The major ingredients of a heart- and brain-healthy diet are fairly well-established: fruits and vegetables, whole grains, beans, nuts, fish and low-fat dairy. Research shows people who stick to this eating pattern are less likely to get sick and more likely to live longer free of chronic disease.
So why isn't everyone eating this way?
Making lifestyle changes can be difficult, even when we know we should. But often, it's not just about willpower. Research shows a slate of intertwined barriers, some obvious and some more under the surface, that can severely impact access to healthy choices and contribute to health disparities.
They are "part of a really big picture related to our food environment," said Penny Kris-Etherton, a professor of nutritional sciences at the Pennsylvania State University College of Health and Human Development in University Park. "It's such a complicated problem."
In a scientific statement last year giving dietary guidance for cardiovascular health, the American Heart Association outlined five issues that make it harder to adhere to healthy eating patterns: targeted food marketing, structural racism, neighborhood segregation, unhealthy built environments and food insecurity, also known as nutrition insecurity.
"This is affecting quality of life and life expectancy," said Kris-Etherton, one of the report's co-authors. She also co-led a 2020 paper published in the Journal of the American Heart Association about the barriers that contribute to disparities in diet-related cardiovascular disease. "Somehow, we have to make healthier foods readily available to underserved people."
Targeted food marketing
The food and beverage industry heavily markets unhealthy foods and beverages – such as processed fast foods and sugary beverages – to low-income neighborhoods and places where historically underrepresented racial and ethnic populations live. Research shows children who live in predominantly Black and Hispanic neighborhoods are more likely to be targeted by ads for processed foods and beverages than their white peers – both inside and outside their homes.
That marketing does damage.
"Marketing works. You see an advertisement or a commercial and you engage in that behavior," said Sparkle Springfield, an assistant professor of public health sciences at Loyola University in Chicago. Her research focuses on psychological resilience and health behaviors that protect against cardiovascular disease.
But racial disparities in marketing disproportionately expose Black, Indigenous, Hispanic and other historically disenfranchised communities to low-quality foods and drinks, she said.
One way to combat that, Springfield said, might be consciousness raising – making people more aware of how they are being targeted. "Just telling people these foods are not good for them will not necessarily work," she said. "But if we alert them to the marketing, tell them they are being targeted with low-quality foods, coupled with the health risks that go with them, that might be a more effective way to encourage positive, sustained health behavior changes in youth and adults."
Structural racism and neighborhood segregation
Structural racism – in the form of discriminatory housing and lending policies – played a major role in creating racially segregated neighborhoods in the U.S. An ongoing lack of investment results in communities having less access to quality education, health care facilities and grocery stores, larger issues with crime and fewer opportunities for high-paying jobs.
These neighborhoods are often food deserts, lacking easy access to supermarkets or farmers markets where people can purchase affordable, healthy foods. Living in a food desert is associated with a 14% higher risk of developing cardiovascular disease within 10 years, according to 2017 study in Circulation: Cardiovascular Quality and Outcomes.
When racially segregated neighborhoods lack access to supermarkets, the people who live there end up relying on more expensive corner stores and bodegas that stock processed foods and beverages.
"People may be doing their grocery shopping at dollar stores because the food is cheap there, and that's the only place they have close by to go grocery shopping. And, they're buying unhealthy processed foods, and not the foods that confer health benefits such as fruits and vegetables, whole grains, beans, low-fat dairy, nuts and fish," Kris-Etherton said.
Or they may be heavily reliant on fast-food chains that offer cheaper meals on the go. Food swamps – the term for when neighborhoods are saturated with fast-food restaurants that sell mostly unhealthy foods very cheaply – are just as bad as food deserts, she said.
Sparkle said she prefers the term food injustice. "Limited access to high-quality foods (in these communities) is a leading social justice issue; that should remain the focal point given our national public health agenda to achieve health equity."
Unhealthy built environments and nutrition insecurity
Residential racial segregation and other forms of structural racism are fundamental causes of health inequities and contribute to unhealthy built environments and food insecurity, Sparkle said. Research shows Black and Hispanic households are more likely to face food and nutrition insecurity, which is associated with poor diet quality and high rates of chronic disease.
Correcting the problem begins with identifying the racist policies that led to disinvesting in these neighborhoods, she said. "It was intentionally done, and it can be undone."
Policies that steer funds toward public health initiatives in under-resourced neighborhoods are a good place to start, Sparkle said. For example, in states that have legalized cannabis, tax revenues from those sales could be used to invest in these communities. Some states, such as Illinois, California and Connecticut, are already doing that.
Policies that create financial incentives for people to purchase healthier foods – such as with federal Supplemental Nutrition Assistance Program (SNAP) benefits to cover those costs – along with incentives for companies to produce healthier foods would also help, Kris-Etherton said. Installing gardens at schools, creating incentives for grocery stores to locate in underserved areas and educating people about the benefits of healthier eating also could contribute to creating healthier food environments.
"We need a huge effort from a lot of fronts," Kris-Etherton said. "It needs to be across the board from multiple domains, and it really has to be intertwined. … We need to build a culture of health."
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