When Michelle Obama and Mike Huckabee sat down for a gracious talk last February on Huckabee’s Fox News show, the unlikely couple chatted about the Healthy Food Financing Initiative, a proposed federal program to bring more fresh fruits and vegetables to low-income neighborhoods. Obama had just unveiled the program in Philadelphia, and visited The Fresh Grocer, a new supermarket in North Philly. The initiative is meant to combat obesity, a problem close to the heart of Huckabee, the former Arkansas governor and presidential candidate who lost more than 100 pounds after he was diagnosed with Type 2 diabetes in 2003.

A lack of access to healthy, fresh food affects the health of poor people, Obama explained. Neighborhoods like the one she visited in North Philly last winter are food deserts, she said, defined as areas without a grocery store within one mile. The supermarket Obama visited, opened with assistance from a state food financing program, was the first supermarket in that shopping center in 10 years.

“So that means that if a mom in that area wanted to make a salad for their kid, even if she was geared up to do it, that means she would have to get in a cab, take a bus, get on a train to get to a grocery store to do that,” Obama said. “Think of families that are busy, they don’t have resources, they just don’t do it.”

At a time when obesity is overtaking smoking as the leading cause of preventable illness in the United States, healthy food financing initiatives seem like a reasonable solution to a difficult problem. About 35 percent of people with incomes of less than $15,000 struggle with obesity, compared to 24 percent of people with incomes above $50,000. Access to fresh food in poor neighborhoods, Obama and other fresh food financing advocates say, could set a generation of low-income kids on the path to good health.

Some recent research, however, suggests that building more grocery stores might not be the answer that Obama and other advocates are hoping for. That research is challenging the connection between access to healthy food and high obesity rates in poor neighborhoods, and questioning the very existence of food deserts. The true drivers of the tie between poverty and obesity, it may turn out, are far more complicated than the location of the nearest market selling fresh fruits and vegetables and other healthy foods.

A study published in the Archives of Internal Medicine last month, for instance, questions whether easier access to grocery stores actually leads to healthier diets. The Archives study collected data on more than 5,000 subjects in Oakland, Chicago, Birmingham and Minneapolis over 15 years. “Supermarket and grocery store availability,” the study found, “were generally unrelated to diet.”

Supporters of fresh food financing, however, say that improving access to fresh, healthy food is a crucial step in improving the health of poor neighborhoods. “Yes, of course, there are other steps that are needed to even increase that consumption more,” said Judith Bell of Policy Link, the advocacy group that successfully presented the idea of a national fresh food financing initiative to the Obama administration. “But because of the pent-up demand,” Bell said, “changing access will change eating habits.”

The fresh food financing model is increasingly popular. The federal program that Obama is championing is modeled after the Fresh Food Financing Initiative, a Pennsylvania program launched statewide in 2004. Obama’s proposed program would give $400 million in grants and loans to encourage stores in low-income areas that offer fresh fruits and vegetables. Several states recently started their own version of the program.

In California, Assembly Speaker John Perez is currently sponsoring AB 851, a bill to eliminate food deserts that also positions the state for federal funds if the Healthy Food Financing Initiative is included in the federal budget. The California Fresh Works Fund, a pot of $200 million of mostly private funds to encourage more sources of healthy foods in low-income areas, launched in July. The project will finance new food stores and encourage innovations like mobile vending, or “veggie carts,” said Marion Standish, the director of community health for The California Endowment, the foundation that spearheaded the Fund.

Such measures assume a deep connection between neighborhood – roughly defined as a mile from where you live – and health. “Where you live matters,” Bell said, “in terms of your health and your quality of life.”

Supermarkets, sickness and poor city neighborhoods

Living in the kind of poverty that now plagues North Philadelphia and other inner city neighborhoods across the U.S. does take a noticeable toll on residents’ health. One third of adults and children who live in the neighborhood around The Fresh Grocer, the store Michelle Obama visited, are obese. And obesity is just one of their challenges. The area also has the highest rates of asthma and mental illness in the city, and the leading cause of death for people aged 15-24 is homicide. Heart disease is the leading cause of death in adults over age 24, followed by cancer. These are the same diseases that kill most Americans, but poor people across the country, and particularly African Americans, suffer from them in higher numbers.

Stress is a possible explanation for the health inequity, researchers say. “The trauma is constant,” said Bob Prentice, the director of the Bay Area Regional Health Inequities Initiative. People do manage to live with the unthinkable – violence, uncertain housing and employment – but it takes a toll. “What does it mean to live with that? I mean how do you carry that, how do you get through day to day?” Prentice asked. “Well, you do. But you pay a price. You’ve got a level of stress that the people who go to golf clubs and tennis clubs and drive BMWs don’t have.”

No matter how healthy their habits, poor people – especially poor black people – have worse health than people with more money. Infant mortality is a classic example of how race and class affect disease and mortality rates, said health disparity expert Helen Lee, the associate director of the Public Policy Institute of California. African American babies die almost two and a half times more often than white babies. A mother who smokes is the strongest predictor of infant mortality, so this disparity would make sense if African American mothers were heavier smokers than white mothers. But they aren’t.

“African American women do not smoke more than white women,” Lee said. “In fact, in some studies, they smoke at lower rates.” Perhaps it is the stress that Prentice described that leads to poorer health, but measuring the impact of stress on health is a difficult undertaking. The reasons for health disparities remain amorphous, so much so that the New York Times Magazine, in an article on disparities, coined a term for the higher rates of illness among the urban poor: ghetto miasma.

The goals of The Food Trust, the organization that spearheaded the drive to bring The Fresh Grocer to North Philly, suggest a clearer connection between place and health than the term ghetto miasma implies. Supermarkets, they say, are the kind of development needed to revive the health of people living in poor urban areas. Philadelphia had the lowest per-capita rate for access to supermarkets in the U.S. before the fresh food initiative, according to the Trust’s deputy director, John Weidman. Their survey of low-access areas also revealed what they saw as a disturbing connection. “We noticed that the same areas that had no supermarkets,” Weidman said, “also had higher rates of diabetes.”

The task force findings resulted in state legislation aimed at wooing grocery stores to low-income areas with financing assistance, low-interest loans and grants, giving birth to the Fresh Food Financing Initiative. The state invested $30 million in the project. “It was just a huge success,” Weidman said. Since the program was launched in 2004, more than 80 stores have opened, from full service grocery stores to mom and pops.

The healthy benefits of a readily available supply of fresh produce are clear, Weidman said, though the impact of the store on the neighborhood has yet to be formally evaluated. If the newly opened Philadelphia stores weren’t there, Weidman said, “People would have to drive or go to the corner store and get unhealthier stuff.” These kinds of connections are, according to Weidman, “just common sense.”

“There is a logic to it too,” Bell of Policy Link said. “If you are at home, and you need to eat, it is probably more likely that you are going to eat an unhealthy diet if it is all that is available in your neighborhood, versus if you have a plethora or some choices between unhealthy and healthy food.”

Bell also pointed to studies that suggest that people do change eating habits for the better once a grocery store is introduced. “If you put a grocery store in a neighborhood,” Bell said, referring to a recent study, “African Americans’ consumption of fruits and vegetables will increase by 30 percent.”

That kind of an improvement in diet is a starting place for preventing the illnesses that the poor suffer from in disproportionate numbers, such as diabetes and heart disease, fresh food financing advocates say. “Chronic disease,” Standish said, “creates a tremendous burden.” Treating the illnesses after they occur, she added, is not enough.

Re-thinking food deserts

Most public health experts have embraced this notion that place and health are intimately related. Some experts do wonder, however, if easier access to fruits and vegetables can reverse the significant health problems, such as high rates of obesity, that disproportionately affect the poor.

Although the concept of food deserts has recently taken off as an explanation for obesity, the idea has been around for about two decades. Politicians introduced the concept in the United Kingdom in the early 1990s. The term was coined after preliminary studies suggested a link might exist between distance to a grocery store and the diets of poor people. But that connection was later found to be incorrect by British researchers, who discovered that poor neighborhoods actually have more – not fewer – grocery stores than wealthier neighborhoods.

Mario Small, a sociologist at the University of Chicago, found similar results in the U.S. Small’s recent study of 331 American cities found that overall, poor neighborhoods do have shops and other amenities that are comparable to well-off neighborhoods. While the 10 largest American cities have 1.86 fewer large grocery stores in poor neighborhoods than in higher income areas, they also typically have better public transportation options than smaller cities, Small said. Large American cities also have a higher number of small grocery stores – that’s grocery stores with less than 100 employees, distinct from convenience stores – than the average American city.

“It is certainly not the case that in most American cities, poorer neighborhoods are more deprived of these amenities than not-poor neighborhoods,” Small said.

The USDA’s own findings support these conclusions. The agency’s report to Congress on food deserts, presented in 2009, found that only about 2.3 percent of households in America lived more than a mile from a supermarket and didn’t have a car. On average, low-income people live .1 miles closer to a supermarket than people who are not low income. Overall, ethnic and racial minorities have better access to supermarkets than white people, according to the USDA.

Also, Helen Lee notes, transportation isn’t necessarily a barrier to shopping in the way that the food desert theory assumes. Low-income people, studies suggest, will often bypass the closest grocery store to drive or carpool to a supercenter or discount store such as Wal-Mart, where they tend to spend most of their food budget. Researchers in Seattle found that people frequently bypass a closer grocery store and travel to the one they perceive as a good match for their budget.

Despite such research, the connection between access and obesity was listed as a major conclusion, without caveats, in the newly revised Dietary Guidelines for Americans, published by the USDA in January 2011. Joanne Slavin, professor of Food Science and Nutrition at the University of Minnesota, helped to develop the guidelines as a member of the advisory committee, which reviews the most recent findings and changes the guidelines to incorporate this new information. But Slavin is blunt in her evaluation of the connection between diet and access to grocery stores. “As far as the data goes,” she said, “it’s really not out there.”

Policy Link and The Food Trust did compile an overview of 58 peer-reviewed reports about food access and dietary quality, including the study about African Americans and vegetable consumption that Bell cited. Most of the research they listed suggested either that food choices may be more limited in poorer neighborhoods compared to middle-income areas, or suggested that the quality of fresh produce might be lower in low-income areas, or that low-income neighborhoods may have fewer grocery stores than high income neighborhoods. Some of these studies also indicated no connection between access and choices about diet, did not show fewer grocery stores in low-income areas, and did not show poorer quality of food in poorer neighborhoods. None of these studies closely tracked the connection between proximity to grocery stores and diet choices over time the way the Archives study did. They were mostly examinations of individual cities, rather than national studies such as Small’s and the USDA.

Obesity is a complicated problem. It defies easy remedies, and affects 24 percent of well-off people who have excellent access to supermarkets. The toll of poverty on health, as experts suggest, is another issue we have yet to fully understand. A closer look at what supermarkets sell provides some clues as to why building more of them might not be the panacea for low-income communities that fresh food advocates are hoping for. Supermarkets do supply healthy food, but they also sell the high-calorie processed foods that are a staple of the American diet. Our food landscape, including the grocery store, is filled with choices, good and bad, that all Americans grapple with, said Penny Gordon-Larsen, associate professor of nutrition at the University of North Carolina, Chapel Hill, and lead researchers on the Archives study. “You can’t just build something,” she said, “and say that will solve the problem.”

An elitist approach to public health?

So what’s causing the disparity, if the problem isn’t access? Studies suggest that poor people and wealthy people, when faced with the same variety of foods, will make different choices about what they eat. The Seattle Obesity Study, helmed by University of Washington epidemiologist Adam Drewnowski, revealed a connection between food choices and income.

“We were stunned by that result,” Drewnowski said.

Shoppers in Seattle chose their grocery stores based not on how close they were to their house but on their income, the study found. Poor people overwhelmingly shop at supermarkets—like 97 percent of people in Seattle do—and will pass up the closest grocery store to shop at the supermarket that matches their socioeconomic status. More affluent shoppers gravitate towards Whole Foods and Trader Joes, while poorer people shop at Albertsons and Safeway, but each of these stores offered shoppers fresh produce and other healthy choices.

Despite the similarity of choices, the differences in obesity rates between the stores’ shoppers were alarming. Five percent of Whole Foods shoppers were obese, compared to 25 percent of Safeway shoppers and 35 percent of Albertson’s shoppers. Shoppers had similar access to supermarkets. The supermarkets offered healthy selections. But people made very different choices in each store. That’s because income and education levels determine not just where, but how people shop, the Seattle Obesity Study suggests. Those choices are driven by time and money.

Advice to poor people to buy more fruits and vegetables is beyond impractical, Drewnowski said – it’s an elitist approach to public health. “Eating local is very nice and eating fresh is very nice,” Drewnowski said. But regular trips to the grocery store to purchase and cook with fresh produce just isn’t a possibility for most low-income people, he added. Fresh produce is among the most expensive items in the store, and working poor people have little of the leisure time required to cook from scratch.

In other words, why poor people weigh more than the rest of the population is a much more complicated question than the push for supermarket access may suggest. More supermarkets might be good for areas that have absolutely nothing in the way of a grocery store, Drewnowski said. Perhaps Detroit is a food desert, and perhaps New Orleans was in the wake of Hurricane Katrina. But most cities, Drewnowski said, are not like Detroit.

Though food choices are rooted in motivations more complex than how much money people make, financial resources are a factor in higher obesity rates in poor people. Low-income people have to stretch a dollar in the grocery store in a way middle-income families don’t. Usually, they try to get long-lasting food that their kids will eat, according to Helen Lee. Low-income families steer away from the cheap fruits and vegetables they can afford, like cabbage, lettuce and bananas.

“Every purchase has to matter,” Lee said, “in a way that it doesn’t have to matter for people with more resources who can say, the food went bad, let’s just throw it away.”

But low-income people also have different priorities, and health doesn’t necessarily make the top three: typically, food, shelter and employment. Because most food is cheap, that need is usually met, Lee said, and government programs for food assistance are in place for people who need help to stave off hunger. Shelter and employment needs, however, are harder to meet consistently. Maybe if jobs and housing were easier to find, health would be more of a priority, according to Lee. But if you’re at an unhealthy weight and about to get kicked out of your house, you’ll inevitably worry about your short-term need for shelter before you think about long-term needs like diet and exercise. The short-term problem is compounded by the often stealth relationship between weight and health. High blood pressure and pre-diabetes blood sugar levels don’t necessarily make you feel sick.

We are constantly making choices about how we eat, whether we are in a supermarket or in a McDonalds. Americans are surrounded, Lee noted, by a vast variety of cheap food that has been processed to taste irresistibly good. Food science transformed the bounty from America’s cornfields into food that hits what former Surgeon General David Kessler calls “bliss points,” ideal combinations of fat and sugar, or fat and salt, or even fat, sugar and salt. Every time we encounter such temptation, we decide: do we eat it or not? People with more money ask themselves this question in the context of a long-term view of health, Lee said. Poor people, however, don’t always have the luxury of that perspective.

To researchers like Drewnowski, this raises the question: can more grocery stores and better individual choices really reduce big health disparities like the obesity gap? “People prefer to look at preferences and choices as opposed to tough economic issues like wages and employment,” Drewnowski said. “We have this idea of unlimited free choice. Not all of us have the same choice.”

To advocates like Judith Bell, the question is also one of parity, but from a slightly different perspective. Market research shows, Bell said, that low-income neighborhoods can support sparkling new grocery stores – the kind that spring up in the suburbs on a regular basis – with a little extra incentive for owners to locate there. So why shouldn’t they have one? “Access to healthy food, yes, it is about obesity,” Bell said. “But it is also about social and economic equity.”

“What we are trying to do,” the California Endowment’s Marion Standish said, “is level the playing field.”

A fellowship from the Kaiser Permanente Institute for Health Policy helped to fund the reporting of this story, and the California Endowment is a funder of www.calhealthreport.org