Food for Thought

Juan Leon, PhD, associate professor of global health, studies the farm side of the process. He is specifically interested in preventing disease outbreaks and illnesses stemming from the food-supply chain by improving grower health and the microbial safety of fresh produce worldwide. While the greatest risk of food contamination occurs closer to the fork portion of the farm-to-fork process—in grocery stores, restaurants, and people’s homes—it is important to work with the entire infrastructure in mind, notes Leon. Much of his research has focused on the U.S.-Mexico border, where a variety of people and products pass through daily. He began his research there in 2004 as a postdoctoral fellow under Christine Moe, PhD, Eugene J. Gangarosa Chair in Safe Water and Sanitation at Rollins.

At the time, Moe was looking at fruit and vegetable contamination on farms in the southern border states where 38% of agricultural exports from Mexico come into the U.S. When she had an opportunity to deepen her safe water and sanitation research, Leon took over the project and received a grant from the U.S. Department of Agriculture (USDA) in 2010. In the 20 years that Leon has been doing this work, he’s realized that access to nutritious foods depends on having clean water and safe work conditions for agricultural workers. For example, on farms where workers are being paid by how much food they pick per day instead of by the hour, people may not take lunch breaks or have paid sick leave, making them more likely to come to work sick.

“If we don’t have good places for farm workers to use the restroom, then fecal waste can contaminate food,” says Leon. “In agricultural fields or in restaurants, if food workers don’t wash their hands thoroughly, they can infect food and contaminate doorknobs, faucets, handles, etcetera.”

At the U.S.-Mexico border—where billions of pounds of fresh produce that Americans consume come into the country— it’s also impossible to ignore the social determinants of health and the impacts of race and policies. According to the 2022 USDA Economic Research Service, about 22 million people are involved in the farm-to-fork chain, including farmers, fishermen, manufacturers, servers, farm supervisors, and many other agricultural workers. Looking at farmworkers, the National Center for Farmworker Health estimates that there are about 3 million farmworkers in the U.S., most of whom are people of color. These demographics show that the very people who grow fresh produce may be less likely to have access to it in their own communities.

“About 3% of the U.S. population is making sure that food gets to the table, but 100% of us eat that food,” says Leon. “We all have a role in supporting our food workers’ well-being and desire that the food we eat is of good quality.”

When fruits and vegetables safely leave the farm without being contaminated by viruses and bacteria, the journey to individual communities is still a precarious one. The aforementioned Fresh Produce Access report notes that less than half of the 150 randomly selected small food stores in Atlanta offer fresh produce. It’s important to note that most of the store owners do not live in the ZIP codes where their businesses are located. This is in line with national and international trends.

Further, even national chains in low-income, predominantly Black communities, such as dollar stores, don’t offer fresh produce. Megan Winkler, PhD, assistant professor of behavioral, social, and health education sciences, led the team that produced the report. She was surprised to learn that in Atlanta, “the disparities worsened among SNAP (Supplemental Nutrition Assistance Program) accepting stores because SNAP is supposed to be a dietary quality support safety net.”

Researchers from The Center for Science in the Public Interest found that dollar stores are second to big box stores in places where SNAP recipients purchase food.

In other work, Winkler and colleagues have found most small food store owners said they were simply responding to customer demand. People would rather buy ultra-processed foods because they have a longer shelf life and can feed more people for less money. However, the power of marketing and advertising to drive demand cannot be ignored, says Winkler. In the United States, ultra-processed food is prevalent and regularly advertised in media. In grocery stores of all sizes, products such as chips, sugary cereals, and candy have vibrant displays that make people want to buy them, while fruits and vegetables do not.

“If we looked at the shelf space in a grocery store and compared it to MyPlate [the USDA’s dietary recommendations plan], it wouldn’t line up,” says Winkler. “Our retail environment should look like our dietary guidelines. Half the grocery store environment should be stocked with fruits and vegetables because half your plate should be fruits and veggies.”

Winkler would like to see Atlanta go the way of Minneapolis, which became the first city to create a Staple Foods Ordinance in 2008. It requires licensed grocery stores (including corner stores, gas stations, dollar stores, and pharmacies) to sell a certain amount of basic food items, including fruits and vegetables, whole grains, eggs, and low-fat dairy. In conversations with small food store owners in Atlanta, Winkler said many expressed concerns about waste and profit loss. But there are ways for the city to incentivize compliance.

“We need to invest in this as a community,” says Winkler. “We don’t need to have the same expectations for all retailers. For dollar stores, we can create mandates because they have large revenues, resources, and scale. For smaller retailers, we need to create support from private and/or government dollars. We won’t see fast changes. We have to reteach communities that they have healthy options.”

Significant shared consequences and costs are associated with disparities in fresh food access, whether people live in a low-income area or not. Increased health care costs and higher taxes are two big-ticket items that affect all Americans. People who do not have access to fresh food and clean water are more likely to develop chronic illnesses such as diabetes, hypertension, high cholesterol, and cardiovascular disease. Consequently, in low-income areas, more people are in the public health care system who may rely on Supplemental Security Income earlier in life. Karen Siegel, PhD, assistant professor of global health and core faculty with Emory Global Diabetes Research Center, believes that one key to preventing such outcomes is a healthy diet.

Last year, Siegel received a grant from the Georgia Center for Diabetes Translation Research and a Synergy Award from the Woodruff Health Sciences Center to research the feasibility of developing a food prescription program within the Emory Healthcare Network. In this program, when someone who is experiencing food insecurity shows signs of diabetes or pre-diabetes, they would be prescribed the necessary medications and a box of fruits and vegetables, along with recipes on how to prepare them. The hope is that receiving a weekly supply of fresh produce may lead people to make better food choices and improve their health in the long run.

Emory researchers are already involved in a program at Atlanta’s Grady Memorial Hospital called Food As Medicine. In this program, an onsite food pharmacy and teaching kitchen are used to help patients better manage chronic conditions and make healthy lifestyle changes. Siegel is learning from Emory School of Medicine professors Jada Bussey-Jones, MD, and Rosette J. Chakkalakal, MD, about how their work at Grady could translate into the larger Emory health system.

“We want to bolster local and regional food systems,” says Siegel. “One thing people have said about produce prescription programs is that they are often short term. I want to partner with local growers to better connect them with consumers and places to sell produce in Atlanta.”

Siegel’s sense of urgency isn’t unwarranted. Climate change has exacerbated shared health care costs due to increases in chronic illnesses. People living in low-income communities in Atlanta often deal with poor air quality, high heat indexes, and inequitable zoning laws that promote less than optimal health outcomes. These factors add injury to insult; most people live in these areas  because of  redlining, historic real estate practices resulting in racial segregation and a lack of investment in community infrastructure.

“When you have rising temperatures, changes in precipitation patterns, and extreme weather events, all of these climate factors can affect crop yields,” says Christine Ekenga, PhD, Rollins assistant professor of environmental health.

Ekenga believes in the power of community-engaged health promotion—getting people to civically engage around environmental justice. It’s an essential step needed to increase access to nutritious foods. Ekenga’s research focuses on chronic diseases, specifically cancers, that are linked to environmental injustices, such as lack of good soil to grow fresh produce in urban areas.

She and her team conducted community workshops in low-income areas of Atlanta to identify residents’ concerns around climate change. Based on those concerns, the team used NASA satellite data to map green space, temperatures, and air pollution in residents’ ZIP codes from 2002–2022. They found that over the past 20 years, people in the selected ZIP codes experienced more air pollution, less green space, and hotter temperatures than the rest of metro Atlanta.

Even if people in some of Atlanta’s most vulnerable neighborhoods had access to healthy food, they would still have poorer quality air than other residents, thus widening the scope of problems to address. Policies must be put into place and/or changed to ensure that everyone has a healthy plate.

 “We acknowledge that this is a big problem, but it requires collective action, such as starting a community garden, writing letters to a representative, supporting legislators who want to address climate change, and attending zoning meetings with neighbors,” said Ekenga. “You have to get people, from the community to policy level, to believe their actions can make a difference.”

Nutrition and health are cumulative. Every step in the right direction contributes to longevity. Rollins researchers have ideas about what can be done to improve conditions for people living in low-income communities throughout the South. All agree that laws and policies are at the core of changes that must be made.

For Siegel, it’s shifting USDA farm subsidies toward fruits and vegetables and supporting farmers who are growing fruits and vegetables. Leon wants to see water, sanitation, and hygiene become a higher priority to ensure food safety and proper nutrition from farm to fork. In their report, Winkler and her colleagues emphasized the importance of adding tax incentives for retailers who carry fresh produce and for produce distributors capable of supplying corner stores with small orders and on-the-go fresh produce snacks that align healthier options with the convenience store business model.

“I can provide communities with resources in the way of data and examples of how people can reduce their carbon footprint, but they have to engage leaders and policymakers and advocate for action,” said Ekenga. “This isn’t something that can be solved by me, you, and a couple of people in a room. It’s a global issue and we have to encourage legislation.”

Story by Kelundra Smith
Designed by Linda Dobson
Illustration by John Jay Cabuay
Portrait Photography by Bita Honarvar