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Counties with higher obesity rates across the U.S. tend to have more food stores selling more unhealthy food options relative to counties with lower obesity rates, according to a report from The Urban Institute published this month.

“We find that areas of higher obesity prevalence are more likely to have greater exposure to the types of food stores likely to offer less healthy options, even when controlling for differences across counties,” the authors wrote.

In high-obesity counties, the study reported that 65.5% of food establishments are likely to be “unhealthy,” as opposed to low-obesity counties where just 51.5% of food establishments are “unhealthy.”

This was true across rural and non-rural areas.

The researchers studied the distribution of places selling groceries — things that people would eat or prepare at home — as opposed to restaurants. That was in part because research already linked high concentrations of fast food restaurants to obesity, but the role of different types of food stores is less well understood.

Notably, the study found that “Dollar” stores — as in Dollar Tree, Dollar General and Family Dollar — represented a substantially larger share of unhealthy food establishments in high-obesity areas than in low-obesity areas.

Dollar stores and other places that sell unhealthy food, such as convenience stores and gas stations, make up what food environment researchers call “food swamps” — places drenched in unhealthy food options and with lower access to healthy food, according to the authors.

Getting past the ‘medical mainstream mantra’

Obesity rates have been skyrocketing in the U.S. and across the world over the past several years — by 2035 experts predict over half of the global population will be overweight or obese.

In the U.S. obesity presence was 41.9% between 2017 and 2020, according to the Centers for Disease Control and Prevention (CDC), with Black adults experiencing the highest rates (49.9%) followed by Latinos (45.6%), whites (41.1%) and Asian adults (16.1%).

Obesity is one of the most common pediatric chronic diseases in the U.S. According to the CDC, 1 in 5 U.S. children and teens are considered obese.

Treatment for obesity tends to focus on administering drugs or modifying individual behavior.

For example, the American Academy of Pediatrics (AAP) earlier this year issued new clinical guidelines for treating childhood obesity, recommending physicians offer weight-loss drugs and surgery alongside “intense health behavior and lifestyle treatment” for almost all obese children.

But even before the new AAP guidelines, critics argued this approach is limited and won’t resolve the issue.

Dr. Michelle Perro, integrative pediatrician and executive director of GMOScience.org told The Defender:

“The medical mainstream mantra that obesity is secondary to laziness and overeating has to be abandoned and abolished.

“The primary culprits have to do with chronic poisoning from environmental toxicants also known as obesogens that are causing metabolic disruption, endocrine disruption, and obesity.

“If we don’t look at the root cause we will never solve the problem.”

The Urban Institute report takes on that challenge. Dr. Elaine Waxman, lead author of the study, told The Defender that the need to understand structural drivers of obesity was the key motivation for doing the research.

She said:

“We often focus on the role of eating and eating behaviors in managing obesity. But a lot of that attention goes to individual choice without paying attention to the food environment.

“And the question we wanted to ask is what do communities potentially need to be talking about changing in order to make more progress, because obesity is so widespread that just taking it individual by individual lives is not going to be a very effective way of moving a population challenge.”

Waxman acknowledged that the study’s findings show correlation and can’t prove for certain that having more stores selling unhealthy foods in a community causes obesity.

However, she said, the study points to a key intervention that ought to be understood and debated at the community level.

“There’s enough of a difference there [in the distribution of unhealthy food vendors] that communities need to be having this conversation about, well, where can people even shop and what’s affordable in those communities?” she said.

“And that becomes a conversation about infrastructure in a community,” Waxman said.

Mapping food vendors and unhealthy food

To do the study, the researchers gathered obesity data from across the nation from the CDC’s Behavioral Risk Factor Surveillance System, a large telephone survey that collects information about chronic conditions, along with county-level data from the CDC’s PLACES 2021.

They analyzed this together with geographic data on the food environment drawn from Data Axle, a national business database that provides detailed information on location, business type, etc. for all businesses in the U.S.

The researchers mapped the presence of food retailers per thousand people across the country and they distinguished among different types of food businesses — grocery stores, gas stations, Dollar Generals, warehouse clubs, etc.

Each business was classified as offering food that is “likely healthy” or “likely unhealthy” by drawing on existing literature about food and food retailers.

“Likely unhealthy” food establishments included convenience stores, Dollar stores, pharmacies and gas stations, which tend to sell “mostly shelf stable and processed,” foods, according to Waxman.

Increased consumption of processed food is linked to increased obesity and related chronic disease. These foods account for about 90% of added sugars — usually in the form of high fructose corn syrup — consumed in the U.S. They also contain other obesogens.

“Likely healthy” food establishments included grocery stores, warehouse clubs, and other department stores because they are likely to have fresh foods and proteins, although they also carry many processed and unhealthy foods, Waxman noted.

The study excluded restaurants and also places like farmers’ markets where only a small sector of the population purchases food.

From food deserts to food swamps?

The study found that obesity is not distributed equally across the U.S. The highest obesity rates are concentrated in the South — in parts of Texas, Louisiana, Mississippi, Kentucky and West Virginia.

The lowest obesity rates are in the West — in parts of Colorado, Wyoming, California and Nevada.

They also found that the counties with the highest obesity rates have more food establishments per 1,000 residents than counties with low obesity rates. These counties tend to have a larger variety of food stores, but more of them are unhealthy.

These findings counter earlier research that linked obesity to lack of access to food stores in what was called a “food desert.”

This shift may indicate a shifting food environment, the authors said. Recent research, including this study, found the presence of food outlets offering less healthy options — or “food swamps” may play a key role in obesity, the study reported.

For example, the study found a much higher frequency of dollar stores in high obesity areas:

“The difference in the number of dollar stores between high- and low-obesity areas is particularly large — with high-obesity areas averaging 0.24 dollar stores per 1,000 residents and low-obesity areas averaging only 0.09 dollar stores per 1,000 residents.”

This may be because Dollar stores have proliferated across the country, particularly in low income areas, in the last decade.

In contrast, over the past 25 years, the median number of grocery stores per capita has declined by 40%, the study reported.

Studies have shown that when a dollar store enters a community in a food desert, that area is more likely not to get any other type of grocery store. In fact, research also has shown that when a Dollar General moves into an area, it drives other grocery stores out.

According to a profile of Dollar General by Cleo Levin in Slate Magazine, Dollar stores have been found to have limited fresh and healthy food options, tending instead to sell soda, snacks, processed foods and alcohol.

“The dollar stores, with their smaller scale and selection, don’t need to pay as many workers as grocery stores, and they can focus on the high-margin packaged products, which happen to be the unhealthy ones,” Levin wrote.

Waxman said it was important to pay attention to the proliferation of dollar stores, adding, “There are benefits to dollar stores, right? People shop at them because they’re low price because often I think they’re the only game in town or nearby.”

She added:

“One could argue that you could leverage them as an asset to make some changes, but you also want to have that conversation about if they’re proliferating, does that limit our ability to have other resources?”

Some communities have started attempting to limit the density of Dollar stores.

Waxman said there are different ways to approach expanding healthy options and the study’s authors are not advocating particular policies.

“But,” she said, “in the end, if you’re not paying attention to the balance between healthy and unhealthy, then you know, we’re not setting people up for success, right? It’s not realistic to ask people to follow medical advice that’s not really feasible where they live.”