Social Determinants of Health: How to Actually Make America Healthy

After the longest January ever, we made it to February and… I’m not sure how much better it is. If you are feeling hopeless in the current state of the world, you are not alone.

I’ve had a lot of sessions with clients who have brought up topics like ultra-processed foods and red dye #3. While I’m happy to talk about what the research shows us around UPFs and food additives, I can’t help but think this is all intended as a distraction from what is actually going on in this country. (By the way, did you know that canned beans and gummy bears fall into the same processing category?)

In the same way that big corporations benefit from offing responsibility for the environment onto individuals (there’s a reason major grocery store chains lobbied extensively for a plastic bag ban here in Colorado, and it’s not because they actually care about saving the planet), our government (and culture) are doing the same with health. This isn’t anything new - ever since the 90s when “obesity” was first declared an epidemic, the impetus for health has fallen on the individual. Harping on the detriments of processed food is just more of the same.

But the reality is, we don’t actually have as much control over our health as we have been led to believe. And that is what I want to talk about today.

The US Department of Health and Human Services (for now) defines social determinants of health (SDOH) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks”. While traditional models of health center the individual as the driver of changes (positive or negative) in health, SDOH considers all of the external factors that play a role.

Here is what actually contributes to our health:

Let’s go through each of these categories:

Individual behavior: 40%

The traditional healthcare model encourages us to exercise and eat well and reduce stress and pursue “wellness”. And these are obviously things that I believe in doing (I am a dietitian after all…). But - I’m not sure about anyone else, but this all seems pretty tone-deaf to me in the grand scheme of things. 40% is not nothing but that still leaves quite a lot out of our direct control. Never mind that the pursuit of wellness is a privilege afforded to those with the time and resources to pursue it. (More on that later.)

Genetics: 30%

We have literally no control over our genes. If you have a family history of heart disease, you can reduce your risk by exercising, eating a heart-healthy diet, and reducing stress… but you still can’t escape these genetics.

Access to healthcare: 10%

In 2023, almost 10% of Americans were uninsured (source). Insurance leaves a lot to be desired but the reality is, people without insurance are less likely to receive preventive care and more likely to have worse health outcomes. Insurance coverage does not guarantee access to care, though. In rural areas, specialists may not even exist.

And even in large cities with a lot of healthcare providers, the quality of care varies considerably on the basis of things like race, income, and body size. Health disparities are well-documented. Many healthcare facilities lack equipment such as blood pressure cuffs or MRI machines suitable for large bodies. Racial and anti-fat bias in healthcare is very prevalent, with providers spending less time with patients in fat or black bodies (see, for example, PMID: 26469668), often resulting in misdiagnoses and delayed treatment.

Social and environmental factors: 20%

This category encompasses a lot of different things - many of which are interconnected and many of which can be impacted by public policy. For example:

• Neighborhood and built environment: If your neighborhood doesn’t have sidewalks and speed limits are high, going for a walk or run outside is dangerous. Research indicates that things like access to parks and sidewalks and ball fields is associated with increased levels of physical activity.

• Environment: Low-income neighborhoods tend to have poor air quality (the Globeville/Elyria-Swansea neighborhoods in Denver are a great example of this).

• Economic factors: A single mother of 3 working 2 jobs to put food on the table may not have the time or resources to exercise or to prepare meals with fresh produce or grass-fed beef. She probably can’t afford the organic candy for her children that doesn’t contain artificial dyes, either.

• Education: This is closely associated with income. People with higher levels of education tend to have higher levels of health literacy, earn higher wages, and have better access to healthcare.

• Social norms and support networks: Social norms surrounding going to the doctor, handwashing, and vaccination can impact health behaviors. Community organizations can be critical in improving public health. Community health workers and promotoras are often on the front lines encouraging things like vaccinations, masking, eating vegetables, and so on.

And all of these things are related! For example, a child from a low income family who misses a meal may go to school hungry. Hungry children have trouble focusing at school and go on to have worse academic outcomes. This impacts future job prospects, and the cycle of poverty repeats.

Why does any of this matter? Because red dye #3 serves as a distraction for the real problems our country faces right now. If we really care about making America healthy, we need policies that support EVERYONE in accessing basics like food, housing, and healthcare. We need to support funding for programs like SNAP and regulate the actions of health insurance companies. We need policies for cleaner air. We need to protect gender-affirming care. We need government regulation of our food supply and we need public health programs that promote vaccination and health literacy.

I know things may feel hopeless right now and I can’t pretend to have the answers to anything. But I do know that it’s important that we keep our eyes on the bigger picture here and don’t get pulled down rabbit holes that are created solely to distract us from the things that actually matter. Sending emails and calling representatives feels really scary (my heart still pounds every single time I pick up the phone). But if everyone who reads this email commits to making one phone call - we may actually make a difference.

When I sent this out in my newsletter, I received some pushback that this was too political for a dietitian. The reality is, the work that I do is inherently political.

Eating disorders and body image issues don’t exist in a vacuum but rather in the social and political contexts that treat fat, black, trans, and female bodies like second-class citizens. If we want a world where everyone can feel good in their skin, we have to create one in which the most marginalized are safe to exist and thrive.

In case it is not abundantly clear, I believe that all bodies, including fat and black and trans bodies, are no less deserving of high quality healthcare free from discrimination, wide sidewalks, and clean air than the rest of us. Creating policies and a culture that supports these bodies is the way that we actually make America healthy.