The Context of Health: Building Healthy Communities featured in the Summer MAD 2012

Expert Update
from David Satcher, MD, PhD and Harry J. Heiman, MD, MPH

Where you live is a powerful predictor of your health and projected lifespan. Public health has long appreciated the importance of the context of health. Many reports, including work from the World Health Organization's Commission on Social Determinants of Health, have stressed the important impact social, economic and physical environments have on both health and health equity. This movement towards understanding and addressing the context of health is particularly important to developing solutions to our nation's challenges related to obesity and access to healthy and nutritious foods.

In response to the obesity epidemic, the importance of a healthy diet and regular physical activity is finally gaining national attention. There is increasing awareness supported by media campaigns like the First Lady's "Let's Move!" and Children's Healthcare of Atlanta's "Strong4Life." While these campaigns are intended to promote cultural and behavioral changes that support positive health behaviors, there continues to be inadequate attention to the context in which people make health and lifestyle decisions.

The context in which people make decisions about food choices is critically important. Both food insecurity and obesity are disproportionately seen in low income and minority communities and correlate strongly with neighborhood environments that have limited access to affordable, healthy and nutritious foods. Low income communities often qualify as "food deserts," a designation by the US Department of Agriculture for low income census tracts where a substantial number of residents have poor access to a supermarket or large grocery store. Neighborhoods without access to affordable healthy foods often have an overabundance of fast food choices and limited green space or other safe places to exercise.

Thomas Frieden, director of the Centers for Disease Control and Prevention, and other public health leaders have stressed the importance of making "the default choice the healthy choice" and transforming "obesogenic" environments into health-promoting environments. There is a growing body of evidence to support the importance of making healthy choices more accessible, affordable and attractive while, at the same time, making unhealthy foods less appealing. While it is important for individuals to take personal responsibility and make good health decisions, even these decisions are greatly impacted by the social and economic context in which they are made. For adults, the challenges of changing lifelong habits of eating calorie-dense foods high in sugar and salt and having a sedentary lifestyle are formidable. For children, providing an environment that supports the development of healthy habits can be life-changing.

To advance health in all communities, especially those that are most vulnerable and have the worst health outcomes, will require engaged and visionary leadership and empowered communities. We need more community leaders and advocates who understand that health decisions do not occur in isolation; they occur in the context of the neighborhoods in which people live, learn, work and play. Turning the tide of the current obesity epidemic and improving our nation's health will require all of us to work to ensure that healthy choices are more available and more affordable to all communities; that every child and adult lives in an environment that provides opportunities to make healthy choices and be healthy.

David Satcher, MD, PhD
Dr. Satcher was the 16th Surgeon General of the United States and former Assistant Secretary for Health in the Department of Health and Human Services. He also served on the World Health Organization's Commission on Social Determinants of Health. He is the director of the Satcher Health Leadership Institute at Morehouse School of Medicine.

Harry J. Heiman, MD, MPH
Dr. Heiman is director of Health Policy at the Satcher Health Leadership Institute and Assistant Professor of Family Medicine at Morehouse School of Medicine.