food and health: using the foodsystem to challenge ... foodsystem to challenge childhood obesity...

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Collaborative Initiatives at MIT Massachusetts Intstitute of Technology @

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FoodandHealth:UsingtheFoodsystemtoChallengeChildhoodObesity

FinalReportontheCurbingChildhoodObesityProject,PhasesIandIIIncludingAbstractandMainText

October2009

Abstract

Dramaticincreasesinearlyonsetofadultmedicalconditionsassociatedwithchildhoodobesity

andtheneedtocontainhealthcarecostshaveplacedobesityatthecenterofindustry,public

health,politicalandmedicaldebate.Theseindependentfieldsmustworktogetherifweareto

implementrealchange.

Utilizingauniquedesignapproach,ColumbiaUniversityandMITwiththesupportoftheUnited

HealthFoundation,joinedforcestostudyabroadsystem‐basedviewofobesity.Themain

conclusion–thefoodsystemandhealthareintegrallylinked.Toensurethateffortstofight

obesityaresustainable,wemustdevelopanationalfoodsystembasedonaccess,affordability,

qualityandhealth.

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ProjectTeamTheCollaborativeInitiativesatMIT

TenleyE.Albright,MD DirectorKenKaplan AssociateDirectorEleanorCarlough DirectorofProgramCherylHardwick FinanceManagerPattyLauria OfficeManagerTheUrbanDesignLabattheEarthInstituteatColumbiaUniversity

MichaelConard ProjectDirector,AssociateProfessorofArchitectureRichardPlunz ProfessorofArchitectureKubiAckerman DesignResearchAssociateCindyChiou PublicHealthResearchAssociateDimitrisVlachopoulos DesignResearchAssociateLindseySchubiner ResearchAssistantExpertConsultants

SusanRoberts,JD,MS,RD FoodsystemlegalandnutritionexpertMichaelRosenbaum,MD AssociateProfessorofClinicalPediatricsattheColumbia UniversityMedicalCenterMarcoSteinberg DirectorofStrategicDesignFinnishInnovationFundAdvisoryBoard

PaulaA.Johnson,MD ExecutiveDirector,ConnorsCenterforWomen’sHealth andGenderBiologyandChiefoftheDivisionofWomen’s HealthatBrighamandWomen’sHospital

KennethMoritsugu,MD,MPH, (RearAdmiral)FormerActingSurgeonGeneral

MichaelPorter,MBA,PhD Professor,HarvardBusinessSchool

GeorgeRabstejnek ChairofCenterforTechnologyCommercialization,Vice ChairmanoftheMassachusettsEyeandEarInfirmary

AlfredSommer,MD,MHS ProfessorofEpidemiologyandInternationalHealthand DeanEmeritus,JohnsHopkinsUniversityBloomberg SchoolofPublicHealth

RoxanneSpillett President,BoysandGirlsClubofAmerica

LouisSullivan,MD Chairman,TheNationalHealthMuseum;Founder, PresidentEmeritus,MorehouseSchoolofMedicine

JimTallon PresidentofUnitedHospitalFund

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MainText

Ithasbeenshownthatonceachildhasbecomeobeseitisdifficulttoreverse.1Atthispointit

becomesalifetimestrugglechallengingtheindividualandfamilies,taxingthemedicalsystem,

anddrivinghealthcarecoststounsustainablelimits.Thesepressuresmakeitimperativethat

nationalprogramstopreventtheincidenceofchildhoodobesitypopulation‐widebe

developed.

InSeptember2007,withthesupportoftheUnitedHealthFoundation,theCollaborative

InitiativesatMITandtheUrbanDesignLabattheEarthInstituteatColumbiaUniversityjoined

togethertostudyChildhoodObesitythroughadesignlens.Basedonanearliersystems‐based

studyonStroke2,thegoaloftheprojectwastotakeacomprehensivesystems‐basedviewof

obesityatmultiplescalestoassesspotentialgapsinthemethodsbeingusedtocombatthe

dramaticriseinchildhoodobesityandtodevelopnewapproachestocurbingtheepidemic.

Design,asadiscipline,considerstheinterdependenceofdiversespecialtieswithinasystem.A

design‐basedanalysisrequiresknowledgeoftherelationshipbetweenvariouspartsofthe

system;anunderstandingofthelong‐rangeeffectofchanginganyonepartofthesystem;and

anawarenessthatapproachinganyonepartofacomprehensivesystemindependentlywill

havelimitedaffect.Todate,applicationofdesignresearchmethodstobroadsocialissueshas

beenlimited,butthepotentialvalueofsuchanapproach,whichconsidersabroadrangeof

factorsaffectinganissueanddetermineswherethepivotalintersectionsoccur,isgreat.

Whatresultedwastheidentificationoftwomajorgapsintheefforttofightchildhoodobesity.

1. alackofcoordinationamonginterventioneffortsleadingtoanendlesscycleof“start‐

up”programs.

2. areluctancetotakeonthelargerfoodsystem

Theteamchosetotargetthechallengeofthefoodsystemasthekeytomountingasustainable

nationalefforttochangethetideofchildhoodobesity.Manygroupsaroundthecountryare

workingtoaddresstheissueofobesityasitaffectschildren.Fromlocalcommunitygroupsto

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nationalfoundationsthereisagrowingmomentum.However,successfulprogramsareoften

limitedbythelargerfoodenvironment.Forexample,asuccessfulschoolprogramislimitedby

achild’shomeenvironmentorthecommunityenvironment;asuccessfulcommunityprogram

islimitedbythesurroundingretailenvironment.Isolatedinterventionsareworkingupstream.

Astrongintegratedfoodsystembasedonaccess,affordability,qualityandhealthwillsupport

themanycommunityinterventionstakingplaceacrossthecountryandenablelong‐term

change.Achievingthisgoalwillrequirenewcollaborationsamongindustry,health,agriculture,

academia,non‐profit,andgovernmentdomainsaswellasthedevelopmentofnewbusiness

modelsfocusedonprovidingahealthyfoodsupply.

Methodology:

Todatetheprojecthascompletedtwophases.PhaseI:in‐depthdesignbasedresearch.Phase

II:stakeholderassessment.

Theprojectteamwasledbyanarchitectapplyingdesignprinciplestotheissueofchildhood

obesity.Toaugmenttheirknowledgebasetheteamworkedwithagroupofadvisors3.Usinga

combinationoftraditionalliteraturereviewanddesignmethodstheteamstudiedexisting

researchonanextremelybroadrangeoftopicsrelatingtoobesity,reviewingprofessional

journals,popularandspecializedbooks,nationalandinternationalreports,andsurveydataata

numberofdifferentscales;researchingandvisitingcurrentinterventionprogramsnationwide;

andinterviewingover150expertsinareasrelatedtotheissueaswellasbehavioral

economists,traditionaleconomists,transportationexperts,businessleaders,andothers.

The team’s broad research effort involved a detailed consideration of the socio‐cultural

changes that have occurred thatmay be responsible for the sudden increase in the rates of

childhoodobesityaround1980.4Someofthesocialtopicsresearchedinclude:

Markettrends(foodconsumption,foodpricing,foodmarketing);

Lifestylechanges(timeusepatterns,familystructure,consumptionhabits);

Policy(theFarmBillandagriculturalsubsidies,foodpolicy,andeducation);

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Socioeconomic factors (shift to a postindustrial economy, socioeconomic disparities,

economicinsecurity);

The built environment (land use patterns, urban/suburban development,

transportation,urbanrenewal).

Tocontextualizetheproblemandgaininsightintoitsgeographicaldimension,theteam

researchedtheprevalenceofobesityfromavarietyofspatialscales,includingglobal,national,

andmunicipallevels.Finally,theteamexaminedthecurrentliteratureonpharmacological,

hormonal,andepigeneticfactorscontributingtoobesity.

Anumberofdesigntoolswereusedtoanalyzethedatagatheredintheearlystagesofthe

study:

ProbePresentations

“Probes”aredesigntoolsintendedtoprovideanopportunityfortheresearchteamtoexplore

specifictopicsmoredeeplythroughvisualizationandmodelingandtoassesspotential

interventionstrategies.Theteamresearched,analyzed,andpresentedfindingsonaspecific

probetopicinabrief,intensiveperiodoftime.Thisprocesschallengedtheteamtoapplyearly

researchdirectionstopotentialrealisticsolutionstothechildhoodobesityepidemic.

Selectedprobesconductedinclude:

• ChildhoodObesityandtheBuiltEnvironment:StrategiesforUrban,Suburban,and

RuralCommunities

• ScenariosandTrendsinChildhoodObesityandtheFoodSystem

• PhysicalActivityandChildhoodObesity:EvaluationofResearchandSuccesses

• ChildhoodObesityandFoodSystems:TheCarbonFootprintofFood

• FoodCultureandFoodAccess:PotentialContributorstoandSolutionsforChildhood

Obesity

• ChildhoodObesityinNewYorkCityandState:EvaluationofCurrentEfforts

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Intervention Evaluation Tools

The primary environmental factors contributing to energy expenditure and intake, the two

components of the “energy equation.” Dotted lines represent strong correlations between

factors on either side of the equation.The diagram can be used to begin to map the scope

of various proposed interventions or combinations of interventions. Because of the

complex, multi-variant nature of the problem, it is necessary to address as many of the

environmental contributors as possible.

InterviewCoding

Anadditionaltoolinvolvedcodingthenotesfromnumerousinterviewsconductedwithexperts

andengagedcommunitymembers.Theprocessenabledtheteamtoextractthemesthat

reoccurredwithparticularinterestininterviewees’opinionsonthechallengestheyhavefaced

intheirwork,potentialfutureopportunities,andtheirperspectivesontheproblemof

childhoodobesityandeffortstoaddressit.

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Matrices

Theresearchteamcompiledtwomatricestofacilitatedatareview.Thefirstwasamatrixof

115existingobesityprogramsaroundthenation.Theseprogramswereclassifiedaccordingto

thetargetagegroup,scale,andareasofconcentration.Theprogramswerethenmappedto

establishspatialconcentrationsandpotentialoverlaps.

Thesecondmatrixwasasearchabledatabaseoutlining600+publishedarticlesandreportson

thecomplexissuessurroundingchildhoodobesity.Thisenabledtheresearchteamto

determinetheemphasesofthevariousdisciplinaryfieldsandpotentialgapsintheresearch.

Whenreviewingthesestudiesandreports,theobesity‐relatedfactorsweredividedintermsof

energyintake,energyexpenditure,medicine,andtrends.Thesewerefurthersubdividedinthe

followingmanner:

• EnergyIntake:Production(agriculture,foodindustry,processing),

Distribution/Access(builtenvironmentdistribution,marketsupply,schoollunches,

schoolvending,foodcosts)andConsumption(education,foodtype,foodquality,

lifestyle,media,marketing);

• EnergyExpenditure:BuiltEnvironment,Education,andLifestyle;

• Medicine:Biology,Treatment,Costs(economicandhealth);

• Trends:Children,Ethnicity,Geography,Income,PoliticalSystem,andRegulation.

Fromthisbodyofresearchtheteambuiltacomprehensivemodelofthecausesofchildhood

obesityandcurrentinterventionsanddevelopedseveralrecommendationsforchangeonlocal,

stateandnationallevels.

PhaseIIinvolvedputtingthePhaseIrecommendationsinfrontofvariousstakeholderstogain

insightandtobuildthefoundationofsupportneededtoeffectnationalchange.Thefindings

werepresentedtoindustryleaders,agriculturespecialists,non‐profitorganizations,

economists,farmers,marketingexecutives,nutritionists,doctorsandgovernment

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representativestoidentifyreal‐worldbarrierstodevelopingtheteam’sdesign

recommendations.

Findings:

Theratesofchildhoodobesityhaveincreasedby325%sincetheearly1960swithdramaticand

steadygrowthsince1980.8

Thedatagatheredduringtheprojectbothsupportstheintuitiveunderstandingofobesityand

challengesexpertstolookbeyondtheobviousanswers.Thebottomlineisclear:thereisan

obesityepidemicbecause,ingeneral,peopleareconsumingmorecaloriesthantheyareusing.

Addtothat,thefactthatmanyofthehealthyfoodsthatarebeingconsumedaredecreasingin

nutritionalvalueandthehealthrisksbecomeevengreater5.

“The10‐to12‐poundincreaseinmedianweightweobserveinthepasttwo

decadesrequiresanetcaloricimbalanceofabout100to150caloriesperday.

Thesecalorienumbersarestrikinglysmall.Onehundredandfiftycaloriesper

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dayisthreeOreocookiesoronecanofPepsi.Itisaboutamileandahalfof

walking.”6

Thehighestlevelofriskisinlow‐incomeneighborhoodswheretheavailablefoodstendtobe

high‐fat,low‐costoptionsandtherearefeweropportunitiesforsafe,accessible,physical

activity.7However,whileincreasingphysicalactivityisacriticalcomponentofbuildinga

healthierpopulation,itcannotaffectapopulation‐wideshiftinobesityratesunlessthecaloric

intakeisaddressed.11

Environmentalfactorsthatarecontributingtothechildhoodobesitycrisisinclude:

o Asteadyincreaseinthecostsof‘healthy’foods–definedforthepurposesof

theprojectasfreshfruitsandvegetablesandminimallyprocessedfoodthat

islowinaddedsugar,fat,andsalt

Sincethe1980s,thecostofhealthyfoodssuchasfruitsandvegetableshasrisenmuchmore

rapidlythanthecostofunhealthyfoods.Averageabsolutepricesforfreshfruitsand

vegetablesrosebetweenfiveandsixpercentfrom1987‐2007whilepricesforsugars,sweets,

fatsandoilsrosebetweentwoandthreepercentduringthatsameperiod.8Inarecentstudy

publishedintheAmericanJournalofClinicalNutritionresearchersfoundthat$1couldbuy

1,200caloriesofpotatochips,875caloriesofsoda,250caloriesofvegetablesor170caloriesof

freshfruit.9

Compoundingthecostofhealthyfoodoptionsisaconsiderationofthetimeandeffort

necessarytopreparethem.10

o Theriseof‘fast’foods,packagedandhighlyprocessedfoodsthatareoften

highfatandlowcost

Theslowerriseinabsolutecostsofprocessedfoodsupplementssuchassugars,fatsandoils

notedabovehascontributedtotheriseinhighlyprocessed,energy‐densefoodswhichtendto

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costmuchlesspercaloriethanhealthyfoods.Inaddition,thesefoodsareoftenmore

convenientandeasilyaccessibleprovidingincentivestofamilieswithlimitedfoodbudgets,

hecticlifestyles,orlimitedaccesstoalternatives.

o Increaseingovernmentfoodsubsidiesthatsupportproductionoflowcost,

‘fast’foods

Thecurrentfoodsystemwasdevelopedwithaneyetoquantitynotquality.Federalincentives

tosupportthecurrentsystemtaketheformofdirectsubsidiesforcommoditycrops11,and

relativelyinexpensivefossilfuelsusedforfertilizer,machinery,andprocessing.Theresultisa

reductionincropvarietyandariseinlow‐costprocessedfoods.

o Anincreasinglywidespreadandcomplexfoodsystem,whichleadstogreater

packaging,transportationandenvironmentalcosts–valueaddedinputs,

decreasingtheprofitmargin,orfarmshareofthefooddollar

Inahighlyglobalizedfoodsystemitisofteneasierandmoreprofitabletoshipfoodaroundthe

worldforprocessinganddistributionthantosellfreshfoodgrownandtransportedlocally.

Thisisdue,inpart,toalackofregionaltransportationinfrastructure.

o Changesinlifestyleandurbandevelopmentthatareloweringtheratesof

physicalactivity,particularlyinlowereconomicpopulations

Activitylevelsinthepopulationatlargehavedecreased.Thesechangesaremoredramaticin

low‐incomeurbanpopulationswheretheopportunitiesforrecreationalphysicalactivityare

lessprevalent.12Changesinthebuiltenvironment13,suchasrezoningefforts,andcreativeuse

ofmoderngamingtrendsarealltoolsbeingexploredtoincreaseopportunitiesforphysical

activity.

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o Arisein‘fooddeserts,’areaswithlimitedaccesstogrocerystoresorfresh

foods

Inmanycommunitiesacrossthenation,ruralandurban,andatallincomelevels,thereareno

supermarketsorotherhealthyretailoptions.ThesecommunitiesaredefinedasFood

Deserts14.Thisisofparticularconcerninlow‐income,underservedneighborhoodswhichare

alreadymostatriskforchildhoodobesity.15Intheseneighborhoods,thelackofhealthyretail

optionsisoftencompoundedbyahighconcentrationof“fringe”retailerssuchas,gasstations,

liquorstores,bakeries,pharmaciesandconveniencestoreswhichgenerallysellhighly

processedfoodswithlongershelflifeandeasystorageoptions.

FoodDesertsareattributedtomanythings:businesspracticesofgrocerychainsthathave

determinedstorelocationsbasedonmedianincomesnotpopulationlevels;thecostsofstoring

freshhealthyfoods;and,inurbanenvironments,thecostsassociatedwithretailspace.

Lendingweighttotheargumentthatgreateraccesslessenstheriskofchildhoodobesityare

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studiesshowingthatthepresenceofasupermarketreducedtheprevalenceofoverweightand

obesemembersofthesurroundingcommunity.16

Astheaboveillustrates,theenvironmentalfactorscontributingtoobesityfallintofour

categories:affordability,access,qualityandphysicalactivity.Thefirstthreeoftheseare

directlyrelatedtothefoodsystemandaretheoutcomesofasystembuiltonincreasingthe

quantityoffoodwithoutanawarenessofthepossiblehealthconsequences.

TheFoodsystemandHealth

Someofthedirecthealthconsequencesofobesityinclude:typeIIdiabetes,arthritis,asthma,

sleepapnea,highbloodpressure,highcholesterol,gallstones,fattyliver,pseudotumorcerebri,

heartdisease,anddepression.Manyofthesetypicallyadultonsetdiseasesarenowbeingseen

inchildren.Thecostoftreatingchildhoodobesityisapproximately$14billionannually,

diabetes$150billion,obesityatlarge$147billion.17

Typically,interventionstofightobesityhavebeendoneonanindividualbasis.Eachofusmust

affectourowncalorieintake/expenditurebalancetoimproveourownhealth.However,to

effectpopulationwidechangerequiresalargerenvironmentalshift.Thefoodsystem

representsthatbroaderenvironmentalchallenge.Asasystemitiscomprisedofseveralparts–

eachactingindependentlybuthavingconsequencesallalongtheline.Initssimplestformthe

foodsystemiscomprisedofproduction,processing,transportation,retail,consumption.

Changingjustonepieceofthepuzzlewillnothavethepowertochallengethesystemof

obesity.

Tobetterunderstandtherelationshipbetweenthefoodsystemandhealthithelpstolookat

thegrowthofthemodernfoodsystem.Overthecourseofthelastcentury,theU.S.

foodsystemhasdevelopedintoanincrediblyefficientmachinecapableofadequatelyfeedinga

growingpopulation.Evenrelativelylateinthe20thCentury,between1970and2006,the

poundsoffoodavailablepercapitaincreasedby16%.18

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Overtimetherehasbeenanincreaseinyields,laborspecialization,efficiency,foodchoice,

varietyandconveniencecoupledwithadecreaseinperishabilityandtheproportionofincome

Americansspendonfood19.However,thesegainshavecomewithsubstantialnegativehealth

effectsandtheyhavecreatedtheenvironmentalproblemssupportingtheobesityepidemic–

lackofaccess,affordabilityandquality.

o Increasedyields,haveledtoincreasedcaloricconsumption‐oftenwithalowernutrient

content.ResearchersattheBiochemicalInstituteattheUniversityofTexasinAustin

studied50‐yearchangesinU.S.Dept.ofAgriculturefoodcompositiondatafor13nutrients

in43gardencrops.Theteamfounddeclinesinconcentrationsofsixnutrientsfromthe

1950sto1999.20Quality

o Advancesinprocessing,whichdecreasedperishability,ledtoincreasedconsumptionof

high‐fat,low‐cost“convenience”foods.Somesourcesshowasmuchas90%ofU.S.Farm

productionallocatedforprocessedfoodswithonly10%reachingtheconsumerfreeof

processing.21Access,quality

o Increasedlaborspecializationandconveniencedecreasedthegeneralpopulation’s

connectiontoandunderstandingoffood.Access,quality

o Increasedfoodchoiceandvariety,aswellascorporateconsolidationledtoincreased

marketingoflesshealthyprocessedfoodsandbroaderdistributionmodels.Access,quality

o Increasedsupportofcommoditycropsledtoadecreaseinagriculturallandavailablefor

otherfruitsandvegetables,decreasingsupplyandincreasingcosts.Italsochangedthe

farmingbusinessmodelforcingsmallfarmersoutofbusinessinfavoroflarge

conglomerates.ArecentTIMEarticlenotesthenumberofU.S.farmshasdecreased“from

6.8milliontofewerthan2‐million”since1935“withtheaveragefarmernowfeeding129

Americans,comparedwith19peoplein1940.”22Access,affordability

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“IfAmericansweretofullymeettherecommendationsfromthe2005Dietary

Guidelinesforfruits,vegetables,andwholegrains,weestimatetheincreased

demandwouldrequireU.S.agriculturetoharvestamaximumof7.4million

acresofadditionalcroplandperyear.This1.7‐percentincreaseisrelatively

small,giventhetotalU.S.croplandof433.5millionacresinthe2002Censusof

Agriculture.23

Justaschangingonlyonepartofthefoodsystemwillnothavetheaffectofaddressingthe

systemasawhole,addressingonlyonepartofthesystemfailurewillnotbeenoughtoeffect

population‐widechange.Addressingtheissuesofaccess,affordabilityandqualityindividually

wouldhavesomepositiveeffectbutisunlikelytostemthetideoftheobesityepidemic.

However,addressingthemcollectivelybyreworkingthenationalfoodsystemwillbuildasolid

foodinfrastructuretosupportapopulation‐widechangeinbehavior.Thisinturnwillprovidea

platformtosupporttargetedinterventionstocurbchildhoodobesityandenableprograms

aimedatpromotinghealthylifestylestobesustainable.

ResponseandRecommendations

Webelievethedevelopmentofintegrated,regional‐scalesystemsnationwide,withproduction,

transportation,processingandretailinfrastructuretosupportthem,havethepotentialto

provideaviablealternativetothecurrentfoodsystem.These“foodsheds”24wouldbesimilarto

theconceptofwatersheds,wherethemajorityoffoodforaregionwouldbeproducedwithin

thatregion.PreliminaryresearchoftheNortheastRegionsuggeststhatthereisthepotential

fortheregiontoprovideamajorityofitspopulation'sbasicfoodneeds.Tradebetweenregions

wouldprovideformorevariedfooddemands.

Suchsystemswouldseektooptimizeandmaximizeregionalproductionandcapacityforself‐

sufficiencywhileallowingforclimaticandgeographicvariabilitythatmakessomeareas

inherentlymoresuitableforcertaintypesofproductionthanothers.Thismodelwould

increaseaccessbyincreasingregionalsupplyandretailoutlets,affordabilitybydramatically

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decreasingproduction,processingandtransportationcostsandimprovequalitybydecreasing

thedistancefromfarmtoplatelesseningtheneedforlongshelf‐life,processedfoodsbetter

suitedtotravelinglongdistances.

Suggestedcomponentsofthismodelcreateatieredstructurewithineachregion.

RegionalFoodshedModel–Theoverarchingconceptwhichincludesnewbusinessmodels

linkingproduction,processing,transportation,retail,consumereducationandhealthoutcomes

withinagivenregion.

1. CooperativeFoodTerminals‐anchoredbyaNationalChainretailer,theseFoodTerminals

wouldincorporategreenmarkets,healthypreparedfoods,financialandhealtheducation

andlocalproductionatonelocation.

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2. MobileMarkets‐thesemobileunitswouldbringgoodsandservicesdirectlyto

communities.

3. 10x10andLawntoFarm–educationprogramsaimedatteachingthevalueoffood‐

economically,environmentallyandpractically.Theyalsoincreaseawarenessofregional

identities,productioncapacitiesandclimate,andtheaffectoffoodonpersonalhealth.

4. HealthyFoodIndex–thisindexwillservetomeasuretheimpactofregionalchangestothe

foodsystemintermsofaccess,affordability,consumptionhabitsandhealth.Bymeasuring

impactregionally,theHFIwillbeabletoquantifyeffectivemeasuresincentivizing

replicationandpolicychange.

Inordertoimplementsuchasystemitisvitalthatindustry,government,agricultureexperts,

farmers,academicsandhealthprofessionalsworktogethertobuildviablemodelsand

measuresofhealthoutcomes.TheColumbia/MITteamhasspentthepastseveralmonths

buildingthefoundationofsuchrelationships.Mostexciting,perhaps,isthebuy‐inand

enthusiasmofmanyofthemajorfoodretailandproductionleaders.

Finally,theRegionalFoodshedmodelhaspositiveimplicationsinotherareassuchasfood

security–ensuringthatregionsareself‐sufficient,andtheeconomy–recovering“farm‐share”

oftheagriculturaldollarbydecreasingvalue‐addedinputs,providingjobs,reclaimingunused

landandmakingfarmingaviablebusinessopportunity.

Ultimately,however,thegoalistoimprovethehealthofchildrenandfamiliesnationwide.

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1LeibelRL,RosenbaumL,HirschJ.Changesinenergyexpenditureresultingfromalteredbodyweight.NewEnglandJournalofMedicine.1995;332(10):621‐628.2StrokePathwaysProjectdonebytheCollaborativeandProfessorMarcoSteinbergattheHarvardGraduateSchoolofDesign.strokepathways.org3PaulaA.Johnson,M.D.,ExecutiveDirector,ConnorsCenterforWomen’sHealthandGenderBiologyandChiefoftheDivisionofWomen’sHealthatBrighamandWomen’sHospital;RearAdmiralKennethMoritsugu,M.D.,M.P.H.FormerActingSurgeonGeneral;MichaelPorter,Professor,HarvardBusinessSchool;GeorgeRabstejnek,ChairofCenterforTechnologyCommercialization,ViceChairmanoftheMassachusettsEyeandEarInfirmary;AlfredSommer,ProfessorofEpidemiologyandInternationalHealthandDeanEmeritus,JohnsHopkinsUniversityBloombergSchoolofPublicHealth;RoxanneSpillett,President,BoysandGirlsClubofAmerica;TheHonorableLouisSullivan,M.D.,Chairman,TheNationalHealthMuseumandPresidentEmeritus,MorehouseSchoolofMedicine;JimTallon,PresidentofUnitedHospitalFund;MarcoSteinberg,AssociateProfessor,HarvardUniversity,GraduateSchoolofDesign8CDCNHANESdata.Retrievedfrom:http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_adult_03.htm5Halweil,B.StillNoFreeLunch:NutrientlevelsinU.S.foodsupplyerodedbypursuitofhighyields.TheOrganicCenterCriticalIssueReport,September2007.6CutlerDM,GlaeserELandShapiroJM.WhyHaveAmericansBecomeMoreObese?JournalofEconomicPerspectives:v17,No3,Summer2003.7FrenchSA,StoryM,andJefferyRW.EnvironmentalInfluencesonEatingandPhysicalActivity.AnnualReviewofPublicHealth,Vol.22:309‐335,May2001.CumminsS,MacintyreS.Foodenvironmentsandobesity—neighborhoodornation?InternationalJournalofEpidemiologyVolume35,Number1February2006.HayneCL,MoranPAandFordMM.RegulatingEnvironmentstoReduceObesity.JournalofPublicHealthPolicy,Vol.25,No.3/4(2004),pp.391‐407.DrewnowskiA,RehmCD,andSoletD.Disparitiesinobesityrates:AnalysisbyZIPcodearea.SocialScience&Medicine.2007December;65(12):24588LeibtagE.“CornPricesNearRecordHigh,ButWhatAboutFoodCosts?”AmberWaves,Vol.6,No.1,USDAEconomicResearchService,February2008.9DrewnowskiAandSpecterSE.Povertyandobesity:theroleofenergydensityandenergycosts.AmericanJournalofClinicalNutrition,Vol.79,No.1,6‐16,January2004.10BitlerMandHaiderSJ.AnEconomicViewofFoodDesertsintheUnitedStates.PreparedfortheJanuary23,2009,NationalPovertyCenter/UnitedStatesDepartmentofAgriculture‐EconomicResearchService(USDA‐ERS)conference“UnderstandingtheEconomicConceptsandCharacteristicsofFoodAccess.”

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11Therearefivecropsthatreceivedirectfederalcommoditysupport(subsidies)fromtheUSDA:corn,soybeans,cotton,rice,andwheat.Theoverallregulatoryenvironment,(whichincludessuchthingsasaprohibitionontheproductionoffruitsandvegetablesonlandthathasbeenreceivingsubsidiesforcommoditycrops)disincentivizestheproductionofhealthyfoods.12IHYenandGAKaplan.“Povertyarearesidenceandchangesinphysicalactivitylevel:evidencefromtheAlamedaCountyStudy.”AmericanJournalofPublicHealth,Vol.88,Issue111709‐1712,1998.13Thehuman‐madephysicalenvironment14PublicLaw110‐246,June18,2008,122Stat.pg.2039.TheFood,Conservation,andEnergyActof2008(2008FarmBill),TitleVI,Sect.7537subsectiona,pg.2039:“DEFINITIONOFFOODDESERT.–Inthissection,theterm“fooddesert”meansanareaintheUnitedStateswithlimitedaccesstoaffordableandnutritiousfood,particularlysuchanareacomposedofpredominantlylower‐incomeneighborhoodsandcommunities.”15GallagherM.ExaminingtheImpactofFoodDesertsonPublicHealthinChicago.MariGallagherResearchandConsultingGroup2006.BlanchardTC,LysonTA.RetailConcentration,FoodDeserts,andFoodDisadvantagedCommunitiesinRuralAmerica.FromRemakingtheNorthAmericanFoodSystem:StrategiesforSustainability(HinrichsCC,LysonTA,eds.)UniversityofNebraskaPress,2008.16CumminsC,MacintyreS.Foodenvironmentsandobesity–neighborhoodornation?InternationalJournalofEpidemiology2006;35:100‐104.17Thesefiguresarefromdifferentstudiesusingdifferentmethodologiesandarethereforenotcomparative.ChildhoodObesity:Costs,TreatmentPatterns,DisparitiesinCare,andPrevalentMedicalConditions.ThomsonMedstatResearchBrief,2006.http://www.medstat.com/pdfs/childhood_obesity.pdf.AmericanDiabetesAssociation,EconomicCostsofDiabetesintheU.S.in2007DiabetesCareMarch200831:596‐615;doi:10.2337/dc08‐9017Finkelstein,EA,Trogdon,JG,Cohen,TJ,Dietz,WH.Annualmedicalspendingattributabletoobesity:payer‐andservice‐specificestimates.HealthAffairs[serialonline],2009Jul.Availableathttp://content.healthaffairs.org/index.dtl.18USDA,EconomicResearchService.“ERSFoodAvailability(PerCapita)DataSystem,”2008,www.ers.usda.gov/data/foodconsumption/.19USDA,EconomicResearchService.“FoodCPIandExpendituresBriefingRoom,”www.ers.usda.gov/briefing/cpifoodandexpenditures/20Includesa6percentdeclineforprotein,a16percentdeclineforcalcium,a9percentdeclineforphosphorus,a15percentdeclineforiron,a38percentdeclineforriboflavin,anda20percentdeclineforvitaminC.Theteamdidn’tfindanynutrientsthatincreasedinthelast50years,althoughthiaminandniacinbarelychanged.

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DavisDRetal.,ChangesinUSDAFoodCompositionDatafor43GardenCrops,1950to1999,JournaloftheAmericanCollegeofNutrition,Vol.23,No.6,2004,pp.669‐682.21Martinez,SteveW.TheU.S.FoodMarketingSystem:RecentDevelopments,1997‐2006,ERR‐42.U.S.Dept.ofAgriculture,Econ.Res.Serv.May2007.22WalshB.GettingRealAbouttheHighPriceofCheapFood.TIMEinconjunctionwithCNN;August21,2009[Internet]www.time.com23 Buzby JC. Possible implications for U.S. agriculture from adoption of select dietary guidelines. Economic Research Report No. 31, U.S. Department of Agriculture, Economic Research Service, November 2006. 24 We acknowledge Fred Kirschenmann; Distinguished Fellow, Leopold Center for Sustainable Agriculture; President, Stone Barns Center for Food and Agriculture, who brought the Foodshed concept to our attention.

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