Americans have more ways to be healthy than ever before. Organic vegetables line grocery store shelves. Yoga studios crowd city streets. Fitbits remind us to skip the elevator and Rocky Balboa it up the stairs.
But just because all these waist-thinning options exist doesn’t mean everyone has access to them. Fresh produce, fancy gyms, and habit-tracking technology are expensive, and cost is one of many prohibitive factors that keeps millions of people from taking good care of themselves.
The obesity rates in America are staggering; more than a third of adults deal with the disorder, with demographics that reflect a complicated web of cultural and socio-economic influences. So how do we even the playing field? In advance of the Zócalo/The California Wellness Foundation event “Is Healthy Living Only for the Rich?” we asked medical experts and others invested the public’s well-being: Given the structure and demands of everyday life in America, what can be done to make healthy living more accessible across classes?
Partner up to change people’s environments
The burden of chronic disease in the United States is substantial. Chronic diseases—such as heart disease, stroke, diabetes, obesity, and cancer—are among the most common, costly, and preventable of all health problems. More than half of all adults in the U.S. have at least one of them.
Improving the overall health of Americans will involve reducing risk factors such as physical inactivity, poor nutrition, and limited or no access to quality healthcare. In addition to these factors, environment (for example, communities, schools, workplaces, restaurants, parks, etc.) plays a large role in helping Americans achieve optimal health. The importance of creating safe places to exercise, increasing access to healthier foods and beverages, and reducing exposure to secondhand smoke in public places cannot be overlooked or minimized.
Bettering people’s environments requires strong partnerships and a commitment to making healthy choices easier. The best successes are where schools, local parks, businesses, faith-based organizations, clinical settings, and restaurants work together through a combination of approaches. These approaches include establishing policies in schools that make available salad bars and healthy-foods vending machines; adopting joint-use agreements with facilities such as schools, churches, and businesses to increase access to safe places to exercise; working closely with corner grocery stores in communities to increase access to fruits and vegetables; and changing prices of healthier foods and beverages relative to the cost of less-healthy foods.
Leonard Jack, Jr. is the director of the division of community health within the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention.
First, address a community’s fundamental needs
There is unfortunately no single, easy answer. We certainly need to encourage healthy eating and regular physical activity, and discourage tobacco use and unhealthful patterns of drug and alcohol use. However, these efforts are unlikely to make a dent in the glaring health inequities we see across socioeconomic and racial and ethnic groups unless we also create environments that promote healthy living.
Sadly, in most communities, and particularly in low-income communities, the deck is stacked against healthy choices. We need to shift the balance in favor of healthy options where landscapes are largely dominated by junk food, unhealthy food and beverage marketing, tobacco shops, and liquor stores, and few if any options for recreation. Even these measures, though, are unlikely to achieve the desired results unless we address even more fundamental needs, including safe and affordable housing, high-quality education, and meaningful employment opportunities that offer a living wage.
Though these issues may seem far removed from healthy living, they are in fact among the most important factors that influence health across the lifespan. In addition, chronic stress associated with living in communities that are rife with violence, disinvestment, and degradation exact an enormous toll on one’s health. We need to work with and support communities to build resilience, strengthen social networks, and create opportunity. Anything less is like putting a Band-Aid on a festering wound.
Paul Simon is the director of the division of chronic disease and injury prevention at Los Angeles County of Public Health. He is also a pediatrician, and teaches at the UCLA Fielding School of Public Health.
Healthy living is truly a privilege in the United States, because many families are focused on survival. I will forever remember the words of a mother who spoke up at a grassroots community-organizing event I attended: She said even though she knows it’s not nutritional, she still gives her sons honey buns in the morning, because it’s quick, cheap, and at least they will have something to eat.
Simply stating that for this woman—and others like her who don’t have access to healthy living—more health education classes is not enough. There is arrogance in that notion. Surely, this marginalized population knows that they should be eating better, getting more exercise, and having more routine physicals. However, there are barriers in the way that seem to be growing—barriers that are among the key reasons why protestors took to the streets during the Occupy campaigns. When we speak of classes, the United States is simply becoming the “have” and the “have-nots,” and public health is suffering because of this, as healthy living options become unattainable.
The problem involves macroeconomics, and should be approached from this macro-level with urgently needed social policies and legislation that will make healthy living accessible. Speaking about the poor is taboo in American politics; politicians prefer to talk about the “shrinking middle class,” without providing any context as to where they are shrinking away to. For that reason, we need to begin to speak about privilege and inequity, and consider diverse public health interventions, such as creating and maintaining community gardens, imposing higher taxes on sugar-laden foods, and extending physical education requirements in schools.
Cherise Charleswell holds a dual position as diversity officer and clinical researcher at Huntington Medical Research Institutes in Pasadena, California. She is the president of the Southern California Public Health Association.
Take care of the easy stuff
This is a critical question with an easy answer: Much can be done, and the imperative to do a lot is strong.
In the United States, there are tremendous gradients in health and longevity by indicators of socioeconomic status. Underlying these gradients are patterns of harmful substance use (tobacco, excessive alcohol, and illegal drugs), availability and affordability of healthy food, psychosocial stress, and access to high-quality preventive and medical care.
What can be done on the short-term?
• Continue to drive down rates of tobacco use, while taking on the new challenge of various electronic nicotine delivery systems. In California, for instance, cigarettes are too cheap, so there’s an opportunity to reduce smoking through a tax increase.
• Invest in research to find better interventions for alcoholism, as the problem of excess alcohol consumption remains deeply rooted.
• Assess, address, and monitor the availability and consumption of healthy foods. We have the tools to do so, and already know the solutions: local growing and selling, and pushing for healthier options from the food industry.
• Promote physical activity by identifying and addressing barriers to it (for instance, lack of walkable routes, lack of education on the risks of a sedentary lifestyle)
• Teach communities to advance their own health. Strategies could include engaging community leaders, providing model initiatives, and offering funding to foster innovation.
For some of the most critical factors, solutions are for the long-term and outside the domain of local communities—healthcare access and quality, and a strong base of jobs—but they should not be forgotten.
Jonathan M. Samet is the chair of the department of preventive medicine at University of Southern California’s Keck School of Medicine. He is also the director of USC’s Institute for Global Health.
Get people exercising
Socioeconomic status is adversely associated with obesity and lifestyle diseases. However, it’s often incorrectly assumed that access to recreational facilities is critical to maintaining a good workout routine.
Exercise is potent and virtually “free” medicine that delivers health benefits independent of education level, financial status, or body size. Cardiovascular disease is the leading cause of death in the U.S., and exercise is extremely efficacious cardiovascular medicine. Current American Heart Association guidelines recommend that adults engage in 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity activity per week.
While these goals may sound unattainable to a time-crunched person or busy family, it is important to note that accumulating 30 minutes of exercise in short bouts is just as effective at lowering cardiovascular risk. Short exercise sessions—as little as 10 minutes at a time—have been shown to be just as effective at reducing blood pressure as a single, longer session. A short walk or bike ride to work, the park, or a store can enhance heart health without the cost of a gym membership.
The salutary effects of exercise occur independently of body weight or body fat. In a series of studies carried out at the Cooper Clinic in Texas, researchers examined the effects of fitness on the risk of death from all causes and cardiovascular mortality. The key finding was that obese and fit individuals had the same risk of adverse outcomes as normal-weight and fit individuals, and half the risk as normal-weight or obese, unfit individuals.
In short, good heart health is possible at any size with a cheap pill called exercise.
Siddhartha Angadi is an assistant professor at Arizona State University. His research focuses on the effects of exercise and diet on cardiac and arterial function in patients with serious cardiovascular conditions. His doctoral student Jennifer Herbold assisted him in writing this response.
This article is supported by a grant from The California Wellness Foundation.