October 2024 Issue
Plant-Forward Diets in Underserved Communities
By Dina Aronson, MS, RDN
Today’s Dietitian
Vol. 26 No. 8 P. 34
RDs can help clients access affordable, easy, and healthful plant-forward meals.
The challenge of food insecurity in the United States isn’t just about the lack of food availability but also the lack of nutritional quality. This is particularly the case in underserved communities where access to affordable, nutritious food often is limited. Plant-forward meals, characterized by their nutrient density, affordability, and ease of preparation, emerge as a potential solution in these landscapes.
Prevalence of Food Insecurity
Food insecurity, defined as the lack of consistent access to enough food for an active, healthy life, remains a significant public health concern in the United States.1 According to the USDA, in 2022, 12.8% (17 million households) were food insecure. These households, at some time during the year, had difficulty providing enough food for their family members due to a lack of resources. The prevalence of food insecurity in 2022 was statistically significantly higher than the 10.2% (13.5 million households) recorded in 2021 and the 10.5% (13.8 million households) in 2020.2
Among these food-insecure households, children are especially vulnerable. The USDA reports that in 2022, food insecurity existed in 8.8% (3.3 million) of all US households with children, up from 6.2% (2.3 million) in 2021 and 7.6% (2.9 million) in 2020.2 Childhood food insecurity may impact many facets of health, including physical development, mental and emotional well-being, and educational outcomes.
Food insecurity disproportionately affects low-income families, people of color, and rural residents, whose access to nutritious foods, such as fresh produce, often is limited by financial, geographical, and educational barriers.3 Strategic approaches to improve food security must account for all these factors. Plant-based and plant-forward meals are one potential means of mitigating these challenges to maximize food accessibility, affordability, and acceptance. Dietitians are uniquely positioned to promote healthy eating in these communities with evidence-based solutions, nutrition education, research, and advocacy.
Nutrition Challenges of the Underserved
Food choice is heavily influenced by food access. Economical constraints often limit choices to cheaper, less nutritious foods, and living in food deserts (ie, regions of the country where it’s difficult to buy affordable or good-quality fresh food) limits access to healthful foods. Lack of nutrition knowledge also plays a role in food choice.
Research consistently shows that lower-income households are more likely to have diets that provide inadequate levels of beneficial nutrients.4 They tend to consume diets higher in ultraprocessed foods and lower in whole foods, including fruits and vegetables, compared with higher-income households. 5 Higher-income households are more likely to buy whole grains, seafood, lean meats, low-fat milk, and fresh fruits and vegetables. Lower-income households purchase more cereals, pasta, potatoes, legumes, and fatty or processed meats. Their vegetables and fruits often are limited to iceberg lettuce, potatoes, canned corn, bananas, and frozen orange juice.6
Historical NHANES data shows that food insecurity is associated with a lower total Healthy Eating Index score and a higher intake of added sugars and empty calories.8 Food insecurity has also been associated with a higher intake of sugar-sweetened beverages and salty snacks.5
Prevailing food trends and cultural perceptions of food value can skew dietary habits away from wholesome, plant-based options. Misconceptions about nutrition and the perceived high cost and lack of familiarity with plant-based ingredients can further exacerbate the issue.
Finally, food quantity often trumps food quality for families struggling nutritionally. For example, $3 can buy a box of 12 Pop-Tarts or a pint of blueberries. While the blueberries may be the more healthful choice for a variety of reasons, providing 84 kcal per one-cup serving, the Pop-Tarts provide 371 kcal per one-pouch serving. People who struggle to feed their family or themselves tend to maximize calories per dollar and may be misled by deceptive marketing and motivated by habitual purchasing patterns.
The Case for Plant-Forward Diets
Poor diet quality, characterized in part by low intakes of whole foods and high intakes of refined grains, added sugars, and other ultraprocessed foods, may increase chronic disease risk. Underserved populations are also at increased risk of cardiometabolic diseases and obesity. Gone unchecked, these conditions can lead to disability and decreased quality or loss of life, especially in those without access to quality health care.
Whole food, plant-forward diets that include foods like whole grains, beans, nuts and seeds, vegetables, and fruits offer a spectrum of health benefits and may be an important element in addressing nutrient gaps in underserved populations. These diets are rich in many vitamins, minerals, fiber, and phytonutrients while being lower on average in sodium, saturated fats, and added sugars. Plant-forward diets have been linked to reduced risks of heart disease, obesity, diabetes, and certain cancers.11
Costs of Plant-Forward Diets
While lower socioeconomic status has been associated with decreased consumption of healthful foods and increased prevalence of chronic disease, many nutrient-dense, plant-based ingredients are affordable and versatile, making such a diet suitable for low-income households.10
According to a 2022 study that compared food costs for more than 1,000 consumers, those who ate a plant-based diet had lower food expenditures than those who ate omnivorous diets. In fact, consumers who ate plant-based diets spent less than all other consumers.12
Given the predominant perception that plant-based foods are more expensive, it helps to contextualize grocery expenditure using food staples. For example, consider dry beans and lentils as staples. Six cups of cooked beans cost under $1; that’s about $0.08 per 1/2-cup serving. Furthermore, on a cost basis per gram of protein, beans cost half as much as turkey and more than half as much as chicken breast.
Other simple swaps can improve nutrition and tip the scales toward plant-based diets on a budget. For example, a typical 10-oz bag of potato chips costs about $3 and may seem like a cheap source of calories, but that $3 also can buy about 4 lbs (16 servings) of raw potatoes or 3 lbs (12 servings) of carrots. Frozen fruits and vegetables are another bargain, especially the generic brands. The nutrient content of frozen varieties is comparable to that of their fresh counterparts, but they may cost up to half the price.13
Efficacy of Plant-Based Diets
Several studies using plant-based nutrition interventions in underserved communities have demonstrated promising health benefits. Their results are summarized below.
• A 2022 study evaluated the impact of whole foods, plant-based nutrition intervention on a population with metabolic disease living in an underserved community. The participants attended federally qualified health center-based group visits that centered around plant-based diets and nutrition literacy. The program was well-accepted and had significant positive impacts on BMI and cardiometabolic biomarkers.14
• The BROAD study, a New Zealand intervention among an economically disadvantaged population, compared whole foods, plant-based diet (no calorie restriction) with traditional care and found the former brought significant improvements in all measures, including BMI, cardiometabolic biomarkers, medication usage, and quality of life. The main tool used was a traffic light diet chart that designated foods to consume, limit, or avoid. According to the researchers, this program achieved greater weight loss at six and 12 months than any other trial that didn’t limit calories or mandate exercise.15
• A randomized controlled trial studied a Latino population with type 2 diabetes living in medically underserved communities. One group of participants was assigned to a predominantly plant-based diet, the other was assigned to a control diet in line with the National Diabetes Prevention Program. The plant-based diet group showed a statistically significant reduction in mean A1c levels compared with controls.16
Helping Communities and Individuals Increase Plant-Forward Meals
Dietitians can play a powerful role in helping clients learn the health benefits of plant-forward eating that respects their individual health needs as well as budgetary, cultural, social, and food preferences. Teaching the benefits of plant-forward meals, working on budgeting strategies, setting personalized, achievable goals, providing appropriate resources, and offering ongoing support are important elements for long-term success and adherence. RDs can begin by counseling clients on how to stock a plant-forward pantry.
Stocking a Plant-Forward Pantry
A well-stocked plant-based pantry can be a step toward improving diet quality. Essentials include legumes (eg, black beans, lentils, chickpeas), whole grains (eg, brown rice, quinoa, oats), nuts and seeds, canned, frozen, or fresh vegetables, and a variety of spices and herbs.
Incorporating culturally relevant foods ensures that dietary changes are consistent with cultural preferences. Dietitians can provide clients with budget-friendly shopping strategies, such as buying in bulk, choosing generic brands, comparing prices, using coupons, taking advantage of sales, and buying in season.
Meal Prep Efficiency
Healthful and efficient cooking techniques for individuals living in underserved communities are invaluable. Basic cooking skills, including steaming, sautéing, stir-frying, and roasting, can transform diet quality. Batch cooking, pressure cooking, and one-pot meals not only save time but also conserve energy and reduce food costs.
RDs can provide education on meal planning, which helps minimize food waste and maximizes the use of available ingredients. Moreover, teaching clients how to repurpose leftovers into new meals can further enhance the practicality, sustainability, and affordability of plant-forward diets.
Assistance Programs, Community Initiatives, and Support
Families and individuals with low incomes are eligible for food assistance programs that can help them buy ingredients for plant-based meals and receive ready-prepared options. Organizations such as Feeding America and Find Help, as well as the USDA National Hunger Hotline, provide local food and nutrition resources. Government programs such as SNAP and WIC are vital for offering nutritious food assistance.
Food pantries and food banks not only provide no-cost, healthful plant foods to families in need but some also may offer classes that teach healthy cooking skills. For example, a six-week cooking program offered by a Rhode Island food bank taught individuals how to cook plant-based recipes, resulting in decreased purchases of soda and snacks and increased consumption of fruits and vegetables.17
Fruit and vegetable incentive programs, community gardens and cooperative grocery initiatives, mobile farmers’ markets, and other support mechanisms can provide access to fresh produce and healthful plant-based staples.
Food as Medicine
A growing number of health insurance providers nationwide recognize the cost-saving advantages of adopting a food-as-medicine strategy for members facing food insecurity or those at risk of cardiometabolic diseases and other health issues.
Many states have received approval from CMS to use a portion of their Medicaid funds to pay for food benefits such as medically tailored meals, nutritious grocery boxes, meal kits, and produce prescriptions. Companies like Tangelo, Rfoodx, and Performance Kitchen distribute healthful, plant-forward, or plant-based, condition-appropriate meals. These meals have made a tremendous difference for thousands of at-risk, low-income Americans. Emerging research shows that these plant-forward food benefits not only improve diet quality and food insecurity but also help reduce hospital admissions and health care spending.18-21 Many of these programs distribute food and promote long-term nutrition literacy and self-sufficiency through education and referral programs.
Multifaceted Role
The dietitian’s role in empowering underserved communities to access affordable, quick, and healthful plant-forward meals is multidimensional. It involves providing nutrition guidance and advocating for access to healthful foods, teaching individuals and families practical cooking skills, and supporting policies that address the root causes of food insecurity. By focusing on plant-forward approaches, RDs can contribute significantly to improving the health outcomes and overall wellbeing of these communities, fostering a culture of healthy, sustainable eating.
— Dina Aronson, MS, RDN, is director of nutrition content for Tangelo, a medically tailored food benefits platform. She works remotely from Bloomfield, New Jersey.
MEAL IDEAS
Nutrition Meets Convenience
It’s essential that RDs provide a range of low-cost plant-based meal ideas that are nutritious and quick to prepare. Meals should focus on simplicity, nutrition, and flavor and appeal to individual food preferences, tolerance, health goals, and cultural background. Here are some examples of affordable, easy, plant-based meals that may cater to the nutritional needs and time constraints of individuals in underserved communities.
Breakfast
• Oatmeal topped with nuts or seeds, frozen berries, and a sprinkle of cinnamon
• Peanut butter banana smoothie
• Whole grain toast topped with chickpeas, sliced avocado, and a squeeze of fresh lime juice
• Savory hash made with potatoes, fresh or frozen vegetables, and tofu
Lunch
• Lentil soup with whole grain crackers
• Black bean burritos
• Baked sweet potato loaded with vegetable bean chili
• Whole grain pasta with tempeh and sauteed or steamed seasonal vegetables
Dinner
• Peanut vegetable stew with barley or quinoa
• Lentil and winter squash tacos
• Chickpea, spinach, and potato curry
• Tofu vegetable stir-fry with brown rice
References
1. Hunger and food insecurity. Food and Agriculture Organization of the United Nations website. https://www.fao.org/hunger/en/. Accessed December 1, 2023.
2. Household food security in the United States in 2022. US Department of Agriculture, Economic Research Service website. https://www.ers.usda.gov/webdocs/publications/107703/err-325_summary.pdf?v=2120.8. Accessed December 1, 2023.
3. Food accessibility, insecurity, and health outcomes. US Department of Health & Human Services, National Institutes of Health, National Institute on Minority Health and Health Disparities website. https://www.nimhd.nih.gov/resources/understanding-health-disparities/food-accessibility-insecurity-and-health-outcomes.html. Accessed December 1, 2023.
4. Oh H, Kim J, Huh Y, Kim SH, Jang S-I. Association of household income level with vitamin and mineral intake. Nutrients. 2022;14(1):38.
5. Leung CW, Epel ES, Ritchie LD, Crawford PB, Laraia BA. Food insecurity is inversely associated with diet quality of lower-income adults. J Acad Nutr Diet. 2014;114(12):1943-1953.
6. Drewnowski A, Eichelsdoerfer P. Can low-income Americans afford a healthy diet? Nutr Today. 2010;44(6):246-249.
7. Morales ME, Berkowitz SA. The relationship between food insecurity, dietary patterns, and obesity. Curr Nutr Rep. 2016;5:54-60.
8. Nguyen BT, Shuval K, Bertmann F, Yaroch AL. The Supplemental Nutrition Assistance Program, food insecurity, dietary quality, and obesity among US adults. Am J Public Health. 2015;105(7):1453-1459.
9. Chan EY, Zlatevska N. Jerkies, tacos, and burgers: subjective socioeconomic status and meat preference. Appetite. 2019;132:257-266.
10. Gonzalgo MR, Nackeeran S, Mouzannar A, Blachman-Braun R. Socioeconomic differences associated with consumption of a plant-based diet: results from the national health and nutrition examination survey. Nutr Health. 2024;30(2):253-259.
11. Melina V, Craig W, Levin S. Position of the Academy of Nutrition and Dietetics: vegetarian diets. J Acad Nutr Diet. 2016;116(12):1970-1980.
12. Pais DF, Marques AC, Fuinhas JA. The cost of healthier and more sustainable food choices: do plant-based consumers spend more on food? Agric Econ. 2022;10(18).
13. Miller SR, Knudson WA. Nutrition and cost comparisons of select canned, frozen, and fresh fruits and vegetables. Am J Lifestyle Med. 2014;8(6).
14. Bansal S, Connolly M, Harder T. Impact of a whole-foods, plant-based nutrition intervention on patients living with chronic disease in an underserved community. Am J Lifestyle Med. 2021;16(3):382-389.
15. Wright N, Wilson L, Smith M, Duncan B, McHugh P. The BROAD study: a randomised controlled trial using a whole food plant-based diet in the community for obesity, ischaemic heart disease or diabetes. Nutr Diabetes. 2017;20;7(3).e256.
16. Ramal E, Champlin A, Bahjri K. Impact of a plant-based diet and support on mitigating type 2 diabetes mellitus in Latinos living in medically underserved areas. Am J Health Promot. 2017;32(3).
17. Flynn MM, Reinert S, Schiff AR. A six-week cooking program of plant-based recipes improves food security, body weight, and food purchases for food pantry clients. J Hunger Environ Nutr. 2013;8(1):73-84.
18. Berkowitz SA, Delahanty LM, Terranova J, et al. Medically tailored meal delivery for diabetes patients with food insecurity: a randomized cross-over trial. J Gen Intern Med. 2019;34:396-404.
19. Gurvey J, Rand K, Daugherty S, Dinger C, Schmeling J, Laverty N. Examining health care costs among MANNA clients and a comparison group. J Prim Care Community Health. 2013;4(4):311-317.
20. Berkowitz SA, Terranova J, Randall L, Cranston K, Waters DB, Hsu J. Association between receipt of a medically tailored meal program and health care use. JAMA Intern Med. 2019;179(6):786-793.
21. Berkowitz SA, Terranova J, Hill C, et al. Meal delivery programs reduce the use of costly health care in dually eligible Medicare and Medicaid beneficiaries. Health Aff. 2018;37(4):535-542.