AbstractIn this case, a physician wonders what he should do to help make nutrient-dense foods available in underserved neighborhoods. I argue that improving diets of people who live in food deserts is a complex problem at the intersection of culture, education, and economics that will require community partnerships and clinician self-education to solve.
At a community meeting, Dr D presented his research on physician attitudes toward and work habits in food deserts and the obstacles that prevent physicians from promoting nutritious diets to patients with low income. Dr D found that physicians have limited training in foods, nutrition, and behavior change counseling, all of which are poorly reimbursed by insurance companies and Medicaid. At the end of the presentation, a local advocate for community services who wanted to eliminate food deserts by building full-service grocery stores asked, “In this day of limited availability of healthy foods and not enough resources to buy them, shouldn’t insurance companies, food banks, and physicians do more to ensure that nutritious food is available in our underserved communities?”
On the way home that evening, Dr D thought about differences in foods available in the communities where he lived and worked. Near his home, there were 3 large, brightly-lit stores with the word “fresh” as a part of their name. These stores were well stocked with an array of produce, whole-grain breads and cereals, freshly prepared foods, and even junk food items cleverly packaged to appear nutritious. They stood in sharp contrast to nameless stores with security gate entrances near the medical center where he worked. In these small stores, aisles were crowded with sugar-sweetened beverages, high-fat sugary snacks, high-sodium convenience foods, and the occasional bunch of overripe fruit or limp vegetables. Given that markets typically reflect consumer demand, Dr D began to think that food availability might be one facet of a more complex problem. Did his patients know what they should eat?
As Dr D thought about the patients in his practice, he recalled early attempts to improve his patients’ knowledge—and ultimately their consumption—of nutritious foods. Dr D came to realize, however, that counseling patients was impractical because counseling must be continued for months to achieve positive behavior changes. Extending appointments to provide counseling decreased the number of patients he could see, impairing his productivity and ultimately the revenue he contributed to his group practice. Besides, many of his patients had deferred medical care of equal if not greater priority than dietary changes. Most of his patients worked more than one job to support their families, and few of them had resources to pursue something as ethereal as their long-term health.
Dr D also realized his own preference for a mostly Mediterranean diet differed from the diets preferred by many of his patients, some of whom were unfamiliar with or perhaps even wary of foods he recommended. Dr D wondered whether foods he consumed really were more nutritious than foods consumed by many of his patients. He came to understand that foods patients viewed as traditional—regardless of nutrient density—can be important simply because they can serve as cultural and community touchstones. As a result, Dr D has become more humble about attempting to steer patients away from some foods in case doing so might be interpreted as disrespectful of food preferences driven by cultural practices.
Dr D now wonders, Given these experiences and what I’ve learned over the years about counseling and the cultural importance of food practices, what should I as a physician do to improve availability and consumption of nutritious foods among patients in communities near the medical center?
In this case, Dr D appears to have met his ethical duty to advance knowledge1 by sharing his research findings about physician attitudes toward and work habits in food deserts. As Dr D might suspect, however, he is likely expected to do more. In fact, the American Medical Ass