The cost of good nutrition

During the good weeks -- when there are no surprise expenses, when the coupons are generous, when she scrounges enough stray pennies -- Robin Smith can afford the skinless chicken breasts.

"And once in a blue moon," she said, "if I'm doing OK, I get some fresh vegetables."

After paying rent and utilities and stashing a few dollars in the credit union, Smith, a Mission Hill resident and longtime hospital worker, can spend $30 a week, maybe $40, on groceries that will keep herself and her daughters healthy.

In broad swatches of urban America and in decrepit industrial towns, people with low incomes struggle and frequently fail to eat a nutritious diet -- the kind necessary to prevent heart disease, diabetes and obesity. Research shows poverty makes people more vulnerable to all three.

It is a plight borne of scarcity -- not enough money, not enough decent food in neighborhood stores, not enough knowledge about what constitutes a healthy meal or the time to fix it.

The consequences become evident when children with delayed development tied to severe iron deficiency from lack of vegetables turn up at the Whittier Street Health Center in Roxbury; or when children are so malnourished that Dr. Deborah Frank has to hospitalize them at Boston Medical Center. The number of babies requiring such treatment tripled from 1999 to this year.

"We've had mothers burst into tears when we've told them their kids have to eat at least three times a day. They can't imagine being able to do that," said Frank, director of Boston Medical's Grow Clinic for Children, which treats youngsters failing to thrive because of poor nutrition.

"Malnutrition is not an eyeball diagnosis in this city. You may have walked past many little round-faced kids on the street and said, 'Oh, what a cute 1-year-old.' What you don't know is that's a malnourished 3-year-old."

Dr. Paula A. Johnson and her colleagues at Brigham and Women's Hospital decided to examine what a dozen Roxbury women were eating and analyze how much it would cost them to stick to a diet designed to provide maximum protection for their hearts.

They found, for instance, that a family of four would need nearly $700 a month, while a senior would require upward of $250. For that amount, they could afford lunches that might include 3 ounces of white tuna and whole wheat bread and dinners consisting of a baked pork chop, sweet potato, and mixed greens with a tomato.

And they learned this, too: Food stamps don't come close to covering the cost. Even with recent increases in the benefit, a family of four would fall nearly $200 short while a senior would need $100 more.

The federal government intends food stamps as an add-on, to enable people to buy foods that are part of federal dietary recommendations, not as the sole source of food payment, US Department of Agriculture spokeswoman Jean Daniel said.

Angie Clark of Mattapan said she gets $107 a month in food stamps for herself and her two youngest children -- and she doesn't have much room to supplement that benefit.

"But they don't go hungry, whether I have to go to a pantry or whatever," said Clark, 47, who seeks help from the Boston Medical Center's food pantry, which makes a point of providing only healthy options.

Food prices alone are not the cause of malnutrition and obesity, said Parke Wilde, a specialist in the economics of domestic food policy at the Friedman School of Nutrition at Tufts University.

In part, Wilde said, research has shown that people in poverty confront a "heat-or-eat" dilemma -- when cold weather forces heating bills higher, food purchases tumble.

"Food prices in the grocery store isn't where the real pinch is in the Boston metro area. I would be just terrified to be low-income looking for housing," Wilde said.

Also, healthy food choices are simply more limited in low-income neighborhoods, studies have shown. Instead of the stadium-sized supermarkets that are the hallmark of suburban America, inner-city neighborhoods are more likely to have corner markets bereft of anything that isn't packaged, processed, or pre-dated.

Boston, it turns out, fares better than most cities, with more urban grocery stores than average, according to the Brigham report, released earlier this month. In Washington, for example, the city's Southeast quadrant, an especially impoverished swath, doesn't have a single big supermarket, the USDA's Daniel said.

And specialists from the University of Massachusetts Medical School working with low-income diabetics in Springfield discovered that their North End neighborhood has no grocery store. To reach a supermarket involves crossing a highway and a river.

"People who live in these kinds of neighborhoods are eating the foods they can get at their corner market or the things stressed out single parents can get easily," said Dr. Paul Geltman, director of pediatrics at the Whittier Street clinic. "And they're eating fast foods, which tend to be high calorie, high fat, and encourage overeating -- the old 'supersize me' phenomenon."

Even when low-income neighborhoods do have groceries, choices can be more limited and less appealing, residents and researchers said. Clark said the meat in one nearby store is bathed in a grayish hue, rather than the juicy, pinkish sheen of beef available a trolley-ride away.

Even when healthy options are accessible, specialists said, lack of education and ethnic traditions can present barriers to eating well.

The UMass researchers are now trying to help Hispanics in Lawrence avoid developing diabetes. They will instruct a group of them in the basics of healthy eating, offering classes on how to prepare healthy meals.

Specialists such as Milagros Rosal also will focus on the psychological and social issues that can prevent the poor from eating well, encouraging them to think twice about how they eat.

"It means having people ask questions like, 'Do I eat a piece of doughnut now because it's pleasurable to me, or do I hold off so I won't get heart disease in 10 years?' " said Rosal, a clinical psychologist. "I've had patients say, 'I might as well enjoy life now because I don't know what's going to happen in the future.' "

Robin Smith, 42, said her secret to eating healthy on a tight budget is being a very careful shopper, reading labels, clipping coupons, buying generics, and rinsing the salt off canned vegetables.

"You can do all kinds of things with rice if you have onions, green peppers and whole tomatoes."

Stephen Smith can be reached at stsmith@globe.com.