Complex problem unlikely to benefit from facile solution, study indicates

I like Michelle Obama.  I really do.  Or rather, I like her as much as one can form a valid opinion of someone one has never met as presented by the media.  She’s always struck me as someone I would like if I did meet her.  Maybe she eats live kittens in real life, but if so she hides it well.

Anyhow, as much as I’ve liked her and admired her decision to make childhood obesity her focus as First Lady, I’ve remained skeptical about how much of an impact it will have.  In previous posts I’ve discussed how difficult it is for obese people to lose weight sustainably, and I don’t really see how the same advice I give with limited effect will somehow become more potent or efficacious coming from the President’s wife, no matter how charismatic she may be.

Thus, I was unsurprised to read this:

It has become an article of faith among some policy makers and advocates, including Michelle Obama, that poor urban neighborhoods are food deserts, bereft of fresh fruits and vegetables.

But two new studies have found something unexpected. Such neighborhoods not only have more fast food restaurants and convenience stores than more affluent ones, but more grocery stores, supermarkets and full-service restaurants, too. And there is no relationship between the type of food being sold in a neighborhood and obesity among its children and adolescents.

This squares with what I have observed, both in my current practice and the job I had before.

Where I am now, I see patients from across the socioeconomic spectrum, from the very affluent to the very poor.  In general, I have observed less obesity in the wealthier patients, but not to a degree that is totally obvious.  I have plenty of overweight patients from well-to-do families.  But for those families with less money, I am confident that their somewhat disproportionate obesity rates are not related to access to fresh fruits and vegetables.  The area has many well-stocked grocery stores, in rich and poor neighborhoods alike.

My last practice was in a much less affluent part of the country, and in my recollection a greater proportion of my patients were overweight.  But some of the poorest areas also had the greatest proximity to a grocery store with an ample supply of healthy foods.

Now, it may be that the healthier foods were still too expensive for many families.  It’s all very well for me to say that store-brand frozen vegetables aren’t that expensive, but I don’t really know what counts as “that expensive” for an impoverished family.  I don’t know their household budgets, and I have no business telling people of limited means what I think they should be spending their money on.  Cost could well be a factor when choosing to buy the unhealthy items, even with a gleaming produce department two aisles over.

But I strongly suspect there’s more to it than that.  Partly because of the Better Half’s vocation, we were relatively closely involved with the local food pantry.  And we learned pretty quickly that the items that were the first to fly off the shelves were some of the least healthy ones.  Even presented with free nutritious foods, patrons would still clear out the instant ramen noodles.  It was actually kind of a quandary when deciding what to provide, one that the Better Half and I discussed at length.  Do you donate ramen noodles because you should give what you know people like, even if they’re pretty nutritionally lousy?  Is it paternalistic and high-handed to donate foods you think people ought to be eating?

In any case, simply giving people access to healthy foods doesn’t mean that they’ll eat it more or unhealthy foods less.  Insofar as poor people want healthy alternatives, I applaud efforts to increase their availability on the merits of giving people as much of an equal opportunity as possible.  But it looks like the intractable problem of obesity will need a deeper solution than just raining produce on food deserts.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. Well offering simplistic solutions to complex problems is as American as apple pie. I think there is a good argument to make that healthy food is more expensive then crap. The Wife has many health problems and food is something she has to pay attention to. Healthy is usually more expensive. However for most people i think they could afford that expense if they chose to. There are so many reasons why people become obese; bad genes, health problems, lazy, terrible eating habits, few resources, poor education. Making healthy food more available seems more like a solution that would help a relatively small number of people a lot, but not make a huge change in obesity rates.

    • I concur, Greg. For those whose access to healthy food really is a limiting factor, increasing their access is a good unto itself. As I tried to make clear at the end of the OP, I would support such efforts on those merits alone. But I just don’t think it holds water to hold them up as a solution to the problem of obesity.

  2. I don’t really think the problem is one of access or expense, but of education.
    For about 11 or 12 years now, I’ve maintained a high-calorie high-protein diet. I have to in order to maintain my body mass, and especially on the down-time. Around 2740 cal, 125 – 145g protein.
    I had quit smoking (with Chantix), and gained 30 lbs. I lost that, and I had to do some label-reading to do it.
    Pre-weight gain, I figured out that it’s healthier to order two double cheeseburgers from the drive-thru than the combo meal. Fries and soda are no good for you. More protein.
    Post weight-gain, crackers were one of the first things to go. The only low-cal ones I could find that fit in my diet tasted like cardboard. There was one brand of low-cal crackers, an onion sesame type, that was 20 cal/serving that didn’t taste so bad.
    I’ve avoided pasta for some time, and eat it once a week, if that.
    I spare no expense when buying bread. It’s the three numbers at the end that are important: fiber, sugars, and protein.
    And 2% milk.
    And so on.
    But I really think it’s more of an education issue.

  3. I’m trying to grapple with the results of these studies, at least as they are described in the NYT article (I have not read the studies) because they challenge some assumptions I had held about the availability of services in less affluent neighborhoods. A few thoughts:

    1. These studies seem to show that food deserts are not as widespread as many–myself included– have supposed. As reported by the NYT, however, these studies do not seem to say that food deserts are non-existent. Maybe most of the less affluent neighborhoods have access to more grocery stores than more affluent neighborhoods, but there still might be some poorer neighborhoods very far removed from grocery stores.

    2. Do these studies account for population density? Poorer neighborhoods may have more grocery stores per square mile, but perhaps they have more people per square mile, too, so that the grocery stores are not enough to serve needs. Also, as the Times report says, not all grocery stores offer equally healthy options. (Even if all this is true, it wouldn’t contradict some larger points Russell, for example, is making: it is probably true that the healthy options at such stores are under-utilized, or perhaps more expensive, although I myself doubt whether price of the goods, by itself, is the controlling factor here.)

    3. My concern about food deserts–assuming it hasn’t been based on wrong premises, as these studies seem to suggest it might be–is part of a larger concern about a “services desert” in poorer communities. My assumption is that poorer communities are not well-served by–in other words, do not have enough of–banking services, retail services, and local service-sector job opportunities. In this sense, the problem is a paucity of choices in general, a paucity reinforced by local government zoning regulations and lack of capital investment, and not simply lack of access to nutritious food. In this sense, I’m going off topic; all I mean to say is that these studies do not appear to contradict what has been my broader concern.

    4. The price / cost of healthier foods over that of less healthy foods is probably a factor, but in calculating cost, we need to take into account convenience. A frozen dinner is easier to make than a healthy homemade dinner, even if the dollar amount spent on the frozen dinner is significantly higher. (I make black bean tacos for me and my girlfriend, and the ingredients cost about $3 altogether, but if we have one of our favorite frozen pizzas, we’re paying about $10, or at least $6 if it’s on sale. The tacos are probably one of the healthiest (non-vegetable and non-fruit) things we eat–the ingredients are beans, garlic, onions, cumin, and corn tortillas, with a little bit of cheese, salsa, an sour cream on the side–but sometimes it’s a lot easier just to pop the pizza in the oven. (I should add that we’re not poor by any standard.))

    5. I don’t know what the right answer to the paternalist question is. I would probably choose to donate things I would myself like, but that doesn’t resolve the issue. As a (probably irrelevant anecdote), my mother always used to donate canned milk. I really don’t know why (is it helpful for cooking?), but she would go out of her way to buy canned milk so she could donate it in food drives. I do know she grew up during the depression and war years (she was born in 1933), so maybe canned milk was one of those staples one could count on as being good and handy to have around.

    • “Also, as the Times report says, not all grocery stores offer equally healthy options”

      I probably should’ve written: “Also, as the Times report says, it is not clear that all grocery stores necessarily offer equally healthy options.”

    • I think point 4 – ease of preparation – is a much bigger factor than cost or availability. In my experience, vegetables are not particularly expensive. They are, in fact, a lot cheaper than either junk food or protein. I’ve been a student on a budget, and the expensive things are typically junk food, meat, and especially cheese (at least 75% of the meals I make include cheese). Apples are reasonably cheap, celery is cheap, carrots are really cheap, purple cabbage is incredibly cheap, frozen peas are cheap, fresh green beans and peas are cheap in season. Peppers are expensive, though.

      Most of those vegetables can just be peeled, chopped and eaten, so it’s not just ease of preparation (although when you’re tired, munching junk food is more appealing that preparing anything at all; I always feel ill around end of term, and I’d bet that absolutely dreadful nutrition has as much to do with it as stress). It’s also the fact that junk food just tastes better than vegetables, and when you’re tired or crabby or having a bad day, eating something tasty and unhealthy is often just preferred to making sure you warm up some frozen peas or cut yourself some vegetable sticks. And the worse you feel about yourself, the more you want something tasty to cheer yourself up. So if someone’s working a crappy job, or unemployed and unhappy about it, it makes sense to me that they’d prefer tasty, unhealthy food over getting their six or seven advised servings of fruits and vegetables.

  4. I don’t think it’s purely education. There are plenty of people who know perfectly well what to eat, and still struggle.

  5. My first First Lady was Bess Truman, so I’ve seen a few, and I’d say Michelle Obama is my favorite.

  6. Purely anecdotal evidence, but when living in Manhattan, there was a huge range in the price and quality of products available. The bodega on the corner might qualify as a “grocer” offering “fresh fruits and vegetables”, but one look at the very wilted lettuce, spotty bananas, and bruised apples showed that lumping this offering in with the D’Agostino down the block offering fresh, organic endive at $9/lb is a bit silly. While I realize that many fruits and vegetables retain both their taste and nutritional value long after losing their “fresh look”, this is a hard sell for people. If I’ve got $1 to spend and can buy an apple that might be bad or go bad within a day or a Twinky that will taste the same for the next several hundred days, the latter can easily seem like a wiser purchase.

    I agree that access is not the whole issue. Nor is education. Nor is taste. There are a whole host of factors at play. But I would want to look more closely at what the studies were considering access to fresh fruits and vegetables. As someone who had to visit three or four different stores to find everything he needed in the quality he wanted and at the price he could afford, I can say that urban grocery shopping on a budget isn’t as easy as these studies make it seem.

    • Yes; combine “apples go bad so fast” with “I don’t have time to cook” and you very quickly get a situation where ramen noodles and Twinkies are staple foods.

      • A few other factors…

        In many urban areas, kitchens are tiny. I would imagine they are only tinier and in worse conditions in poor neighborhoods.

        There are some higher upfront costs to cooking. Maybe the basic ingredients for a simple, healthy meal are less than a buck per person, but this ignores the tools required and other ingredients that you are assumed to have. I remember a blog that claimed to have all meals under $1. But the problem was they calculated their costs in such a way that everything was averaged out. So one tablespoon of olive oil only cost 7-cents or whatever, but that ignores the fact that you can’t buy one tablespoon of olive oil for 7-cents. You have to buy the whole bottle for $12. Sure, a whole bottle might last you several weeks or months, but you still have that upfront cost.

        It is absolutely possible to eat healthy and cheap in the city. Don’t get me wrong… I did it for two years. But it was harder than when I lived in the ‘burbs and when I was making more money. No if’s, and’s, or but’s about it.

        • It would be an interesting, if impossible, study to take one neighborhood and put in a few cheap, healthy, tasty take-out options.

          • I’ll volunteer myself, presuming it gets a Chipotle within 50 miles of here!

  7. I think there are some unique complicating factors for children suffering from obesity. Young children have a unique relationship with food. Children can be incredibly finicky eaters. This often has much less to do with taste or texture and much, much more to do with control. Generally speaking, children are in very little control of their lives and world. Two of the few things they can control almost entirely are what goes into and out of their body. Which is why anxiety and stress in children so often manifests itself through issues with eating and toileting. They can’t control the stressors, so they’ll take extreme control of what they can. For this, and other reasons, developing healthy eating habits in children can be very hard. Especially with parents who tend towards an authoritarian parenting style, and there is plenty of evidence that this parenting style has a certain correlation with poor parents and parents of color. Very, VERY broad strokes here, obviously, but developing healthy eating habits in children requires a lot more than simply plopping some carrots down in front of them.

    • Russ-
      On this note, I’m curious how much of your training to be a pediatrician involved developmental psychology. I doubt much, if any, of what I said here is lost on you. But I’m curious what is required, what is common, and what we might be surprised to learn pediatricians might have no idea about. Thanks!

      • I have discussions with parents about what you discuss all the time. It’s very much a part of my practice.

        But having said that, I have no I idea when I learned it. I’m sure I was taught it at some point, probably during residency, but I have no clear recollection of when.

        • Good to know that that is (or at least was) a part of your training. I assumed as much, but realized that might not be a fair assumption to make. Is it (development) something you try to stay on top of as you do other arears of your craft?

          • I try to stay well-informed as broadly as I can, which seems to get more and more difficult. I’m lucky in that I have access to really great teaching conferences at the hospital where I’m on staff, and I keep abreast of current developments just through coordinating my patients’ care there. (The residents are also not shy about telling me if they have more up-to-date recommendations than I had in mind.)

            As far as developmental pediatrics goes, much of it (like avoiding food battles, for example) is so central to being a pediatrician that you have to keep on top of it. That said, one of my partners is a specialist in developmental and behavioral pediatrics, so I’m off the hook for more complicated stuff.

          • I was surprised to learn that in many medical fields, there are “developmental” specialists. A parent recently had her pediatrician recommend she take her daughter to a developmental optometremist (or opthamologist? Whichever…) I didn’t even know suchh a thing existed, but it is certainly a good thing. Many parents need support that is beyond what they or their child’s teacher can offer, but fall short of needing special ed or other sorts of services. Knowing that medical professionals, largely accessible via insirance, can and do speak to these issues is great. Sounds like your practice is truly a boon to your patients. You’re in Boston, right?

          • FWIW, the issue of developmental ophthalmology has come up in our practice, and we are skeptical of its legitimacy. FWIW.

            We are located outside of Boston, but have hospital affiliations/privileges within Boston.

          • I am blown away. I thought I had visited every subfield of pediatrics with my kid, including regular visits to a developmental psychologist and an ophthalmologist. I’ve never even heard of developmental ophthalmology.

          • Although the county does proved early intervention vision services, but I am assuming that’s not the same thing!

          • Interesting to note. I had never heard of it before myself. What makes you skeptical?

          • Keep in mind this is based entirely on my own recollection, which may be faulty and based upon poor information. That said, our shared impression was that the claims of benefit were not supported by any reliable science.

  8. First four years on the road I put on a LOT of weight. I’d get up in the morning, never eat breakfast, go out to lunch at a restaurant, eat at the bar. And drinkdrinkdrink.

    Outgrew all my clothes, started in on fat boy pants. Finally got disgusted and started looking at my life. Moved out of those upscale hotels and into a place where I could cook for myself, with a full sized refrigerator. Got up earlier and ate breakfast. Packed a lunch. Stopped taking the elevator. Walked once around the hotel every morning before I got in the truck for work. Instead of heading for the bar, I’d drink in my hotel room, lots cheaper, too. Got a pedometer, started walking where I could.

    Shocking how fast the weight started coming off. Simply shopping at a decent grocery store and eating out of my fridge changed everything. Oh I’ve still got some weight to lose and I’m about to start in on some Leinenkugel’s Amber but getting my fat ass out of bars and restaurants changed it all for me. The serving sizes in restaurants are preposterous. And there’s all that grease. Hell, if I want grease, I’ll plop some butter in the pan and control how much I put in. Mindless eating, mindless drinking, it’s not what you eat but how much — and more importantly — why you eat it. Stuffing food and drink into your mouth won’t fill my empty heart.

    Well, after seven years, five of them mindless gaining of weight and about three of mindful eating, I can honestly say I enjoy eating and drinking more now than ever. Hark! What do I hear? Six cheerful little voices from within the fridge, yodeling and yoo-hooing my name.

    • Ugh… I should proofread before posting. Stuffing food and drink into MY mouth won’t fill my empty heart. Stuffing food into yours, well, if anyone ever comes by Augusta, I’ll put a nice bowl of gumbo and rice in front of any of you. That would indeed fill my heart.

    • “The serving sizes in restaurants are preposterous.”

      Yep. The food service industry realized that people scale cost directly by volume, but that actual cost scales much less rapidly (there’s a set cost for service and prep, and volume is almost immaterial after that.) So they doubled portion size, doubled retail price, and tripled profit. (This is why movie theaters sell you a bucket of soda for eight dollars. It only costs them thirty cents–but if they gave you an eight-ounce cup instead, it would cost them twenty-five cents.)

      The whole “put the calorie count on the menu” thing is one of the few examples of government-mandated activity that I think was a good idea. It doesn’t actually stop anyone doing anything, it just requires that consumers have easier access to information about their food (and it is notoriously hard to get or estimate the nutritional values of a restaurant serving.)

      • Many years ago, I went to lunch with a small group of people. We were taking a candidate for a job at our clinic out in between interviews. As it happens, she was from Russia.

        I remember her starting to laugh after we were served our food. She had ordered a salad, and she looked at it and said “In Russia, a small family would share a salad this size.” It didn’t even look all that big to me.

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