From The Field S E P T E M B E R 1 9 , 2 0 1 1 Disparities in Food Access and in Opportunities for Physical Activity ALLISON F. BAUER, J.D., M.S.W. Senior Program Officer, The Boston Foundation I n Massachusetts, about one-third of all children aged 10- populations are disproportionately affected. As one study 17 and 58 percent of residents of all ages are either summarized, “Health, disease, and death are not randomly overweight or obese (MPHA 2011; CDC 2011). Obesity distributed…illness concentrates among low-income people is a risk factor for numerous preventable chronic diseases, from and people of color residing in certain geographical places” type 2 diabetes to heart disease, stroke, and some cancers. (Beyers et al. 2008). Type 2 diabetes, once almost unheard of among children, now According to the Boston Public Health Commission’s represents a significant portion of all diabetes reported in the annual Health of Boston report, in 2008, lower-income Boston state. Overall, diabetes has jumped by nearly 40 percent in just residents (having household incomes of $25,000 or less) a decade (CDC 2011). How has this happened and who is it reported higher rates of asthma, diabetes, heart disease, high happening to? This article discusses the causes for the rising blood pressure, and obesity compared to higher-income resi- tide of preventable chronic disease, not only in Massachusetts dents. Roxbury, North Dorchester, and South Dorchester but across the country. It also highlights some of the key fac- were three of the five neighborhoods with the highest annual tors that have produced this change and the parts of the heart disease hospitalization rate. Obesity disproportionately population that are often more affected. affects blacks – 32 percent of black adults are obese, compared to just 17 percent of whites (Boston Public Health MASSACHUSETTS: HEALTH ACCESS AND Commission 2010). In 2009 a higher percentage of black and OUTCOMES Latino high school students were overweight in comparison to white students (CDC 2009). Roxbury, Dorchester, and Massachusetts leads the nation when it comes to access to another neighborhood with a high concentration of low- health care, and health reform in the state effectively increased income residents, Mattapan, are also home to more fast food access to health care and reduced disparities. Three years after restaurants per capita than all other Boston neighborhoods it was enacted in 2006, Massachusetts health reform was asso- combined (Boston Public Health Commission 2010). These ciated with a 7.6 percent increase in health insurance among geographic and environmental realities clearly have an impact residents – a 4.8 percent decrease in those foregoing health on disparate health outcomes. care due to cost and a 6.6 percent increase in residents having a primary care physician (Massachusetts Division of Health ACCESS AND AFFORDABILITY OF HEALTHY Care Finance and Policy 2010). But while access to care is FOOD critical to screening and responding to illness and injury, no amount of care can substitute for healthy behaviors. Lifestyle A 2010 report by The Food Trust found that Massachusetts is and environmental factors account for almost 70 percent of the third worst state in the nation for food deserts, defined as the average person’s health, yet only 4 percent of national areas where healthy and affordable food is difficult to obtain. health expenditures are focused on healthy behaviors (NEHI This lack of access is true in rural and urban areas, and particu- 2007). Additionally, there is great disparity in the environ- larly prevalent in communities that have low socioeconomic mental, physical, and socioeconomic factors that influence status and are populated primarily by people of color. The same health by neighborhood, often with those who are predomi- report found that Massachusetts has fewer supermarkets per nantly low-income or minority having limited access to the capita than any other state. The lack of access often means that families will sacrifice quality for the convenience of food that is very social determinants that permit healthy choices. available at the local corner store. The lack of competition also drives up prices, making healthy options unaffordable. BOSTON HEALTH DATA: A PICTURE OF Farmers markets are one way to help bring healthy food into DISPARITIES low-income and minority communities, and with the option The obesity epidemic affects all races and ethnicities, but some of using the Supplemental Nutrition Assistance Program (SNAP) benefits with electronic benefit cards, the food is most effective tool to address these issues over the long term more affordable. However, less than 25 percent of the mar- and on a large scale. States must make daily physical activity in kets in the state participate in this program. schools mandatory; not give sugar-sweetened beverages prefer- ential tax treatment; ban the use of trans fats; engage in health OPPORTUNITIES FOR PHYSICAL ACTIVITY impact assessments in communities; increase funding for effective public health programs; and generally engage the The health benefits of physical activity are well-documented, population in a public health campaign similar to those waged yet less than 25 percent of Americans get the recommended to stop smoking and encourage the use of seatbelts. These are amount (CDC 1999). In addition, there is recent recognition part of The Boston Foundation’s Healthy People Healthy of the impact of various environmental factors on active living Economy Initiative, a coalition to make Massachusetts the – including both the social environment and the built envi- preeminent state in the country for health and wellness, build- ronment. Socioeconomics, the condition of sidewalks, and ing on the successful Mass in Motion state initiative that aims safety all contribute to creating environments that are either to promote wellness and prevent overweight and obesity in supportive of activity or not. If there are no convenient green Massachusetts, with a particular focus on the importance of spaces, parks, athletic fields, or opportunities for walking or healthy eating and physical activity. biking, it is harder for individuals to make the choice to This type of multisector, multifield effort with an equity lens engage in physical activity. Also, neighborhoods that have the targeting those most at risk and least supported in making highest levels of violence are the very same neighborhoods healthy choices is the only way to successfully address health with higher rates of chronic disease. This is not a coincidence. disparities in health outcomes, particularly those related to Additionally, in recent years we have lost the utilization of preventable chronic disease. schools as a venue for children to be active, both in their commute to and from school, as well as in the absence of recess and physical education. In 1969 half of all school chil- dren either rode their bikes or walked to school, but that SOURCES percentage has dropped to fewer than 15 percent (Safe Routes to School National Partnership 2011). Also, a majority of Beyers, M., J. Brown, S. Cho, et al., Life and Death from Unnatural students attend schools with no physical education. A 2010 Causes: Health and Social Inequity in Alameda County (Oakland, CA: study by the Trust for America’s Health found that Alameda County Public Health Department, August 2008). Massachusetts had the worst score in the country in a study Boston Public Health Commission, Health of Boston 2010, of physical activity among high school students. Only 17 <http://www.bphc.org/about/research/hob2010/Pages/Home.aspx>, 2010. percent in the state reported being physically active 60 min- utes or more every day (Trust for America’s Health 2010). Centers for Disease Control and Prevention (CDC), Behavioral Risk Factor Surveillance System, “Prevalence and Trends Data, Massachusetts ENCOURAGING HEALTHY BEHAVIORS – 2010, Overweight and Obesity (BMI),”<http://apps.nccd.cdc.gov/brfss/ display.asp?cat=OB&yr=2010&qkey=4409&state=MA>, accessed 2011. What must be done in order to make the healthy choice the easier choice, especially in communities most affected by Centers for Disease Control and Prevention (CDC), Physical Activity and Health: A Report of the Surgeon General, <http://www.cdc.gov/nccdphp/ overweight, obesity, and diet-related chronic diseases? The sgr/index.htm>, 1999. answer is not simple – and it requires a multisector approach. One encouraging program is Boston Bounty Bucks. The Centers for Disease Control and Prevention (CDC), “Youth Risk Food Project, a local nonprofit, and the City of Boston spon- Behavior Surveillance System – 2009” <http://www.cdc.gov/ sor this program, which has dual goals: to enable all residents HealthyYouth/yrbs/index.htm>, 2009. of Boston to have access to the local bounty of farm products The Food Trust, Food for Every Child: The Need for More Supermarkets in available at city farmers markets and to strengthen the econ- Massachusetts, <http://www.thefoodtrust.org/pdf/FoodForEvery omy of local farmers. More than 82,000 Boston residents that Child—MA.pdf>, December 2010. participate in SNAP can use their benefits at over 20 partici- pating farmers markets. All purchases made with SNAP Massachusetts Division of Health Care Finance and Policy, Health benefits are matched up to $10, meaning that SNAP users at Insurance Coverage in Massachusetts: Results from the 2008-2010 farmers markets can get their food at 50 percent off up $20. Massachusetts Health Insurance Surveys, <http://www.mass.gov/Eeohhs2/ In the area of physical activity, there are some best practice docs/dhcfp/r/pubs/10/mhis_report_12-2010.pdf>, December 2010. programs that help fill the gaps left by a lack of formal physi- Massachusetts Public Health Association (MPHA), “Childhood Obesity,” cal education in schools and community-level activity. <http://www.mphaweb.org/issues_childobesity.htm>, accessed 2011. Playworks is a national best practice model that started in Oakland, California. This year, 86 percent of Boston’s ele- New England Healthcare Institute (NEHI), The Boston Paradox: Lots of mentary and K-8 schools will experience a positive recess Health Care, Not Enough Health, <http://www.nehi.net/publications/22/ environment with Playworks delivering direct service pro- the_boston_paradox_lots_of_health_care_not_enough_health>, June 2007. grams to 30 schools and recess implementation for 34 Safe Routes to School National Partnership, “Quick Facts,” <http://www. schools. saferoutespartnership.org/mediacenter/quickfacts>, accessed 2011. These programs are a great way to shape local changes in high-need areas, but statewide policy change is the best and Trust for America’s Health, F as in Fat: How Obesity Threatens America’s Future (Washington, DC: June 2010).