A couple of months ago, I heard rumors that our county grocery store might close. That’s right -- not town, not local, not biggest, not best, but the ONLY store in the county might go out of business.
About 500 people live in Clay, W.V., and roughly 9,000 live in the county. It seemed like one of those things that just couldn't happen because there is plenty of demand for the business. So it wasn’t until the store's sign was gone and the doors were locked that I accepted the fact that my patients no longer had access to a grocery store. A list of brittle, insulin-dependent diabetics and precariously balanced heart-failure patients flooded my mind. I worry about all of them every day.
Since the store closed, I’ve been asking my patients where they buy their food. If they have diabetes, I ask what their sugar has been doing. My heart sinks when they say they are buying all their food at the Go-Mart. Not that it's a bad place (if you need gasoline) but the food choices are high-carb, high-salt and deep fried. (My patients also complain that it's expensive.) This isn’t just a run-of-the-mill gas station. It also offers prepared foods, and it reportedly has the best fried chicken in town. A couple of miles away are Family Dollar and Rite Aid stores, both of which have a few shelves of food as well, but, again, it is mostly processed and less than ideal.
On May 8, the comment period ended for the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC) which is produced by the HHS Office of Disease Prevention and Health Promotion. As I read Chapter 4: Food Environment and Settings, I was surprised (and happy) to find the list of reference articles contained numerous studies regarding access to healthy food. We know what foods to avoid and what foods are better for us and our patients. But proximity to a grocery store or farmer’s market is critical to the chronic disease status of a community.
My concern as I searched through the document wasn’t how many fruit and vegetable servings we were now going to recommend, but how much social and geographical inequalities were contributing to poor health outcomes, and what was the plan for addressing it?
The CDC’s Community Health Improvement Navigator provides resources and examples of improvement strategies for various stakeholders, including physicians. It attributes 40 percent of our health outcomes to socioeconomic factors and 30 percent to health behaviors. Both far outweigh the 20 percent physicians contribute to via clinical care.
A recent study by Virginia Commonwealth's Center on Society and Health examined how life expectancies vary by ZIP code within the same communities. For example, Richmond, Va., had the starkest data with life expectancy variances of 20 years in two neighborhoods that are just 5.5 miles apart.
Understanding such health disparities is not as simple as identifying who chooses to eat fast food or smoke. It is about so much more than that. Something as simple as how a home is heated can have serious, long-term implications on patients' health. Largely due to cost, many of my patients heat their homes by burning wood or coal. Often I see a grandparent with chronic obstructive pulmonary disease raising a grandchild with asthma, and both patients suffer through the winter due to poor air quality inside their home.
So, what does the DGAC report say about diet? Access to farmers markets and produce stands result in healthier eating habits. The data is less clear when it comes to supermarkets and grocery stores. But in the more rural, seasonal growing areas, the grocery store is the produce stand. The report readily admits that it was difficult to compare data across studies, and most were specific to one type of geography, e.g., inner city vs. rural. The report clearly found that proximity to a convenience store led to higher BMIs.
The report also studied influences and efficacy of school- and work-based interventions. In the end, the report found that multiple strategies work to improve healthy eating habits at all ages, but that a definitive, all-encompassing approach is impossible given the variability between communities. It defines areas of future research, highlighting projects that work and encouraging partnerships of all types to create thriving businesses that would improve food access as well as workplaces that promote healthy behaviors.
A few years ago, a local health department study concluded Clay County residents lacked access to fresh produce (even with a grocery store) so the local extension service set up a farmers market. The market opens June 4, but it will only operate four hours a day, one day a week.
The growing season is just getting rolling here in West Virginia and lasts through August before dwindling in the fall. Fortunately for local families, school is running later than usual to make up for numerous snow days, so kids will get a couple of meals a day at school until June 15. After that, parents will struggle to find easily accessible food sources during what may be a trying summer break.
My hope is that someone takes over the vacant store, reopens it with the county’s needs in mind, and my patients realize how much they missed having access to healthy food while the store was closed. Perhaps that will prompt some to make up for lost time and replace all the packaged, fried food they likely will consume in the next few months with fresh, lower-calorie meals when they have the opportunity.
A few months ago, I bought cookbooks for each of my exam rooms, and my nurse encourages patients to look through them while they are waiting for me. One patient asked to borrow one and take it home, to which I obviously said yes. But right now, no one without the means to travel 40 miles to a grocery store in an adjacent county could make even one of those recipes.
Kimberly Becher, M.D. graduated from Marshall University's family medicine residency in 2014 and practices at a rural federally qualified health center in Clay County, W.V.