The Bagel Shop

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As of March 2011, certain fast food establishments began posting calorie information on their menus



Pennsylvania has terrible bagels.  While the Keystone State has many redeeming qualities, its bagels are not one of them.  About a year ago I was visiting upstate New York and made my regular stop in one of my favorite bagel shops.  It was a chain establishment, not quite like the “mom and pop” ones in New York City, but still one of my favorites.  The menu however had changed since my last visit.  Next to all the menu items there were numbers for the calories in each item.  As a health educator that has spent a lot of my career working with adolescents conducting personal diet analysis, I was fascinated and intrigued by this new phenomenon in New York. 

I was so used to working with students and clients that were not aware of calorie content in the food they eat, particularly what they drink, that I must have been speaking out loud to myself at seeing the 430 calorie coffee drink right there in black and white.  At that moment, the shop owner engaged in a conversation with me regarding this recent New York State menu regulation.  He explained to me that within a few months, many restaurants were going to be required to reveal the calorie content on their menus.  I nodded with interest and continued to listen.  He summarized his explanation with, “Now the government has to tell us what to do.  As if we can’t make our own choices!”

A conversation about ideology seemed rather fruitless because swirling through my mind was the reality.  We are now looking at an American public where 2/3 are considered overweight or obese.  The health and economic costs to this reality has been devastating.  While obesity is associated with an increased risk of heart disease, diabetes, stroke, some cancers, hypertension, high cholesterol and sleep disorders, it has had a detrimental impact on our healthcare costs.  In 2008, an obese person cost our medical system $1429 more per person than someone of normal weight.  Overall, this adds up to a systemic cost of $147 billion a year to our public and private insurance pools.[i]  In a study done by the USDA, Americans spend 42% of their food budget away from home.[ii]  An extra 134 calories a week from one additional meal away from home amounts to an extra 2 pounds of body weight each year.[iii]

As of March 2011, nutrition labeling in chain restaurants came to Pennsylvania as well as the rest of the country.  A provision in the Patient Protection and Affordable Care Act now states that there must be clear nutrition labeling on the menu at all chain restaurants with 20 or more establishments.  Additionally, vending machines must also contain nutrition information.  Establishments in which their primary role is not to sell food, such as movie theaters and bowling alleys are exempt from this provision.  


I simply replied to the store owner, “because of your new menu labels, now I can make my OWN informed choice.”

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[i] Finkelstein, EA, Trogdon, JG, Cohen, JW, and Dietz, W. Annual medical spending attributable to obesity: Payer- and service-specific estimates. Health Affairs 2009; 28(5): w822-w831.

[ii] Todd, J., Mancino, L., Lin, B., The Impact of Food Away from Home on Adult Diet Quality.  USDA Economic Research Report #90.  February 2010.

[iii] Ibid.

The Health/Wealth Gap: Stacey's Story part II

This is the conclusion Stacey's story, which is a part of a three-part series called "The Health/Wealth Gap".

Stacey in Philadelphia

Stacy can hear the distant gun shots as she sits in the living room of her home in the Philadelphia neighborhood she grew up in.  The police sirens echo in the dark night.  As a single mom, she keeps her 2 boys close.  Cleats and sports paraphernalia are in the hall.  They are the only luxury in the budget for the boys.  The free sports programs keep them off the street.  Nursing textbooks for Stacy’s bachelor’s degree program are strewn about the floor of this home she now owns.  She is prideful of being the first homeowner in her family, but she is determined that life can offer better. 

Each day Stacy goes to her job caring for a terminally ill child.  Changing G-tubes, Oxygen, trachea care, and vents are a part of her daily routine.   It’s October, usually her patient gets sick and ends up in the hospital.  Fortunately for him and Stacy this year he is able to be managed at home.  Stacy wouldn’t get paid if he wasn’t.  Stacy makes $33,000 a year as an in-home Registered Nurse in Philadelphia.  She is paid hourly with no steady schedule.  She does not have sick time or personal days.  To get any personal days she has to work 2000 hours (almost 1 year).  Stacy, an educated Registered Nurse who cares for terminally ill children also does not have health insurance.

While she is offered health insurance by her employer, they do not contribute and she simply cannot afford the $650 a month for the family, or 30% of her income.  After the mortgage, electric, water and groceries it is financially impossible.  Under the shadow of this financial reality, Stacy rubs her sore joints.  She has Lupus, an autoimmune condition like her mother.   

The cycle never broke.  The demons that haunted Stacy in childhood hover.  They torment and crawl into every crevice of her being and refuse to leave.  Why won’t they go away?  Like her parents before her, she did what she was supposed to do, but the demons of poverty refuse to leave.

The reality that lack of health insurance is synonymous with poverty is evident.  However, what is the possibility that children can break out of the cycle of poverty?  A report from the Congressional Budget Office states that between 1979-2004, roughly the timeline of Stacy’s story, the poorest one-fifth of Americans saw their income rise 9%, the wealthiest one-fifth saw their income rise 69% and the top 1% saw their income rise 176%.  As economic inequality has grown, so has the inability for intergenerational social mobility.[1]  According to a 2010 OECD report, social mobility between generations is dramatically lower in the United States compared to other developed countries.[2]

While the Patient Protection and Affordable Care Act gives hope to the working poor because they can now access healthcare on the individual exchanges with premium tax credits, we are still left with the question about prosperity.  Are we really the land of opportunity?  Do we really live in a society that rewards its citizens for their efforts and values them for their contributions?  Does the American Dream really exist?

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[1] Sawhill, I., Morton, J., “Economic Mobility:  Is the American Dream Live and Well?”  Economic Mobility Project.

[2] Economic Policy Reforms:  Going for Growth.  A family Affair:  Intergenerational Social Mobility Across OECD Countries.  2010

The Health/Wealth Gap: Stacey's Story Part I

This is the second of a three part series called "The Health/Wealth" Gap and features Stacey from Philadelphia.

October 2011:  Stacey in Philadelphia

Stacey's mother, Susan, rubbed her child’s cheek.  With each stroke she prayed that it would take away the pain or at best, sleep would rescue her baby from the suffering.  Susan was recently widowed and with no dental or health insurance, the gentle touch of a mother’s hand was the best she could offer her child.  Its the mid 1970's, Stacey is age one, the youngest of the three children her widowed mother had to care for in this working class neighborhood of Philadelphia.  Stacey's father died at 38.   After almost 20 years of service to the steel mill, the family couldn’t prove that the years left him with the cancer that took his life. They were certain however, that the years of service did leave the family without any health insurance.  Stacey's father died 10 months shy of the family being able to collect his pension.  

It wasn’t supposed to be like this.  When Stacey's parents got married in the early 1970's, they were prepared to fulfill the roles expected of them at the time.  Stacey's father had a reliable union job in the steel mill while her mom became a stay-at-home mom of 3 children.  They had staked their claim in a home in the Philadelphia neighborhood.  They had captured the “American Dream”.  At least they thought they had.    

Stacey's father's untimely death wasn’t part of the plan.  Either was the rheumatoid arthritis that soon set in to her mother's hands.  Rheumatoid arthritis, an autoimmune disease, is a condition where the body attacks itself.  Like the condition that slowly began to cripple Susan's hands and the rest of her body, life seemed to be doing the same for Stacey's parent's “American Dream.”

As the years went on, Stacey's mother raised the 3 children on the SSI left to them by their father.  It was the 1980’s, economic prosperity seemed to loom about the nation.  Those were not the memories of Stacy’s childhood.  Her mother didn’t qualify for Medicaid because she ‘made too much money’ from the children’s SSI.  It was only because of the goodwill of a neighborhood doctor that her mother received free medical oversight.  However, kindness and goodwill from one caring doctor didn’t pay for expensive procedures, equipment and medications.

As Stacey grew up, she was determined to break the cycle of poverty she witnessed as a child.  Like many Americans, she believed that with hard work she could pull out of poverty.  Education was the way to go.  She received her LPN and eventually her associate’s degree in nursing (RN).  Her first patient was her mother.  By this point Susan was considered clinically disabled and qualified for Medicaid.  With each changing administration, policy and budget change however, Stacey fought to keep her mother insured.  As unpaid bills and cancellation notices came in, Stacey fought.  Susan died at the age of 63, 2 years shy of being eligible for Medicare.  

Please return next week for Part II of "Stacey's Story".

*names have been changed to protect the identity of the subjects.

The Health/Wealth Gap: Stacey's Story

This is the first of a three part series entitled the "Health/Wealth Gap".

Stacey in Philadelphia

In reflection of President Obama’s State of the Union last week, the issue of fairness was a prevailing theme.   This theme has often been painted with slogans such as “class warfare” or “redistributing the wealth”, but when we dig deeper behind the meaning of fairness, we can see that it really is about access to opportunity.

It is a common statement in the field of public health that the “less you have, the more you have”.  In other words, those from lower economic means have a greater prevalence of disease and disability.  The poor have a tendency to live in crowded or environmentally toxic living conditions with substandard housing and are less likely to have access to healthy food.  In fact, the poor disproportionately live in areas we dub “food deserts”, regions in which affordable healthy food and transportation to them is lacking.  It also shouldn’t be a surprise that the working poor are also disproportionately represented among the pool of the uninsured, therefore exponentially increasing their prevalence of disease and disability.  Finally, the poor live in areas with a low tax base resulting in substandard education that leads to lack of awareness concerning health issues and opportunities to rise beyond their current social status.   

My travels across Pennsylvania have certainly shown many things about our healthcare crisis.  Our changing global economy with its evolution from manufacturing jobs to service sector jobs has taken its toll on the working class.  Between 1980-2007, the number of Americans with access to employer provided healthcare has drastically declined.[1]  The need for cheap labor has meant increase in low wage jobs with little or no benefits.  In other words, there has been a lack of opportunity for the working class to achieve economic social mobility which guarantees protections and security in the area of health.

In the Fall of 2011 I became intrigued by what I saw emerging in the national landscape and ongoing dialogue about economic inequality as the “Occupy Wallstreet” movement unraveled across the country.  Being aware of what I have come to call the “Health/Wealth gap”, I was certain that this national dialogue about economic inequality had to encompass those that have been shut out of access to healthcare. 

With this in mind, in mid-October I hit the road and headed to Philladelphia to join an “Occupy Philly” rally to see what I could find.  I had no idea what to expect and the day I went I only had enough change to plug my parking meter for 2 hours.  It only took 10 minutes before I met Stacey, a full-time employed nurse and mother of two.  I spent those 2 hours talking to Stacey and documented her story.  For the next 2 weeks I will tell her story that goes back 2 generations, beginning with her parents.

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[1] Cohen RA, Mukuc DM, Bernstein AB, Billheimer LT, Powell-Griner E. Health Insurance coverage trends, 1959-2007: Estimates from the National Health Interview Survey. National halth statistics reports; no 17. Hyattsville, MD:  national Center for Health Sttistics. 2009.