Steep rise in heart-disease risk factors among low-income people.

A senior living alone would need at least $100 extra, researchers said. The study focused on low-income, African-American residents in Roxbury, Massachusetts.

"Low-income people, in this particular community, who receive food stamp benefits have very limited access to a culturally appropriate diet filled with heart-healthy foods," said Rachael S. Fulp, M.P.H., director of the Center for Cardiovascular Disease in Women at Brigham and Women's Hospital in Boston. "Food cost can be a significant barrier to developing and maintaining healthy lifestyle behaviors."

Roxbury is one of the poorest neighborhoods in Boston. Twenty-seven percent of its residents live below the federal poverty level, and according to self reports, they have some of the worst lifestyle habits in Boston.

Extensive Focus Group Testing

The cost of heart healthy foods coupled with the steep rise of coronary risk factors in this African-American community caught the attention of Fulp and her colleagues. They hypothesized that maximum food stamp program benefits in Massachusetts would be insufficient to purchase heart-healthy, culturally appropriate meals for families and seniors living alone in Roxbury.

The researchers conducted two sets of extensive focus group testing with six African-American women who had children under age 18 and six African-American women age 65 and older living alone. Women were targeted for this study because they generally make key dietary choices and influence lifestyle decisions for their families. All participants were Roxbury residents.

Culturally Appropriate Food Plans

A series of model seven-day menus was developed, tested and revised based on focus group discussions about household food preferences, preparation, cost and access issues. The menus were translated into shopping lists, and food prices were collected at two large local grocery stores where focus group members shopped. Average daily and monthly food costs were then calculated.

"Many sets of cost-effective menus have been developed in the past for members of low-income communities," said Fulp, "but none were developed with as much input from the community related to taste and cultural appropriateness as were ours."

Fulp emphasized that their menus incorporated a lot of regular items, such as regular margarine, regular maple syrup, and 2 percent milk, along with healthier items.

"We found out what participants would eat on a regular basis and adjusted the recipes to make the dishes healthier without sacrificing taste. We wanted to develop menus that real women would use, so we thought that it was imperative not to eliminate all of the foods that the focus group members enjoyed," she said. She described the menus as modest, yet meeting nutritional needs.

The average monthly food cost was $242 for a senior living alone and $692 for a family of four. Maximum food stamp benefits in Massachusetts are $139 for individuals and $465 for a family of four.

Community Involvement Needed

"At current funding levels, low-income people will have a very hard time accessing the kind of foods they need for a heart-healthy diet. It is very important that we use these findings to develop interventions to educate and engage community members, advocates, legislators, healthcare providers, health educators and other constituents. All interventions that stem from this study will be developed in line with political and funding realities," said Fulp.

Researchers plan to work with the food stamp program in Massachusetts, along with various government programs, educational institutions, and statewide businesses and organizations such as grocery stores, community-based organizations, community coalitions, advocacy groups and schools. By joining with these local groups, they hope to develop interventions, educational programs and incentives that address the major factors affecting dietary choice -- knowledge, skills, accessibility, availability and affordability.

In addition, said Fulp, "Communities need to work collaboratively with local businesses to address the issue of quality heart-healthy foods that are accessible and available.

It is also critical that food pricing and government subsidies are addressed as a matter of public health policy."

Fulp notes that a limitation of the study is that the data are confined to one ethnic group within one community. For this reason, they plan to conduct a similar study in another local community, Jamaica Plain, Massachusetts, with Latina women.

Co-authors are Katherine D. McManus, R.D., M.S. and Paula A. Johnson, M.D., M.P.H.