefit them in reducing the risks of having obesity, they believe that barriers to changing their eating and exercise habits are relatively low and can be overcome; there are cues to action, such as a loved one or a medical professional telling them the seriousness of the situation; the individual has a high level of self efficacy, meaning they believe they have the capability to make the necessary changes to their behavior to lose weight and keep it off (Glanz, K., Rimer, B. K., & Viswanath, K., 2015). One study (James, D. C., Pobee, J. W., Oxidine, D., Brown, L., & Joshi, G., 2012) used the health belief model to design weight loss programs for African American women. Overweight or obese African American were interviewed, and asked about each of the constructs of the health belief model. The researchers found that the women had a skewed view of obesity, and most did not feel they were overweight or obese.
In addition to the health belief model, social cognitive theory can also be used to determine a person’s behavioral capabilities, similar to self efficacy in the health belief model. One aspect of building self efficacy is through social persuasion, support, and reinforcement (Glanz, K., Rimer, B. K., & Viswanath, K., 2015, p 163). Showing a person that others in their community are taking actions to change their health behaviors, and demonstrating exactly how to make the change can help that person gain self efficacy, and they can then take actions on their own to make the necessary changes. Using both the health belief model and social cognitive theory in designing an educational intervention program targeted at those living in low income food deserts, combined with the Healthy Food Financing Initiative can make for positive health outcomes in the targeted communities.
Food Education and Obesity Intervention Program
The Pennsylvania Fresh Food Financing Initiative may have given many of those living in low income food deserts easier access to fresh produce, but according to one study (Cummins, S., 2014), this access did not increase the consumption of fresh produce, or have any change on body mass index. The initiative is in need of supplemental education in order to be successful. To determine the target population, research must first be conducted to determine the level of need for education in a given neighborhood or city. This would involve surveys given, either phone or in person, to residents in the given area with a newly opened grocery store, or a previously existing store that had recently added fresh produce purchasing options. The questions to be asked would include the research participant’s current purchasing habits, such as location and specific food items, if they had heard about their new shopping options, and if they plan to utilize these new options. Participants would also be asked if they would attend free or low cost nutritional educational classes if given the opportunity. Once a target population has been found, this research would be used to raise awareness of the issue of underutilization of fresh food purchasing options to policymakers and stakeholders, who already have an interest because of their involvement in the Fresh Food Financing Initiative, and to propose funds to be allocated for a supplemental intervention program: nutritional and obesity education.
Once funding has been taken care of, training of volunteer instructors, and location of services must be decided. Many local areas such as the local Department of Human Services center, community centers, and even local churches could be asked to participate in holding classes. Volunteer instructors will be taught about proper nutrition, and how to incorporate a healthy diet and exercise into a person’s lifestyle. The instructors will also be taught about obesity and its consequences. If funding allows, cooking classes may also be offered, to show participants how to incorporate healthy foods into their every day diets.
Recruitment for participants may be done by flyers posted in local grocery stores, pamphlets handed out at health care clinics and the Department of Human Services, and radio, television, and newspaper advertisements may be made. Classes will be limited to a certain number of individuals based upon the space the class is held in, and classes will be held for one half hour on a rotating time and day schedule each week, so that more people can attend. Children and adolescents are not exempt from obesity and healthy eating, so they are also welcome to attend any class sessions, and childcare services will be offered at each class if needed. Volunteers will also be available before and after class sessions to take measurements, including height and weight to determine body mass index, and will also be available to take blood pressure readings, and give participants information on obesity and its consequences, such as high blood pressure. Participants that receive measurements will be asked for contact information to receive information about follow up measurements in the future.
A typical nutrition education session would go as follows: Class enrollees would enter the ‘classroom’ and sign in, supplying the instructors with an email or phone number with permission for the researchers to follow up at a later date. Information packets on proper nutrition and exercise, healthy weight, and obesity will be available at the sign in table. An ‘pre test’ survey will also be handed out to each participant. The instructor will conduct the class by means of lecture and questions to encourage participation by the group. The components of the health belief model will be included in each lesson. For example, the instructor will address obesity, and discuss the fact that no single person is immune from developing it, or from its health consequences. The class will be concluded with an ‘post test’ survey, with a comment, concern, or suggestion section included. Referral cards for friends and family members will also be handed out at the conclusion of the class. Pre and post test surveys will be anonymous, but collected together to use for program evaluation. Class participants will also be given the opportunity to ask questions either as a group, or on an individual basis at the conclusion of class. Cooking classes would run the same way, but with a specific recipe taught each class session. Participants who are eligible for SNAP (supplemental nutritional assistance program) may also receive credit towards the purchase of fresh produce or meats for attending a class as an added incentive to attending a session.
Program Evaluation
Evaluation of the program will include follow up phone calls or emails to previous participants who provided their information, asking if they would be willing to provide feedback on the class they attended. Survey questions will also be asked, including purchasing and consumption habits now compared to before attending the class. Participants that were asked to come back for measurements at a later date will be contacted, and if allowed, their height and weight will be measured and their body mass index will be recalculated and compared to the previous measurement. Evaluations will also be taken from the local participating grocery stores. Purchasing statistics on healthy foods such a fruits and vegetables after the implementation of the program will be compared to the statistics of the sale of these items from before the program. If the program is successful, stores should see an increase in the sales of healthy foods, and those who have volunteered to have their measurements taken before and after the program should have a lower body mass index after the program than before.
Conclusion
Obesity is a problem for adults and adolescents alike, and the health consequences can cause morbidity or mortality. The previously discussed intervention program is not just about bringing low income neighborhoods across the country the option to purchase foods that are healthy for themselves and their families, but also teaching them the importance of making healthier choices, and guiding them to a new lifestyle. This problem is so important to address because of the severity of the obesity epidemic in the United States. Getting those who are already obese on the right track to losing weight and living a healthier lifestyle will not only benefit them, but they will most likely pass on what they have learned to their friends and family. They will teach their children from a young age the importance of making healthy choices, and good habits start young. Although this specific program will be targeted at those who are living in poverty, anyone who wanted to could benefit. If this program proves to be successful, it could be implemented in food deserts and low income communities across the country, and could once and for all end the obesity epidemic.