Advancing food is medicine: lessons from medical anthropology for public health nutrition

Food insecurity is particularly relevant as a public health concern, as emphasized by the historic Whitehouse Conference on Hunger, Nutrition, and Health on September 28th, 2022. This feature provides commentary on the promise of methodologies and theories derived from medical anthropology to understand the contexts of food insecurity and co-occurring health conditions and advance the implementation and evaluation of Food is Medicine interventions within public health.

Food insecurity is a pressing public health concern associated with adverse, often co-occurring, consequences, including risk for obesity, type 2 diabetes, hypertension, and depression. In the US, approximately 45 million people live with food insecurity. Population-based studies demonstrate that food insecurity disproportionately affects households with incomes below the federal poverty line and those who identify as Black or Hispanic. ¹ Increasingly, healthcare-based ‘Food is Medicine’ programs are emerging to improve food and nutrition security as a mechanism for reducing adverse health outcomes. Food is Medicine interventions generally refer to a range of programs and services that seek to address the links between nutrition and health; these programs typically include the provision of fresh foods through partnerships between governmental, non-governmental, and healthcare agencies.^2,3 At present, target mechanisms, program effectiveness, and the afterlives of these programs remain sparsely documented.^4,5 As such, it is an opportune time for researchers and practitioners to understand the promise, limitations, and potential perils of Food is Medicine. Perspectives from medical anthropology may offer crucial insights into such programs in support of health and nutrition equity.

Contexts and Lived Experiences

Public health practitioners and researchers must consider the broader contexts of food and nutrition to catalyze this work. The scholarly contributions of social scientists, including anthropologists, remain minimal in the context of these and other US-based food and nutrition interventions. As other scholars argue, anthropological methods are well-positioned to contribute to intervention-related research by proffering emic insight – that is, insight into social and cultural dynamics. ⁶ Anthropological methods, including ethnography and participant observation, can reveal how food is discussed, understood, and prescribed within the healthcare system. Moreover, such methods can be applied to examine intrahousehold dynamics of food, eating, and care, including culturally and contextually preferred foods and cooking practices. Such topics are vital for understanding how people engage with food and nutrition interventions. As other anthropologists have stressed, public health concerns, including food insecurity, and the policies and programs that seek to address them are inherently social phenomena shaped by the social norms and cultural knowledge of people. ⁷ Adams and colleagues underscore that the evaluation of these public health phenomena must recognize the dynamic qualities of the social as ‘a teeming source of information’. ⁸ Building on this idea, I argue that the construction of meaning and sociality of food are critical yet underexamined elements for concurrently advancing food security and wellbeing within nutrition interventions. These dynamics may affect perceptions of stress and social support, which buffer food insecurity’s adverse effects.^9,10 Similarly, a medical anthropological lens may shed light on how engagement with these programs alters mental health, an underexamined aspect of health in the context of Food is Medicine interventions. The examination of how food comes to possess meaning among individuals is imperative for creating more efficacious and equitable food and nutrition programs. Such an examination requires looking beyond what humans eat to when, how, why, and with whom they eat – centring social life and foodways as points of departure and paths toward improving health. ¹¹

Structural and Systemic Inequalities

In addition, scholars must begin contextualizing the co-occurring experience of food insecurity and adverse health within social and economic systems. Efforts to do so within public health have primarily used the lens of social determinants. The concept of social determinants draws from the observation that inequalities in health are associated with discrete factors such as class and socioeconomic status, now often referred to as ‘social determinants of health’. ¹² Despite being an often cited social determinant of health, few studies position food insecurity as a deeply embedded social phenomenon in the lives of humans. While the prominent social determinants of health (SDH) framework explicitly invokes connotations of determinacy, ¹³ frameworks from critical medical anthropology create space for multiplicity, indeterminacy, and inter-relationality among factors that collectively form a social assemblage. ¹⁴

Instead of localizing health as a relatively fixed state within an individual, medical anthropologists document the iterative ways in which people conceive, negotiate, constitute, and practice states of health within larger contexts. Within critical medical anthropology, much research adopts a structural violence or structural determinants perspective to emphasize that disparities are originally and systematically embedded into policies, institutions, and organizations by those in power as a means of systematically oppressing, disenfranchising, and disempowering minority groups. Many medical anthropologists and, increasingly, public health scholars, note that, semantically, the term ‘social’ imparts responsibility on the sociocultural norms and social environments of the affected group instead of the systems that explicitly and implicitly structure and regulate their daily environments.^14,15 For example, studies employing an SDH framework may examine factors such as food retail environments yet eschew the policies and practices that created and maintain them. In contrast, a structural determinants lens contextualizes the environment within broader histories of supermarket redlining, racial discrimination, and systemic poverty. Scholars must consider these factors to address the contexts of food insecurity among program participants and potential barriers to program engagement and efficacy. Therefore, although the phrases ‘social determinants’ and ‘structural violence or structural determinants’ are employed as frameworks to view health inequalities, each has distinct epistemologies, connotations, and proposed solutions. ¹⁵ Looking beyond a social determinants framework to dig deeper into the structural violence interwoven with food insecurity also encourages program implementers, organizers, and evaluators to acknowledge that these programs must be interwoven with policy changes that provide additional resources and re-structure our food and healthcare systems.

Ultimately, methodological integration is critical for a deepened understanding of how lived experiences of inequality become embodied to produce, uphold, and shape nutrition-related health disparities and alter nutrition interventions. There is a need for more locally grounded approaches to assessing the contexts that differentially promote or impede nutrition and health intervention effectiveness. By continuing to illustrate how food and health-related policies and programs play out in their articulations with local communities and everyday realities, anthropological methodologies can advance the field of public health nutrition.