NC1196: Food systems, health, and well-being: understanding complex relationships and dynamics of change
Statement of Issues and Justification
While the importance of food to health and well-being is clear, the specific ways in which food systems contribute to individual and community health are not well understood. This is a complex issue, which requires improving food systems as well as changing mindsets and behaviors of individuals within the food system. The purpose of this project is to investigate these complex relationships, involving key stakeholders in analyzing and addressing problems and solutions. Our goal is to increase understanding of food and nutrition practices and systems, and to facilitate food-related institutional, community, family, and individual behavioral changes that can improve health and well-being.In this project we take a broad view of health and well-being, moving beyond the framework of the absence of disease. We incorporate Buchanan's (2000) notion of well-being, which includes a holistic view of individual health and community well-being, as well as their intersection. Incorporating such a notion is important because global biophysical and socio-cultural systems, as well as community and family systems, impact health and well-being directly and also indirectly through their impact on food decision-making (Gillespie and Smith, 2008). For Buchanan, individual well-being is integral to community well-being, in the sense that institutions must function to facilitate health for individuals. Our work at the community level aligns with Allen's notion that food-system localization is a window and a pathway for addressing the environmental, social and economic issues in the food system that constrain and enable human health and safety (Allen, 2010).
Clearly, there are major health issues in the American food system, as the mounting reports regarding the prevalence of food-related conditions, diseases, and ill health indicate. Risk factors for chronic disease (such as diabetes, cancer, and heart disease) and poor health include obesity and food insecurity. Obesity rates among some segments of the US population continue to rise (Flegal et al., 2010), and nowhere have such rates begun to decline. Rates in 2007 ranged from 32% of adults in Mississippi to 18.7% in Colorado (Obesity Society, 2010). Obesity rates are disproportionate across ethnic groups but are positively related to poverty and sociocultural influences (Levi et al., 2010; Pleis et al 2008). Understanding why and how obesity rates are stabilizing among some groups while increasing in others is key to developing strategies for decreasing obesity across populations.
One link is the connection between obesity and food insecurity, which is increasing in the US. Nearly 15% of households over 50 million people were food insecure in 2008 (up from 11% in 2007), meaning that at times they did not have enough money for food. Food insecurity has been exacerbated in recent years due to the increased cost of food and fuel, inadequate food stamp benefits, unemployment, the recent spike in foreclosures and rent or mortgage costs, and the increased cost of living in general. A May 2008 national survey by Feeding America, the nations largest charitable hunger-relief organization, found that an average of 15 to 20% more people were forced to resort to emergency food aid in 2008 than in 2007. More than 80% of surveyed food banks indicated they were unable to meet demands without reducing the amount of food distributed per person served (Feeding America, 2008). Compounding the issue, U.S. Department of Agriculture bonus foods have declined by $200 million and local food donations were down nationally by about 9% during the same period (Feeding America, 2008).
Many of the food-related health problems in the US disproportionately affect children, women, ethnic minorities, and low-income people. For example, low-income and minority populations in the US have higher rates of food-related chronic illnesses such as obesity, heart disease, hypertension, and diabetes, and lower rates of physical activity compared to higher-income and non-Hispanic whites (Taylor et al., 2006, Kumanyika, 2008, Sankofa and Johnson-Taylor, 2007). For women, higher obesity rates tend to occur among population groups with the highest poverty rates and the least education (Drewnowski and Specter, 2004; Phipps et al., 2006). Furthermore, food insecurity is disproportionately experienced by poor, single-mother, Hispanic, and African American households (42%, 37%, 27%, and 26%, respectively) (Nord et al., 2009). And food insecurity is experienced significantly in the Native American populations as well (Pleis et al 2008). Vozoris and Tarasuk (2003) also found that low-income, food-insecure individuals had significantly higher odds of reporting poor or fair health, of having poor functional health, restricted activity and multiple chronic conditions, of suffering from major depression and distress, and of having poor social support than higher income individuals. Individuals in food-insufficient households were also more likely to report heart disease, diabetes, high blood pressure and food allergies (Vozoris and Tarasuk, 2003). Smith and Richards (2008) found that the majority of homeless youth in their sample had inadequate intakes of calcium, vitamin D, and potassium, and less than the Estimated Average Requirements (EAR) for vitamin A, vitamin C, vitamin E, phosphorus, folate, and zinc. The many factors that influence dietary behaviors and subsequent health among low-income minorities are associated with inequalities in education and income, healthy food access, cultural norms, racism, psychology, and health care quality and access (Sankofa and Johnson-Taylor, 2007).
Addressing these problems requires that we understand more about the processes of institutional change, structural conditions, perceptions, and decision-making. As the obesity epidemic has come to dominate health care, prevention and treatment, and as food insecurity continues to increase, nutritionists are beginning to understand that we must move beyond the dominant public health paradigm of individual behavior change to include the contexts in which change for better or for worse occurs (Gillespie and Johnson-Askew, 2009, Larson et al., 2009, Wells and Olson, 2006, Gillespie and Gillespie, 2007, Flora and Gillespie 2009). The environment itself determines much of what individuals can draw from it. Community norms may dictate who has access to food assistance; civically engaged communities for example provide more food assistance and make food resources for the poor more easily accessible. Furthermore, consumer and producer attitudes and interests may conflict over some issues surrounding sustainability and health (Selfa et al., 2008). Engaging the food environment requires strategies that include planning by middle-class food procurers (McIntosh et al., forthcoming b) and the use of food stamps, stealing food, consuming food in retail stores rather than paying for it, scavenging and going without food so that other family members can eat (Richards and Smith, 2006).
We offer a new approach that builds on family and community assets and takes a systems perspective. New and community-engaged approaches to the conceptualization, study, and outreach and their integration are needed to address constraints to health and well-being including obesity, food insecurity, diabetes and other chronic diseases. The keys to understanding the rise of obesity and other maladies associated with over-nutrition lie, in part, in these communities, which are in turn shaped by larger social, economic, and institutional structures (Allen, 2004). A systems approach to food in local communities and families, one that takes into account the social, economic and cultural aspects of food, is required to unravel the mysteries of food-related problems in multiple dimensions.
Moving from medical and educational models of intervention, this approach focuses on how changes in the social and physical environment enhance the ability of families and individuals to make healthy choices (Flora and Gillespie, 2009). Food decision-making processes, acquisition, transformation, presentation, consumption and disposal are also social acts with biophysical implications for children, their families, and communities (Gillespie and Gillespie, 2007). Thus, we will try to unpack how social and biophysical systems interact to define individuals' food choices, impact their food decision-making processes, and change their way of thinking about food, eating, health, well-being, and engagement in their community food system decision-making (Gillespie and Smith, 2008, Gillespie and Gillespie, 2007). For children, these include family, school, and community food systems (Gillespie and Smith, 2008).
The interactions within and between family and community food decision-making systems affect both the health and well-being of children and their families, as well as the sustainability of community food systems (Gillespie and Johnson-Askew, 2009). Family food and eating routines are enabled or constrained by the availability and accessibility of healthy eating alternatives in their community food system. At the same time, families' appreciation of nourishing foods grown sustainably can shape the community food system. Thus, the food decision-making systems of families and communities interact at multiple levels. These interactions impact the appreciation, availability, and accessibility (AAA) of foods that promote family and community health and well-being by improving eating practices and food choices and increasing demand for sustainably produced foods (Gillespie, unpublished manuscript). The AAA frame expands the supply-demand paradigm to take into account that eaters are more than just consumers in the market place or recipients of government or private food assistance, but can effectively engage in community food decision-making for systems change in their environment.
Each person has a connection to the wider food environment that is both the result of their individual circumstances (e.g., where they go to school, work, shop on their own, hang out with friends) and as a family member. In addition each has a social network that, because they are members of the same family, will overlap to a certain extent. In the case of children, peers, grandparents, teachers, and others represent potential influences on their choice of foods and perhaps the amounts they consume. Similarly, parents will have neighbors, co-workers, friends and fellow association members that may influence food intake. Researchers have found that network characteristics influence network members' behaviors. At least two studies have found that individuals whose networks consist of overweight individuals tend to be overweight themselves (Christakis and Fowler, 2007; Valente et al., 2009). This may be the result of network members eating and exercise activities or because overweight individuals gravitate towards persons like themselves.
Family members may bring home with them food preferences developed as members of their differing social networks. Family members may also bring pre-prepared food home with them, which is either consumed by the family member who brought it or shared with others. Our understanding of the impacts of convenience foods, fast food, and groceries on the food intake of family members is incomplete, and must include Americans from all walks of life, the poor and the well-to-do. Understanding the food environment requires strategies that include planning by middle-class food procurers (McIntosh et al. forthcoming a, McIntosh et al. forthcoming b, Mancino et al., 2010), as well as strategies used by the poor to obtain food, including the use of Supplemental Nutrition Assistance Program (SNAP), Food Distribution Program on Indian Reservations (FDIRP), stealing food, consuming food in stores without paying for it, dumpster diving, using social networks, and going without food so that other family members can eat (Richards and Smith, 2006). Research by Smith and Morton (2009) shows that community infrastructure, along with social, cultural, personal, and household factors all influence consumption patterns. In addition, family environments include their food decision-making structure, parental work constraints, and family traditions or rituals (particularly dinner rituals) (Gillespie, 2010, McIntosh et al., forthcoming a, McIntosh et al. forthcoming b). Our proposed research will examine what people are actually eating and how they influence or are influenced into eating that food.
We approach these issues from a food systems perspective, which requires the identification of the key actors in the system and their interrelationships. One method we will use for mapping key actors and their relationships is the tool developed by Gillespie and colleagues (Gillespie et. al., 2010 SNE; familyfood.human.cornell.edu). These actors include but are not limited to consumers (both individuals and groups such as families or grade school children), educators, change agencies, retail food outlets, food wholesalers, schools and school districts, and alternative options such as community supported agriculture, farmers markets, and local food assistance programs such as food banks and pantries. Issues of availability and access to food, particularly healthy alternatives, remain for both families and schools as they cope with financial constraints and family member and school childrens preferences.
Innovative practices for enhancing health and well-being and building sustainable food systems are blossoming in urban neighborhoods and rural communities. For example, schools have begun to make healthy changes in their breakfast and lunch offerings and their food environments. An example of this are the schools that participate in the California Endowments Healthy Eating, Active Communities program, which have made changes in vending machine offerings and physical education programs, and have influenced stores in the area surrounding the schools to offer healthier foods (Samuels et al., 2010). Communities are exploring options such as taxing sugared drinks (New York) and getting farmers markets to accept food stamps (Los Angeles). At the same time there is a surge of interest in community gardening, community supported agriculture, and farmers markets. It is as yet unclear whether these efforts will reverse these negative trends in fruit and vegetable consumption and obesity prevalence. Research to date shows that some changes in the food system can lead to better health. For example, neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity. Morland and Evenson (2009) measured the association between the presence of food establishments and obesity among adults living in the southern region of the United States and found the prevalence of obesity was lower in areas that had supermarkets and higher in area with small grocery stores or fast food restaurants (Morland and Evenson 2009).
We will gather data on how individuals and families make food-purchase, food-preparation, and food-consumption decisions. We will study the contribution of various family members to both food acquisition and food preparation, and how eating together influences the intake or lack thereof of particular foods. In addition, we will examine how community food infrastructure affects food availability and access through the local retail stores, gardens, farmers' markets, and food-assistance programs. Associations will be examined among food choice, access, and availability and outcomes of health and well-being. Also, data on the availability of healthy and unhealthy food choices will be collected. We will then connect these data on family decisions and food availability to outcomes of health and well-being. We will also study other linkages in the food system, including connections between the retail food sector and food assistance programs in communities. Furthermore, we are working to document food security, increasing understanding of the ways in which food-system innovations (such as CSAs) contribute to health and well-being, and are engaged with community-based efforts to change the food system in ways that support health and well-being (such as those working with school food programs). Project members will explore ways to improve family and community food decisions and increase healthy food consumption in communities through schools, households, community gardens/farmers' markets, tribal programs, and to increase access to healthy foods in stores in an effort to improve the health and well-being of community residents.
This project will examine family, community, and institutional dynamics to better understand how the food system influences individual and population health and well-being. This includes investigating the interaction between food consumption by families and how family food selections are influenced by interactions family members have with one another and with their food environments. In this project we will work to increase understanding of problems and solutions in food-related health and well-being. We will engage with the underserved as well as community stakeholders and decision makers through Collaborative Engaged Research Methodology (Gillespie, 2010), and explore other means for creating community access to research. While university-based research, education, and outreach programs have not always served or been accountable to people of color and underserved populations (Slocum, 2006), in this project we will develop an inclusive, community-oriented, participatory approach. This will require a focused effort to work with groups that have historically had less ability to access and benefit from university programs than have traditional agricultural clients.
University engagement with the public and its various communities is mutually beneficial and can both improve the quality of research as well as lead to enhanced problem-solving and ultimately transformative action. It can advance the interests of specific external partners and the general public while also advancing and enhancing the interests and work of academia (Kellogg Commission, 1999). Community-based research goes beyond public scholarship in that it directly involves the public in developing the research questions and treats them as equals in the research process (Gillespie, 2009). In addition, community projects are often isolated and idiosyncratic rather than integrated into cumulative learning and policy change to lead to sustainable system changes for increased well-being (Allen and Guthman, 2006); our goal is to enhance learning and changes across regions and sectors of the food system.
Our interdisciplinary research team is well positioned for this multi-state effort of conceptual and empirical engagement with the complex issues of food systems, health, and well-being. The team has extensive experience in working at multiple levels and with a range of stakeholders to integrate research with education and outreach. Since our project group is composed of members from states in many areas of the country, we will be able learn from and engage with people with different historical experiences and contemporary conditions. This diversity and range will greatly increase the scope of action, and the knowledge base for future work. Moreover, multiple disciplines (including economics, nutrition, sociology, and geography) are represented on the project team, ensuring that problems and solutions will be addressed from a range of perspectives and methodologies.
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