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Social class and diet quality

SUNY-Health Science Center
Department of Pediatrics
450 Clarkson Avenue
Brooklyn, NY 11203
E-mail: rkarp{at}downstate.edu

Dear Sir:

The commentary by Darmon and Drewnowski, "Does social class predict diet quality?" (1) provides support for a phenomenon well described in the English literature (2, 3). As food costs rise, food selection narrows to those items providing the most energy at the lowest cost. When these conditions persist, essential nutrients disappear from the diet and malnutrition ensues (3, 4). This, the [Freidrich] "Engels’ phenomenon," derives from an 18th century observation of the deteriorating diet of English working men whereby "...at the lowest round of the ladder, among the Irish, potatoes provide the sole food" (2-4). Nutritionists in the United States have not been exposed to this observation, reflecting, perhaps, its origins with an original Communist theorist and disbelief that poverty was widespread here (5).

The authors are to be commended for their consistent use of the phrase "Socioeconomic status (SES) associated variables," rather than SES (1), because the dimensions of the outcomes are greater between SES groupings than they are within them (6). SES, like race-ethnicity, never explains. Rather, it points to social gradients or "causes of causes" affecting well being (7). These are, as Marmot writes, "....influenced by such factors as social position, relative versus absolute deprivation, and control and social participation" (7).

I have 2 concerns. First, economic factors, taken alone, do not determine the nutritional status of individual children in a family or community (4, 8, 9). Elements of food culture have a powerful impact on outcome, more so perhaps among the poor than among the affluent. As Gopalan writes, "Differences in the nature of intra-familial distribution of food, in particular in infant feeding and childrearing practices, between the families and between communities can result in important differences with nutritional status (especially of children) between households, and between communities with nearly similar overall levels of dietary inadequacy" (8).

Second, we need not stand idly by while the costs of essential goods and services rise beyond the ability of those who produce those goods and provide those services to afford them (10). Mechanisms to reverse Engels’ phenomenon are at hand. Supplemental programs such as WIC, School Feeding, and Food Stamps improve nutritional status in 2 ways (11). The foods provided have a high nutritional value, and families then spend the same dollar amount to meet lower energy needs. Thus, the nutrient value of the foods purchased by a poor family increases to that of the "nonpoor." The foods consumed would move to the right on the curves provided in Figure 2 of the article by Darmon and Drewnowski (1), essentially reversing Engels’ phenomenon.

Promoting good nutrition and addressing issues of availability and affordability must inform public policy. I would appreciate comments from the authors on the effect of food culture on the adequacy of diet and the impact of social interventions to make culturally acceptable nutritious food available and affordable. Thank you for this excellent contribution to the literature on nutrition and poverty.

ACKNOWLEDGMENTS

No conflicts of interest were declared.

REFERENCES

1. Darmon N, Drewnowski A. Does social class predict diet quality? Am J Clin Nutr 2008 May;87(5):1107–17.[Abstract/Free Full Text]
2. Engels F. The conditions of the working class in England. London, United Kingdom: Penguin Books, 1845 (republished in 1985).
3. Burnett J. English diet in the eighteenth and nineteenth centuries. Prog Food Nutr Sci 1976;2(1):11–34.[Medline]
4. Karp RJ. Malnutrition among children in the United States. The impact of poverty. In: Shils ME, Shike M, Ross AC, Caballero B, Cousins RJ, eds. Modern nutrition in health and disease. 10th ed. Baltimore, MD: Williams Wilkins Lippincott, 2005:86–874.
5. Karp RJ. Introduction and overview. In: Karp RJ, ed. Malnourished children in the United States: caught in the cycle of poverty. New York, NY: Springer Publishing Co, 1993:24.
6. Wachs TD. Necessary but not sufficient: the respective roles of single and multiple influences on individual development. Washington, DC: American Psychological Association, 2002.
7. Marmot MG. Understanding social inequalities in health. Perspect Biol Med 2003;46(3):S9–23.[Medline]
8. Gopalan C. Undernutrition: measurement and implication. In: Osmani SR, ed. Nutrition and poverty. New York, NY: Oxford University Press, 1992:17–48.
9. Karp RJ, Cheng C, Meyers AF. 2005. The appearance of discretionary income: influence on the prevalence of under- and overnutrition. International Journal of Health Inequities. Available from: http://www.equityhealthj.com/content/4/1/10 (accessed 8 August 2008).
10. United States Catholic Conference, Inc. Economic justice for all: pastoral letter on Catholic social teaching and the U.S. economy. Washington, DC: United States Catholic Conference, Inc, 1986:99.
11. Karp RJ. Problem of changing habits: how food habits are formed. In: Karp RJ, ed. Malnourished children in the United States: caught in the cycle of poverty. New York, NY: Springer Publishing Co, 1993:188.

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