Honest reflections on the whole “Make America Healthy Again” situation.
How I think we’re forgetting the forest and neglecting social determinants of health.
I’ve been avoiding social media for weeks now, mostly because I’m getting overwhelmed by the onslaught of content related to MAHA. I’m really annoyed and frustrated and deeply concerned about how this whole “movement” is going to impact already rising eating disorder statistics and generally contribute to people having a fear and shame-based relationship with food (which - ironically - isn’t health-promoting). Eating disorder statistics have skyrocketed since Covid and the average onset age continues to get younger and younger. Some studies point to age 10 as an average onset now, which is heart-breaking.
But Rachel, how could you argue with wanting America to be healthier? Are you saying that you’re pro food dyes? How could you promote ultra-processed foods? Don’t you care about the health of your family?! (*insert Homer Simpson face slap*)
Of course, I want Americans to be healthy. Of course, I want my family to be healthy. And…here is my hot take on so much of this “movement”: it’s not that I’m against removing food dyes and certain ingredients from our foods. It’s just that I think it’s unhinged and narrow-minded to focus so intensely on those things without addressing the social determinants of health: the significant, evidence-based factors that we know contribute to physical and mental health outcomes. People are fighting about food dyes and raw milk when over 18 million households are food insecure, lacking access to fresh fruits and vegetables and safe neighborhoods. I think this whole conversation is neglecting the forest - the multi-faceted contributors to our health that expand far beyond simply what we eat. Wellness influencers peddling the narrative that *it’s most definitely the ingredients in our food* (so they can sell their expensive, highly processed protein powder) that are the SOLE CAUSE of the chronic disease epidemic in our country is a wildly false interpretation of data and science.
What are the Social Determinants of Health?
I remember when I first learned about the Social Determinants of Health (SDOH), I was pretty flabbergasted. After all, I was taught in my youth that our health is mostly influenced by what we eat and how we move. If you just do those things “right”, you can be healthy. And that was even before the age of social media and “wellness culture”! Thanks to “wellness influencers”, these (inaccurate) messages are even more intense and accessible, creating confusion, fear, and obsession in the name of “health”. But what contributes to our health outcomes is complex and far more vast than just diet and exercise. Social Determinants of Health are the factors that, combined, “determine” or influence our health. (**If you’re like me and you’re a visual learner, try and imagine a pie chart below with the different percentages).
So what actually determines our health?
Socioeconomic factors + physical environment: 50%
Family/social support (*there are significant studies that point to people with the longest life span being people with the most connected relationships)
Physical environment/community safety
Air and water quality
Education and job status
Income (*several studies - like several - point to *wealth* as the most significant predictor of health and longevity)
High trauma exposure and chronic stress
Adverse Childhood Experiences (ACES)
Access to Healthcare: 20%
Provider accessibility
Quality of care received
Individual Health Behaviors: 30%
Alcohol and substance use
Physical activity
Diet and nutrition
Tobacco use
Sexual activity/health
There are a lot of directions I could take this but here are the important points I want to make…buckle up, buttercup. (*does my sarcasm translate? I really don’t know - one can only hope).
ONE
Health is incredibly multi-factorial. Individual health behaviors account for 30% of our health outcomes and that 30% INCLUDES alcohol use, tobacco use, and sexual health. While it’s impossible to know exactly what percentage of that 30% is related to exercise and nutrition, it’s logical to say that it’s less than 30%. And yet, our mainstream culture (Instagram/TikTok/“influencers”) continues to sell narratives like, “You are what you eat”, “Food is medicine” and “Sugar is poison.” If we situate health within the context of the largest category that influences it - social and economic factors - we would be more accurate to say, “You are the quality of relationships you have”, “Community safety is medicine”, and “Trauma is poison.”
TWO
We continue in this culture to overemphasize the role of nutrition, food ingredients, and exercise and blatantly ignore the systemic factors that are making America sick. We are overworked, underpaid, and lonely as hell, and it is delusional to continue to downplay the role of social factors as they relate to our health outcomes. Based on the Social Determinants of Health, these things impact our health more significantly than the food we eat does. You can eat all the organic kale in the world but doing so won’t mitigate the devastating physical and mental dis-ease that is caused by trauma, loneliness, chronic stress, and repressed emotions. And this isn’t just therapists trying to push some agenda - we have so much data now to back these claims. Our world just wants to continue to turn a blind eye to them.
And in terms of overemphasizing the impact of specific foods/certain ingredients (i.e.: seed oils, gluten, sugar, you-freakin-name-it), the research is incredibly muddy and not actually very conclusive (despite what other people on the internet say). The most important thing I learned about research (other than the fact that research is incredibly flawed despite best efforts) in graduate is school was this: Correlation doesn’t equal causation. What this means is that just because X is correlated with Y (for example, exercise and skin cancer) doesn’t mean that X (exercise) causes Y (skin cancer), it just means that people who live in places that get a lot of sunlight tend to be more active in their daily lives. So while there is correlation, these variables are not causely linked.
There are so many people (influencers) on the internet “translating research” who never took a masters levels research and statistics class and are not credible sources (yet, are seen as such) because they don’t know how to interpret data. Having a large social media following doesn’t make someone an expert.
THREE
If you’ve read anything on IG (especially from the big-name “influencers” in this MAHA movement), you’ve heard the whole, “Food is healthier in Europe” spiel as a way to “prove” the American food system is the whole problem. I think it’s fascinating that we’re quick to compare ourselves to other European countries that have better health outcomes than we do and immediately blame food ingredients. Which - let’s set this record straight right now, people - Red 40 is not actually banned in Europe, it simply goes by another name (E129 or Allura Red AC). The misinformation on Instagram about this is WILD.
But here is honestly what I wonder about: is it really that their ingredients are better (maybe - it could be) and that’s why they have better health outcomes? Or could it be that their lifestyle factors are more health-promoting than ours since those contribute more signicnatly to health outcomes? Their cultures, unlike ours, tend to: prioritize rest and play, take care of mothers in the form of paid maternity leave and more affordable childcare, have wider health-care access, spend far more time outside in nature, live in walkable/bikeable communities, and have much higher values for relationships.
FOUR
We are fighting about food ingredients when over 18 million households don’t have access to healthy food. Why the heck are we not prioritizing efforts to decrease food insecurity, increase access to healthcare (including mental health care) and nutrition information (*from actual experts not IG influencers who spread fear/misinformation left and right), eliminate food deserts, and stop subsiding crops in favor of large food corporations? Truly, I am absolutely in favor of ending corporate greed from big-name food companies but where is the zeal for finally moving the needle on the systemic factors and social inequalities keeping Americans sick?
Do you want to know my hunch about why this hasn’t happened/isn’t happening? My hunch is that it’s because no one gets rich doing the right thing(s). With “big wellness” as opposed to “big food” or “big pharma”, people still make money and other people (poor people) continue to not have access to seed-oil-free tortilla chips, expensive protein powders, and other “clean” foods (that will surely only remain accessible to those with certain degrees of economic privilege). I used to not be so much of a realist (*sigh).
FIVE
So let’s address the fact that the food we eat and how we move our bodies are two contributing factors to our health. No one is denying this but there is more nuance here that what is paraded on social media. What might be a set of health-promoting food and exercise behaviors for one person *might not* be health-promoting for another person.
For some people, what is “health-promoting” might be things like increasing fiber and fruit/vegetable intake, increasing physical activity, and decreasing added sugar. And yet for several other people, namely the millions of people in this world who are recovering from an eating disorder, those same “health-promoting behaviors” would be harmful. For someone in eating disorder (ED) recovery, what might increase their lifespan is to decrease fiber and fruit/vegetable intake, decrease physical activity, and increase high-calorie foods to combat the impacts of malnutrition. We’ve been led to believe that diet and exercise behaviors are a one-size-fits-all situation. They are not, our bodies are different and the sea of (mis)information online around blanketed nutrition and exercise advice perpetuates the myth that what’s best for one person’s “health” is best for all.
Is anyone even still reading this?
What I am basically saying is this - why are we wasting so much energy trying to make Fruit Loops healthier when we have so many bigger fish to fry? Fish that if we did fry, might actually make a significant, positive impact on public health and chronic disease since they contribute *more* to our health outcomes. I think we’re really missing the forest here.
And to add some nuance - because ya (your?) girl loves a good sprinkle of it…
I don’t think that food dyes are beneficial to our health and I’m not poo-pooing on higher quality ingredients in our food. I’m for better quality food (sounds rad). Because I’m financially able (*key point there), I prefer buying meat from our farmer’s markets (which doesn’t always happen), I make sourdough bread weekly (because it makes me happy and tastes superbly delicious), and if you looked in our pantry you might see a lot of things that could be deemed by MAHA peeps as “clean foods”. You’d also see things that absolutely aren’t “clean” - they’d FOR SURE send me to the toxic people's jail or something. But jokes aside, some people might even call our family a little bit “crunchy”. And we are (sorta).
People like to stay “it’s about balance” but honestly, balance isn’t the right word - it doesn’t capture nuance enough - and the assumption underneath “having balance” is often that external “rules” about food/exercise are driving the bus versus values, intuition, body trust and flexibility. The assumption is that one camp is “good” while the other is “bad”. While some people might prefer me to choose a camp (crunchy or not crunchy, holistic or not holistic), there are things from both camps that align with our values and work for us. (*also, don’t put me in a box. I get triggered in boxes).
I’m also recovered from an eating disorder, and because of my genes, my daughter is genetically predisposed. So a big part of our “valuing health” means that we also value mental health and our relationship with food over obsessing over single ingredients. We recognize that what we eat and how we move is a fraction (truly, a fraction) of what will determine our health outcomes, and we talk about and normalize food being more than just nutrition or “fuel”. While I can’t entirely prevent my daughter from ever having an eating disorder (which not-so-low-key kills me on the inside), I can do everything in my power to help her have the best shot at developing a secure, mindful, and peaceful relationship with food and her body from a young age.
*A caveat here that I always feel like I have to say - I am not saying that nutrition doesn’t matter. I am not saying that exercise doesn’t matter. Our bodies were created to move and eating vegetables is generally good for our health. And - as a therapist who now specializes in treating eating disorders, I feel confident in the following statement: Food, health and body obsession, anxiety, and rigidity aren’t good for you and will only undermine your health (physically and mentally), not improve it.
And to be honest, I’m kind of tired of having to repeat these things over and over again. It’s like the eating disorder community is yelling into a giant void and no one ever listens to us. I am tired of the lack of critical thinking that exists anymore because of social media. I am tired of always seeing nuance (and trying to explain it) in a culture that promotes and parades extreme sides and perspectives. I am tired of both sides shouting at each other (the eating disorder community and diet culture/wellness culture) and getting literally nowhere.
*^That was a bit of a digression (but - it felt important)
In sum and what scares me the most about it all…
I am deeply concerned with how all of the “toxic this” and “clean that” jargon is impacting our kids and younger minds, creating fear instead of body trust and negative judgment towards themselves and towards others who don’t or can’t eat in certain privileged ways. There is significant research that supports not morally labeling foods (i.e.: refraining from putting them in “good” or “bad” categories) is tremendously helpful for cultivating a positive, secure relationship with food. This is sometimes referred to as “food neutrality” (a concept from the Intuitive Eating framework) and the rise of all of this MAHA stuff is going to make food neutrality so much harder (despite it being really helpful and health-promoting). (*Morally neutral doesn’t mean nutritionally equal, by the way, but that’s a can of worms that I’m not opening right this second - the article I linked above on food neutrality speaks more to this).
And here are my other thoughts, the ones that keep replaying in my mind the most, the ones that I think are the most important, the ones I wish more humans were asking, too.
What’s going to happen when we realize that chronic disease rates don’t actually change, or only change slightly? (I mean, heck, I hope I’m wrong, truly - but if the Social Determinants of Health teach us anything, I think it’s that we’re fighting the wrong battle here or that we should at least be fighting the other battles while people fight this one). What happens when we realize that these proposed changes in the name of “health” won’t even come close to helping our most marginalized, the people most at risk for chronic disease? Will it collectively wake us up and (finally) see things like trauma/Adverse Childhood Experiences (ACES), chronic stress, social/emotional stressors, and poverty, for the issues that they actually are and for the significant ways they’re impacting the health of Americans? And what happens when we realize that public health and public profit will always be at war with each other and so long as we do what’s best for public profit, the health of many Americans will continue to suffer? At what point are we going to start to take serious the profound health impacts of how chronically disconnected we are from ourselves and from each other (this article is worth your time)?
Signed,
A sorta cynical and sorta hopeful therapist and mom who values health
(**Also - and it’s annoying that I even have to say this but in our cultural climate, I feel like I have to - my thoughts on this topic have nothing to do with my political party alignment. I actually have pretty nuanced political party ideas and have issues with both sides. My stance would be this stance regardless of which political party was behind it because my stance is data and research-informed in terms of what influences health. Period. And thanks for coming to my Ted Talk.)