Health and Healthcare Systems

How cities can have an impact on healthier food options

Some three billion people worldwide cannot afford healthy food.

Some three billion people worldwide cannot afford healthy food. Image: Unsplash/engin akyurt

Joneigh Khaldun
Vice-President and Chief Health Equity Officer, CVS Health
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This article is part of: Centre for Urban Transformation
  • Food can help us live healthier lives but the poorest urban populations often face barriers to accessing nutritious foodstuffs.
  • Three billion people worldwide cannot afford healthy foods, while in the US, 54 million do not have reliable access to them.
  • City leaders, private sector partners and civil society organizations can work together to provide cooking and nutrition lessons.

Food has the power to bring people together, express culture and help us live healthier lives. However, the poorest urban populations still face economic, environmental and geopolitical barriers to accessing nutritious food.

Some three billion people worldwide cannot afford healthy food. In the US, 54 million do not have reliable access to food and only 1 in 10 people eat the recommended amount of fresh fruits and vegetables.

This lack of access to nutritious food not only contributes to health inequities that can lead to obesity and malnutrition, but can also have repercussions on a local community and societal level – including increased health care costs and poor educational outcomes.

Cross-industry collaboration is therefore needed to address the intertwined issues of food insecurity and urban affordability. Many urban localities, particularly in the US, have already found success through an alleviate, educate and ideate framework.

Alleviating the cost burden of nutritious food

Cities can make healthy food more accessible and provide immediate relief for city residents by alleviating the cost burden of nutritious food, which is often more expensive than “fast food” or ultra-processed food.

By leveraging community partners, city leaders can address the economic and geographic barriers to access. It’s critical that they work with trusted local organizations that meet people where they are – right in their communities.

The City of Seattle’s Fresh Bucks programme, for example, provides eligible enrolled individuals with financial assistance each month to purchase fruits and vegetables at local grocery stores and farmers markets. This has helped reduce the cost of healthy food while supporting local businesses.

In the first year of operation, 90% of shoppers using Fresh Bucks said they bought more fruits and vegetables due to the scheme. In 2022, it served 12,000 households and unlocked $7.36 million in economic impact.

The programme is successful because it uses funding from the City of Seattle – including from a tax on sweetened beverages – and additional support from the Washington State Department of Health to subsidize fresh produce.

Another approach to alleviating the cost of healthy food is by incorporating healthy food into the range of medical solutions provided to patients. Food is medicine (FIM) initiatives, such as creating medically-tailored meals or giving prescriptions for fresh produce, unlock additional sources of funding by allowing federal health programmes or benefits (like Medicare and Medicaid, among others in the US) to cover costs of healthy food for those who cannot afford them.

In Louisiana, Aetna Medicaid works with the Healthy Families Produce Rx program to provide eligible members in communities throughout the state with financial support each month to help them pay for fresh produce.

This joint effort from retail, health and community partners receives funding from the US Department of Agriculture’s Gus Schumacher Nutrition Incentive Grant Program (GusNIP), investing over $1 million in the local Louisiana food and health system, and also enrolling 50 families each month.

Local collaborations that bring resources from different sectors together, as well as the financial incentives unlocked for programme partners and participants, are why this initiative has been so successful to date. Across all GusNIP Year 3 Produce Prescription Programs, 9 in 10 participants (93%) were satisfied, and participants reported higher levels of fruit and vegetable intake and food security.

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Though FIM programs are still relatively new and are being tested and piloted, analyses have shown that these initiatives improve health outcomes and reduce overall health care costs. Using a model of a partial Medicare and Medicaid subsidy, researchers found that a healthy food incentive would lead to over three million prevented cardiovascular disease cases and nearly $40 billion in savings to health care costs.

These FIM interventions should be piloted and strengthened at the local level through cross-industry collaboration, helping to support local economic growth and making healthy food financially and geographically accessible.

Educating communities with culturally responsive approaches

Civil society plays a critical role in food insecurity. By teaching people healthy diet behaviours and how to utilize the food that is accessible to create healthy meals, communities are strengthened and individuals are able to take control of their own health.

At the El Pasoan food bank in El Paso, Texas, dietician staff from Aetna Medicare recently took a bilingual approach to providing food recipes that promote healthy eating. They developed healthy recipes to mitigate the risk of chronic disease, using ingredients that were easily accessible at the pantry.


During cooking demonstrations, community members learned how to cook the meals, sampled the food prepared and asked questions – thereby empowering individuals with information and resources to manage their own diet and health in a culturally responsive way that aligned with their circumstances and lifestyles.

Aetna Medicare’s multicultural care managers also provide culturally relevant cookbooks to members in local communities to raise awareness around the importance of a healthy diet and eating habits. These cookbooks have provided thousands of members across the US with healthy alternatives to common soul food and Latino meals.

City leaders could partner with city schools, food pantries and health care organizations to provide cooking and nutrition education. Teaching people how to make meals that are nutritious, accessible for their living conditions and relevant to their cultural background can create lasting healthy eating habits.

Addressing the link between food insecurity and urban affordability

City leaders can also address food insecurity and urban affordability through creative solutions that recognize the link between food and civic participation. Though food may be categorized as a basic resource, it’s also at the heart of humanity – and tapping into this connection can lead to community and food security benefits.

Mexico City was an early adopter of this approach, creating community dining halls known as comedores comunitarios that help provide affordable meals for urban residents while also building community and healthy nutrition practices.

The initiative has drawn together partners from all sectors, including government (with a government food subsidy), academic institutions, private companies making donations and most importantly, the citizens themselves.

Citizens play a critical role in creating community around the dining experience. Many of the dining rooms also offer employment to historically marginalized populations, including older adults and victims of domestic violence. Since the programme started in 2009, the population experienced a 10 percentage point decrease in food scarcity (from 15.5%-5.6%) as of 2018.

City leaders can address food insecurity with this same creative vision, recognizing how food is inextricably linked to community and empowerment. Food is not just something to be distributed – it also builds local connection, employment, solidarity and community responsibility.

By coming together to address food insecurity through nutrition education, alleviation of economic burdens to healthy eating and innovative programs that engage the community, city leaders and collaborators across public, private and civil society can advance both urban affordability and health outcomes for historically marginalized communities around the world.

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