Unlike many forces in our lives that feel or are beyond our control—from genetics to health care access to pollution—food consumption is often depicted as a place where we can directly apply our willpower and agency to affect our health. It is unsurprising then that food and diet decisions are the focus of a substantial amount of popular attention—from blogs and news stories to recipes and TV shows—with an emphasis placed on the agency and choices of individuals. Among these sources, messages surrounding what constitutes a healthy diet vary. However, it has largely been established that a diet based in a high proportion of fresh fruits and vegetables is associated with more positive health outcomes, while the “Western” style diet rooted in sugars, animal fats, and processed foods is a way for food consumption to translate into lower health outcomes. While dietary advice varies substantially around this simplified scheme, many pieces of advice one observes for choices of food consumption emphasize the importance of eating fresh fruits and vegetables.
Food deserts are a now classic example of the popularization of this way of thinking about the complexity and structural characteristics that constrain and enable individual food consumption. This is all to say that while food consumption does involve personal agency, the decisions about what foods to eat and how are fundamentally influenced by institutions and systems beyond one’s immediate control.
Population Health, Population Food, and Global Food Systems
Fruit and vegetable consumption is the focus of political, health, and social movements, which translate into sometimes sizable health differences between national publics. Over the past several decades, changes in the global food system have resulted in altering diets based on changes in the availability and accessibility of certain food bundles. Availability calls attention to the very presence—or lack thereof—of food options in a particular setting, and accessibility has to do with the resources necessary for acquiring available foods. Many governments, volunteer groups, and intergovernmental organizations devote a substantial amount of attention to the task of shifting individual diets through improved access and availability of food, and through shifting individual preferences and knowledge about food consumption. Furthermore, issues of access and availability highlight unique but interconnected structural factors that impact dietary behaviors. Because of their association with health outcomes, the inability to access or have available fresh fruits and vegetables represents important structural inequality across countries and publics.
The reach of such inequality is captured in recent estimates, which suggest that global consumption of fresh fruits and vegetables falls short by as much as 50 percent of goals set by the World Health Organization. In fact, under-consumption of fresh fruits and vegetables is one of the highest-ranked risk factors for attributable mortality, and is responsible for upwards of 3 percent of all deaths worldwide (WHO 2020). Notably, these deaths are disproportionately concentrated in middle- and low-income nations. Despite this, a central feature of modern global food systems is the increased provision of energy-dense and unhealthy food options, such as animal fats, vegetable oils, sugars, and cereals. In response, governments and intergovernmental organizations have initiated policy reforms and public health campaigns to increase the share of fresh fruits and vegetables in population diets. Thus, beyond individual choices, or even an individual-centered analysis of structure and agency, food consumption represents a central pillar of population-level issues of health.
Where Are People Eating a “Healthy Diet” and Who Benefits?
These examples all suggest that the decisions to consume fresh fruits and vegetables, and the consequences of these food consumption decisions, may be at least partially influenced by broader social systems. In some of our published work, we examined the questions of who consumed fresh fruits and vegetables more frequently, and who was especially likely to benefit from such decisions.
To examine the multileveled nature of food consumption, we examined patterns across different countries, and we considered how individual-level associations systematically vary by a country’s level of economic development. We find this approach to consumption decisions exciting because it highlights how food consumption decisions, and even the benefits of healthy eating decisions, are situated in a wide variety of contexts.
We examined how the consumption of fresh fruits and vegetables varied across and within countries, using nationally representative samples from 31 countries ranging from middle-income countries such as the Philippines and Chile to high-income countries such as the United States and Norway. We examined the frequency that individuals in these countries consumed fresh fruits and vegetables, as well as the magnitude of the association between healthy eating and health outcomes. We examined how these factors varied across richer and poorer countries, and how these differences affected class and gender dynamics within countries. Our findings suggest that social context—both within and between countries—has a strong influence on who participates in, and who benefits from, healthy eating habits.
We found that individuals in richer countries ate fresh fruits and vegetables more frequently than individuals in poorer countries, and that individuals in richer countries tended to have better health than individuals in poorer countries. Access and availability to healthier food options tend to be greater among richer countries, suggesting that this broader social context provides greater opportunities for individuals to pursue healthy eating. At the same time, we found individual structural factors to also impact healthy eating. Individuals with higher incomes tended to eat fresh fruits and vegetables more frequently than individuals with lower incomes, and that women tended to eat healthily more frequently than men. However, we find a substantial amount of variation among these broad trends.
For example, while we find that more frequent consumption of healthy fruits and vegetables is associated with more positive health outcomes, this association is much stronger among higher-income individuals in higher-income countries. The further away one moves from either one of these socioeconomic pillars, the association diminishes. Similarly, we find interesting gender differences in the relationship between healthy eating and health outcomes. Women who infrequently eat healthily in poorer countries have worse health than men who infrequently eat healthily in poorer countries, while women who eat healthily frequently have better health than comparable men in richer countries. In total, we found that to explain who eats fresh fruits and vegetables more frequently, and what health benefits are associated with these consumption patterns, we had to think about how individuals are parts of multilevel systems that open and restrict opportunities for health behaviors. Simply put, the benefits and payoffs to similar people making similar food consumption decisions depends on a broader national context.
Two sociological theories can help us understand why this is the case. First, the work of Bruce G. Link and Jo Phelan (1995) suggests that certain social structures—in particular socioeconomic status—may operate as “fundamental causes” of health and illness. As a fundamental cause, socioeconomic status impacts access to key resources that may be utilized through multiple mechanisms, serving to mitigate risk or the overall consequences of illness. While individuals may make decisions that are not health promoting, for those with higher levels of socioeconomic status, their greater access to resources generally translates into improved health outcomes.
Second, William C. Cockerham (2005) draws attention to how health lifestyles are impacted by structural factors beyond social class, including social identities, roles, and living conditions. Our findings of gender differences in eating behaviors and health benefits may be explained, in part, by a broader examination of the way gender operates at a structural level, influencing dietary choice through gender socialization, norms, roles, economic power, and practices surrounding fruit and vegetable consumption.
This work highlights the dynamic interplay between individual agency and broader structural constraints for a health behavior that many people perceive to be individualistic. The choices that we make to improve our health undoubtedly contribute to our ability to live healthier lives. Yet the ability to make these health positive choices, and the payoffs to these choices, vary based on our social position and the economic conditions of our broader national context.
Our research highlights the importance of considering food consumption choices as part of a system of fundamental causes that operate at individual, country, and cross-national levels as individuals, advocates, and policymakers attempts to adjust individuals’ diets and food consumption behaviors to improve population health.
Any opinions expressed in the articles in this publication are those of the authors and not the American Sociological Association.