Tackling America's Public Health Problems by Going to the (Food) Source

No one disputes that the way we eat in the U.S. has contributed to a national health crisis of diet-related diseases like obesity, diabetes, heart disease, cancer and stroke. According to the Centers for Disease Control and Prevention, more than one-third of all U.S. adults (over 72 million people) and 17 percent of U.S. children are obese. And there are serious health effects of unhealthy food choices, even for individuals of normal weight.

Dr. Sean LucanEinstein researcher Dr. Sean Lucan, wants to change that. He is using several different research approaches to tease out real-world solutions and create change on the ground floor to make a national impact. In a series of recently published papers, he is mapping out causes and effects to quantify and qualify the relationship between the environment and eating habits.

"Where you live affects what you eat," said Dr. Lucan. "If you want to change people's diets, you have to change their environment."

Dr. Lucan's interest in public health was first sparked as a Yale medical student. "One of the first things I learned is that the leading causes of death in the U.S. are chronic diseases," he said. "They are diseases caused by lifestyle – tobacco, diet, exercise." That revelation and a desire to have the highest potential impact, led him to pursue a Master's degree in public health and take a population approach to the practice of medicine.

It is a path that led him from the University of Pennsylvania and a fellowship as a Robert Wood Johnson Clinical Scholar to his position as assistant professor of family and social medicine at Einstein, to family practice in the department of family and social medicine at Montefiore Medical Center, and to the streets of the Bronx. Here, Dr. Lucan is evaluating the success of breakthrough public initiatives, like the New York City Green Cart program, which aim to bring fresh fruit and vegetables into neighborhoods where fast food is king.

For Dr. Lucan, the Bronx is an ideal laboratory for the study of social health issues – dense and diverse, with significant extremes in health, economics and racial disparity. It is also ground zero for a broad range of social health initiatives. "The New York City Department of Health is really forward thinking; they are far ahead of the curve," said Dr. Lucan. "They are ideal collaborators."

This summer, students working under Dr. Lucan's direction fanned out through the Bronx to undertake a full assessment of the Department of Health's Green Cart program. Established in 2008, the Green Cart initiative brings mobile fruit and vegetable vendors to designated areas where rates of fruit and vegetable consumption are low and rates of obesity and diet-related diseases are high.

Dr. Lucan found some success with the program, but also room for improvement. "We found that vendors were covering about half the targeted territory," he said, "While that's good, the flip side is that half the area is uncovered. Most vendors were clustered close together. If we can incentivize them to spread out, they might reach more people."

As Dr. Lucan's previous studies have revealed, access, availability and perception are critical when it comes to changing people's diets. "The worse people perceive their food environment to be, the worse they eat," he said. "We need to address convenience and create ways to eat healthy that are convenient. People largely eat what is there because it is there."

In a survey of bodegas in some of Philadelphia's poorer neighborhoods conducted while he was at University of Pennsylvania, Dr. Lucan and colleagues found that the stores were stocking unhealthy snacks to the near exclusion of any healthy options. "Some of the single snack foods had a day's worth or more of fat, sugar, and sodium. That creates a toxic environment."

While offerings at farmer's markets can be healthful, they often are held at inopportune times during the work week.Dr. Lucan's more recent survey of all street food vendors in the Bronx, found that unhealthy foods outnumbered healthy foods by three to one.

But the solutions are not always what we might believe. This summer, Dr. Lucan's team analyzed farmer's markets. "I was surprised by the results," he said. "Farmer's markets are talked about as a way to get fresh produce into 'food deserts,' but we found that all Bronx farmer's markets were actually within a half-mile of a supermarket or produce store. And, although they are thought to be a source of whole, fresh foods, 25 percent of what they sell is processed items, such as jams, jellies, cider, and pies – all of which are undesirable from a health standpoint."

According to Dr. Lucan's research, while farmer's markets might be ideal for certain audiences, such as self-employed, wealthy seekers of organic produce or heirloom vegetables, when it comes to those on the lower socio-economic end of the spectrum, they may actually be less than ideal. "They are more expensive, they carry sugary unhealthy products, and they don't make fresh produce very available, since they usually are held only once a week at a time when most people are working," he said.

One of Dr. Lucan's next projects is to take a look at local food advertising, such as billboards, bus posters and store window signs, to measure the messages that children are seeing daily and what they are being told to eat. "Our eating behaviors, habits and preferences start early in childhood," he explained. "Unhealthy advertising may work against setting kids on a path toward healthy eating and healthy lifestyle choices."

His team also will be expanding the Green Cart assessment, continuing their study of street cart food sources, assessing local stores and restaurants, and estimating the potential impact of the City's Health Bucks program at farmers' markets.

While, they have a lot of ground to cover, Dr. Lucan is undaunted. "The great thing about Einstein is that it is a teaching institution," he said. "With access to undergrads, med students and residents, there is no paucity of individuals who can help with the research. It is amazing what you can accomplish working with smart and motivated young researchers."