2008 Shiriki Kumanyika Award for Public Health Leadership

Healthy Food as a Human Right

 By Joanna Holsten

Our world is fraught with nutritional challenges ranging from overweight and obesity to stunting and wasting. Vulnerable populations, including the young and the poor, suffer disproportionately from these challenges. My work centers on the challenge of childhood obesity in the United States, but recently grew to include the escalating nutrition transition in developing nations. From food deserts in North Philadelphia to agricultural difficulties in North West Cameroon, I have learned so much about public health nutrition, but most fundamentally, I have come to believe that healthy food access is a human right. Entrenched in social, cultural, economic, and political complexities this an arduous decree, but one that guides my work.  My vision is to ensure that individuals are informed of and have equitable access to nutritious foods needed to lead healthy and productive lives.

My clinical, research, and advocacy experiences have demonstrated steps taken to reach my goals and continued to help my vision evolve. While obtaining my bachelors degree in nursing, I gained clinical experience with diverse populations. As a nursing student, I worked in many acute care settings from a post-operative cardiac unit in Oxford, England to a bariatric surgery center in Philadelphia. I also studied in community settings, gaining an understanding of primary care and community health. My first in-depth encounter with disparities in the food environment came during a community assessment around the Broad Street Health Center in North Philadelphia. My eyes were opened to a world of inequity. As I searched for a supermarket in a sea of corner stores, I grappled with the reasons for this structural injustice. My vision began to take shape. Working with patients struggling with obesity and related comorbidities in all of these settings, I became frustrated with the low priority of prevention efforts and the under-recognized disparities in food access. My frustration with the lack of preventative efforts directed me towards a career of public health nursing research.

In my graduate education, I continued to explore the underlying causes of the obesity epidemic. I recognized the need to account for the multidimensional context of dietary decisions extending from intrapersonal factors to public policy. I became focused on understanding the role of the food environment and its effect on weight and nutritional status of individuals, especially children. The food environment involves sources of calories and nutrients and the circumstances surrounding their procurement, such as accessibility, price, and promotion of foods. Our toxic food environment and the circumstances maintaining it threaten the rights of individuals to achieve healthy food access. Understanding the effect of the environment and the reasons behind this structural injustice will help ensure equitable access to nutritious foods for all. With the guidance of many experts in the field of obesity and health research, I started my own research and advocacy efforts to understand the food environment and nutrition disparities.

My first independent investigation of these matters consisted of a qualitative investigation of the food environments in elementary school catchment areas of varying poverty levels in Philadelphia. I documented food items, food outlets, and promotional signage during an environmental assessment using field notes, photography, and a Global Positioning Device. The observations were compared across areas to identify risk factors for unhealthy dietary patterns and childhood obesity. The lowest poverty area had the most food outlets with the majority consisting of sit-down restaurants and specialty shops compared to the mid and high poverty areas, which had fewer outlets and mostly small corner stores. The mid and high poverty areas had more advertisements for energy-dense and processed foods than the low poverty area. Through this preliminary work I was able to formally illustrate the disparity that provoked my vision as a young nursing student. This work pushed me to explore further.

In order to more clearly understand the relationship between risk factors in the food environment and weight and nutritional status, I designed a cross-sectional study to examine their association for my dissertation work. The diffuse and underdeveloped base of research on the food environment of children prohibits health organizations from offering firm recommendations for a lasting solution to the obesity epidmeic. This study will help fill the gaps in knowledge by investigating the relationship between the consumer and home food environments and the body mass index of middle school children. By quantifiably measuring the availability, price, quality, and promotion of foods in stores, restaurants, and homes this study can elucidate the relationship between these factors and the health of children. Understanding this relationship will help direct future research and interventions to address the nutirtional disparities in our communities.

The evolution of my vision has not been linear. Certain experiences in my life have caused me to leap forward. During the summer of 2007, I took such a leap. I traveled to rural Cameroon, West Africa. I studied the paradox of over- and under-nutrition. With the help of community members, I carried out a qualitative assessment of individuals’ practices, perceptions, and knowledge, interpersonal interactions, and organizational influences on diet and health. I conducted focus groups with women, interviews with farmers and food sellers, and performed market surveys in seven villages in the North West Province of the country. I saw the food environment through a completely different lens. This experience opened my mind to a new world of nutrition disparities and further crystallized my vision. Through this experience, I articulated a theme that connected rural African villages and US cities; the idea that healthy food is a human right.

I returned to my work on obesity and the food environment with a global perspective, but remained dedicated to local action. In addition to my research efforts, I also started to play a role in advocating for healthy food in communities. My first step in advocacy consisted of performing a network analysis of organizations working toward healthy food actions in Philadelphia. I identified organizations that contribute to nutrition education, access, or advocacy and depicted their relationships in a network map. The network map was disseminated to the public through an interactive website (www.philadelphiahealthyfoodnetwork.org). I found that an overarching collaborative entity that directs these efforts and ensures that resources reach all communities might help in organizing the citywide system. The network map website was an initial step in understanding the system and improving community planning. I will continue to play a role in advocating for polices on a local and national level to increase healthy food access and nutrition education. Menu labeling in Philadelphia and the Farm Bill Revisions on a national level are two recent examples of my budding efforts in advocacy.

Another step toward my goals involves spreading my perspective and facilitating the opportunity for others to bear witness to these disparities. In my position as a teaching assistant, I was given the opportunity to help design a community-based service learning experience for undergraduate students in collaboration with the Urban Nutrition Initiative (UNI). I facilitated a project for the Penn and high school students from West Philadelphia to critically examine and assess the food environment surrounding the high school. Through this experience a group of students from varying backgrounds got to connect to a community. They came away from the experience with an understanding of disparities in food access. I intend to take part in a similar opportunity in Cameroon this upcoming summer. In helping to lead a group of students back to Cameroon, I hope that I can facilitate a leap forward for other promising minds. Talking with young people and organizing nontraditional learning experiences can ignite ideas, spread my vision, and give rise to future nexuses of action.

Through persistent and targeted research and advocacy efforts, I aim to reduce the burden of malnutrition and its sequelae in communities worldwide. I will continue to conduct research on the relationship between the food environment and childhood obesity in my local community. I also look forward to returning to Cameroon and working with the community on nutritional information and access issues. I will continue to advocate on behalf of local and national efforts that aim to increase nutrition education and health food access. And along the way I hope to awaken minds around me to see that everyone deserves consistent access to healthy food.