Assessing Dietary Quality and Chronic Disease

Among Adults in Grand Rapids, Michigan

NUTR 642 Community Needs Assessment
November 8, 2021
Maddie Yaw

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Background Section

The purpose of this needs assessment is to assess dietary quality and chronic disease among
adults in Grand Rapids, Michigan. The prevalence of certain chronic diseases such as diabetes and
cardiovascular disease (CVD) and chronic conditions such as obesity have risen over the years in the
United States (1), and dietary quality often goes hand in hand with these. Although the Dietary Guidelines
for Americans provide recommendations for a salubrious diet, Americans’ 2015 Healthy Eating Index
(HEI) score – a metric that reflects how closely aligned actual dietary habits are with recommended ones
– is only 59 out of a possible 100 (2). An HEI score for Grand Rapids alone is unavailable, but the
community reflects national prevalence of certain chronic diseases. For example, data from the 2015-
2018 National Health and Nutrition Examination Survey (NHANES) found the national prevalence of
diagnosed diabetes to be 9.8% (1), and the current prevalence in Kent County – the county in which
Grand Rapids is found – is 9% (3). Furthermore, the rate of people per 100,000 who died of heart disease
in 2018 in Kent County was 168.2, slightly higher than the 2018 national rate of 165 per 100,000 (4).
Admittedly, the 30% current prevalence of obesity in Kent County (3) is lower than the national
prevalence of 40.6%, which was again pulled from 2015-2018 NHANES data (1). Even so, the racial and
socioeconomic disparities in chronic disease prevalence and dietary quality seen nationwide are also
exemplified by Kent County.
For Blacks in this community, the rate of people per 100,000 who died of heart disease in 2018
was 278.4 people – nearly twice the average rate of 165 in Kent County (4). Moreover, in 2017-2019 data
from the Michigan Department of Community Health, 50.4% of Blacks and 45.3% of Hispanics in Kent
County were classified as obese compared to only 29.6% of whites (4). The same source also revealed
22.2% of Blacks in Kent County had diagnosed diabetes whereas only 9% of whites did (4). As
mentioned, the latest national HEI is 59 out of 100 points, which is the same score assigned to whites (2).
Hispanics and Non-Hispanic Blacks, however, have HEI scores of 57 and 56, respectively (2). Disparities
in HEI also exist based on income: the HEI for those who make 350% greater than the income-to-poverty
ratio (PIR) is 61 whereas it is only 57 for those who make between 150 and 350% PIR and for those who
make less than 150% PIR (2).
These racial and socioeconomic factors not only exist but are also risk factors for chronic diseases
such as CVD and diabetes as well as the chronic condition obesity (1). Moreover, obesity is associated
with a higher prevalence of diabetes, and both obesity and diabetes are risk factors for CVD (1). Certain
dietary patterns are risk factors for overall mortality (including deaths related to chronic disease) such as
high sodium intake, low whole grain intake, and low legume intake (1). Thus, the disparity in and low
overall HEI scores are concerning. Importantly, certain dietary behaviors can be preventative for CVD or
diabetes such as higher whole grain and lower sodium consumption for CVD and lower sugar-sweetened
beverage consumption for diabetes (1).
Clearly, poor diet and chronic disease are major nutrition concerns, and the former can be a risk
factor for the latter (1). Individuals in Grand Rapids who have a poor diet may be at risk for a chronic
disease such as CVD or diabetes, and hence their quality of life may suffer as a result of years of painful
symptoms, expensive treatment, or even a shortened lifespan. The burden of chronic disease is felt at the
individual, community, national, and global levels, as the treatment of chronic diseases puts a monstrous
financial strain on the economy. In the United States alone, the estimated annual medical cost of the
chronic condition obesity was $147 billion in 2008, $363.4 billion (direct and indirect costs) for CVD in
2016-2017, and $237 billion for diabetes in 2017 (1). Interestingly, it is estimated that a 20% increase in
HEI compliance or Mediterranean-diet compliance would result in annual healthcare cost savings of
$31.5 billion and $16.7 billion, respectively, most of the savings attributable to reduced costs associated
with chronic diseases like CVD or type 2 diabetes (1). Public-health measures to improve dietary quality,
therefore, may in the long term reduce the financial strain on the healthcare system by preventing the
development or lessening the severity of chronic disease. This needs assessment can evaluate existing

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programs in Grand Rapids that aim to improve dietary quality or to help those with chronic disease and
inform whether public-health interventions are needed in the community to improve dietary quality or
further aid those with chronic disease.
Grand Rapids is in Kent County, Michigan and is one of the state’s larger cities with a population
of 198,917 as of 2020 (5). With a population this large, engaging community stakeholders in this needs
assessment is imperative to its success. Just outside of Grand Rapids in Ada lies the headquarters of the
global corporation Amway. The families of the founders of this company, the DeVos family and the Van
Andel family, have extensive influence throughout the community, having financed countless buildings,
events, and even organizations – including the research-driven non-profit Van Andel Institute – over the
years. Thus, recruiting a member of either family to aid in conducting the needs assessment would be
beneficial, as the families have many community connections and access to equipment that would be
useful for collecting and analyzing biochemical data. In addition, a representative from the Grand Rapids
African American Health Institute (GRAAHI) would be an ideal community stakeholder because that
representative would have connections within the African American community in Grand Rapids, and
Blacks are both at a greater risk for certain chronic diseases (1) and may have poorer diets as a group (2).
A representative from the Kent County Health Department would also be a good stakeholder to recruit
because the Health Department has access to public-health data and may have innovative strategies for
collecting new, primary data that would benefit this needs assessment.

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Community Profile Data
Demographic and Economic Data

Grand Rapids city is in Kent County, Michigan. This section will provide demographic and
economic data for the city’s population with a focus on race. Slightly more females than males live in
Grand Rapids (Table 1), and the median age of the population is 31.4 years (5). The distribution of the
population by age is shown in Table 1. Non-Hispanic Whites make up most of the population at just over
57.5% with non-Hispanic Blacks and Hispanics following at 18.3% and 16.5%, respectively (Table 2).
Levels of education attainment overall are similar for the populations in Grand Rapids and Kent
County as a whole (Figure 1). Notably, Grand Rapids falls behind Kent County in terms of percent of
high school graduates, but a slightly higher proportion of the Grand Rapids population has a bachelor’s
degree. Examination of education attainment by race reveals that non-Hispanic Whites have the highest
proportion of high-school graduates at both the city and county level (Table 3). Interestingly, a higher
proportion of Native Hawaiians and other Pacific Islanders have at least a bachelor’s degree at the city
and county levels, though non-Hispanic Whites and Asians follow relatively close behind. Table 3 also
reveals disparities in education by race in Grand Rapids, with American Indians and Alaska Natives
having the lowest proportion of those with at least a bachelor’s degree and those of some other race than
the ones listed having the lowest proportion of high-school graduates. There are also marked differences
in education attainment among Blacks and Hispanics. Education may confer health and nutrition literacy
to people, which may enable those with a higher education to better understand what a healthy diet – and
lifestyle – looks like and practice one. A healthy lifestyle, in turn, may help prevent against chronic
diseases. Moreover, nutrition information is often taught in schools, and one meta-analysis found
evidence of a weak, positive association between nutrition knowledge and dietary intake, though the
analysis was limited by inconsistent techniques across the studies examined (6). Thus, these disparities in
education levels are concerning from both a nutrition and overall health point of view.
Disparities by race also exist in terms of unemployment rate (UR), median income, and percent of
population below the poverty level in both Grand Rapids and Kent County (Table 4). Specifically, Blacks
in Grand Rapids have the highest UR at 16.2% and the lowest median income at $31,515 compared to all
other racial and ethnic groups for whom data were available. Furthermore, Grand Rapids fares worse than
does Kent County in terms of having a higher overall unemployment rate, a lower overall median income,
and a higher percent of the population below poverty. American Indians/Alaska Natives, those of some
other race, those of two or more races, and Hispanics/Latinos in Grand Rapids have the highest
proportions of those below the poverty level. Native Hawaiians/other Pacific Islanders seem to fare the
best in regard to the aforementioned metrics, but the sample size of this racial group is most likely very
small; thus, these data may not be truly representative of this race at a national level. Again, the racial
disparities in UR, median income, and percent of population below the poverty level are worrisome from
a nutrition point of view given that those with a lower income may be unable to afford nutritious food and
instead rely on cheaper, processed foods that lack nutritious profiles. Indeed, one international meta-
analysis found that globally, energy-disease (as opposed to nutrient-dense) foods are cheaper per calorie
and lower-quality diets are also generally cheaper. These cheaper, energy-dense are also found to be more
prevalent among lower-income groups (7).Overall, because of poor dietary quality, those with low
incomes may be put at greater risk for chronic disease development.
Access to transportation is a social determinant of health since those without reliable
transportation may not be able to go to stores with nutritious food nor to medical appointments, and their
health may be consequently impacted. In Grand Rapids, a greater proportion of the population bikes,
walks, or takes public transportation to work as compared to the population of Kent County (Figure 2).
This is unsurprising given that Grand Rapids is an urban area whereas Kent County as a whole has many
rural and suburban areas, so biking, walking, and taking public transport are more feasible in Grand
Rapids. Viewing means of transportation to work by race and ethnicity in Grand Rapids reveals that more
non-Hispanic Whites drive to work alone than carpool or take public transportation (Table 5). Moreover,
more Blacks take public transportation than carpool or drive alone, and more Hispanics/Latinos carpool

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than take public transportation or drive alone. These findings highlight that access to transportation is not
equitable in Grand Rapids, so food access may consequently be unequitable.

Table 1. Population of Grand Rapids by Age and Sex in 2019

Overall Male Female
N 201,004 99,741 101,263
Age (%)
Under 5 years 6.8 7.4 6.3
5 to 9 years 5.6 5.6 5.6
10 to 14 years 5.5 5.7 5.4
15 to 19 years 7 6.6 7.4
20 to 24 years 9.8 10.2 9.4
25 to 29 years 12.1 13.2 11
30 to 34 years 9.2 9.3 9.2
35 to 39 years 6.6 6.7 6.5
40 to 44 years 4.4 4.4 4.4
45 to 49 years 4.7 4 5.4
50 to 54 years 5.1 5.9 4.4
55 to 59 years 4.9 4.4 5.3
60 to 64 years 5.3 5.4 5.2
65 to 69 years 3.9 4 3.8
70 to 74 years 3.8 3.2 4.3
75 to 79 years 1.7 1.5 1.9
80 to 84 years 1.3 1.1 1.4
85 years and over 2.2 1.3 3
Source: US Census Bureau, 2019 American Community Survey 1-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan&tid=ACSST1
Y2019.S0101

Table 2. Population of Grand Rapids by Race/Ethnicity in 2020

Overall
N 198,917
Race/Ethnicity (%)
Hispanic 16.5
Non-Hispanic:
White alone 57.5
Black or African American alone 18.3
American Indian or Alaska Native alone 0.3
Asian alone 2.3
Native Hawaiian and Other Pacific Islander alone 0.04
Some other race alone 0.5
Two or more races 4.6
Source: US Census Bureau, 2020 Decennial Census; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan&tid=DECEN
NIALPL2020.P1

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Figure 1. Education Attainment for Population Aged 25 Years and Older in Grand Rapids and
Kent County, 2015-2019

Graduate or professional degree

Education Attainment

Bachelor's degree
Associate's degree
Some college, no degree
High school graduate (includes equivalency)
9th to 12th grade, no diploma

Kent County Less than 9th grade

Grand Rapids 0 5 10 15 20 25 30
Percentage
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan%20Education
&g=0500000US26081&tid=ACSST1Y2019.S1501&hidePreview=true

Table 3. Education Attainment by Race/Ethnicity in Grand Rapids and Kent County, 2015-2019
Grand Rapids (%) Kent County (%)
White alone
High school graduate or higher 90.8 93.3
Bachelor’s degree or higher 43.1 38.3
White alone, not Hispanic or Latino
High school graduate or higher 94.2 94.8
Bachelor’s degree or higher 45.8 39.5
Black alone
High school graduate or higher 83.2 85.8
Bachelor’s degree or higher 17.4 19.7
American Indian/Alaska Native alone
High school graduate or higher 71.9 78.4
Bachelor’s degree or higher 0.8 9.8
Asian alone
High school graduate or higher 72.3 74.5
Bachelor’s degree or higher 43.9 41
Native Hawaiian/Pacific Islander alone
High school graduate or higher 86.4 67.9
Bachelor’s degree or higher 50 48.9
Some other race alone
High school graduate or higher 40.7 49.8
Bachelor’s degree or higher 7.9 9
Two or more races
High school graduate or higher 88.9 88.8
Bachelor’s degree or higher 23.7 29
Hispanic or Latino Origin
High school graduate or higher 50.3 59.9
Bachelor’s degree or higher 11.9 14.3
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan%20Education
&g=0500000US26081&tid=ACSST1Y2019.S1501&hidePreview=true

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Table 4. Unemployment Rate (UR), Median Income, and Percent Below Poverty Level by
Race/Ethnicity in Grand Rapids (GR) and Kent County (KC)
GR KC GR % KC %
GR UR KC UR Median Median Below Below
(%) (%) Income Income Poverty Poverty
Level* Level*
Overall 6.3 4.4 $50,103 $63,053 20.4 11.7
Race/Ethnicity
One race:
White 4 3.5 $56,586 $67,324 15.6 9
Black/African American 16.2 11.1 $31,515 $35,203 29.5 25.9
American Indian/Alaska Native 0 1.5 $49,196 $53,684 32.5 21.8
Asian 7.8 3.4 $43,461 $62,732 22.2 10.7
Native Hawaiian/Other Pacific 0 0 - $98,199 8.2 17.6
Islander
Some other race 6.6 6.8 $39,892 $47,390 32.5 22.9
Two or more races 7.4 8.4 $38,539 $45,076 33.1 22.6
Hispanic/Latino origin (any race) 7.5 6.4 $40,069 $46,458 33.3 23.3
White alone, not Hispanic/Latino 3.7 3.4 $58,509 $68,541 13.5 8
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/
*These estimates are for the population for whom poverty status was determined. The percent below poverty level
for families in Grand Rapids is 14.2% versus 7% in Kent County.

Figure 2. Means of Transportation to Work for Population Aged 16 Years and Over in Grand
Rapids and Kent County, 2015-2019

Worked from home Kent County

Taxicab, motorcycle, or other means Grand Rapids

Bicycle
Transportation Type

Walked

Public transportation (excluding taxicab)

4-or-more person carpool

3-person carpool

2-person carpool

Drove alone

0 20 40 60 80 100
Percentage
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan%20Employm
ent&g=0500000US26081&tid=ACSST5Y2019.S0801&hidePreview=true

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Table 5. Means of Transportation to Work by Race/Ethnicity in Grand Rapids, 2015-2019
Car, Car, Public
Percent of Truck, Truck, Transportation
Population Van: Van: (excluding
Drove Carpooled taxicab) (%)
Alone (%) (%)
Race/Ethnicity
One race: 96.0 96.8 92.8 89.5
White 74.2 77.5 60.8 46.4
Black or African American 14.0 13 17.3 29.7
American Indian/Alaska Native 0.3 0.2 0.5 1
Asian alone 2.5 2.3 2.6 3.8
Native Hawaiian/Other Pacific Islander 0 0 0 0
Some other race 4.9 3.8 11.6 8.6
Two or more races 4.0 3.2 7.2 10.5
Hispanic or Latino origin (of any race) 13.2 10.6 29.3 16.6
White alone, not Hispanic or Latino 67.4 71.9 46.3 40.3
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Kent%20County,%20Michigan%20Employm
ent&tid=ACSST5Y2019.S0802

Health Data

Table 6 compares the ten leading causes of death in Grand Rapids, Michigan, and the United
States. Although the leading cause of death in Grand Rapids, Michigan, and the United States is heart
disease, Grand Rapids has the highest death rate from heart disease at 828.0 deaths per 100,000 people.
Examination of the death rates for the ten leading causes of death in Grand Rapids by race (Table 7)
highlights the large disparity between Blacks and Whites: the death rate for Blacks in Grand Rapids is
nearly twice that of Whites.
The burden of chronic disease in Kent County and Michigan is depicted in Table 8 as crude
hospital discharge rates per 100,000 people. Chronic diseases, such as cardiovascular disease or diabetes,
are a nutrition concern because certain dietary patterns can either be protective against or risk factors for
certain chronic diseases (1). Kent County fares better in terms of the burden of acute myocardial
infarction, congestive heart failure, stroke, arthritis, asthma, and diabetes, but Michigan has slightly lower
crude discharge rates for hip fractures and osteoporosis. Kent County, though, has an obesity prevalence
about 1.5% less than that for Michigan and thus a greater prevalence of people at a healthy weight (Figure
3). The age-adjusted rate of cancer incidence per 100,000 people is also slightly lower in Kent County at
423.1 versus 448.5 new cancer cases per 100,000 people at risk at the state level based on 2019 data (8).
The crude prevalence estimates of obesity, CVD, and diabetes in Michigan are presented in Table
9 by race/ethnicity. Complete data were not available by race/ethnicity at the county level, so state-level
statistics are shown. While the prevalence of obesity and diabetes are similar for county and state,
Michigan has about a 3% higher prevalence of CVD than does Kent County. Furthermore, clear
disparities in the prevalence of these conditions exist among different races/ethnicities. Hispanics and
non-Hispanic Blacks have the highest prevalence of obesity at 43.1% and 42.5%, respectively, and
American Indians/Alaska Natives have the highest prevalence of both CVD (22.3%) and diabetes (19.3%)
despite the group making up a small proportion of the state population.
Some prevalence estimates for Kent County by a subset of races were available and are depicted
in Figures 4 and 5. While Whites and Hispanics in Kent County have a higher prevalence of being
overweight, Blacks have a higher prevalence of both obesity and diabetes (Figure 4). The fact that Blacks
in Kent County have a higher prevalence of diabetes is not surprising given that in the Coronary Artery
Risk Development in Young Adults (CARDIA) study, it was found that Blacks were at higher risk for

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diabetes than were Whites (1). A separate study also found an association between obesity and diabetes
(1), which may explain the high prevalence of obesity in Blacks as well. Moreover, Blacks surpass all
other races (for which data were available) in terms of heart disease deaths and high blood pressure
(Figure 5). Admittedly, Whites have a slightly higher prevalence of having high cholesterol, but the
available data together overwhelmingly suggest clear health disparities by race and ethnicity at both the
county and state levels.
Disparities in health insurance coverage among different race and ethnicities in Grand Rapids
also exist as shown in Table 10. For the most part, Grand Rapids and Kent County have similar
proportions of the population with health care coverage. Admittedly, those of some other race besides the
ones listed and those of Hispanic ethnicity have the lowest proportions of health care coverage compared
to all other races/ethnicities for which data were available.
Overall, the health data highlight the unequal burden of chronic disease among different race and
ethnic groups in Grand Rapids, and concern regarding chronic disease in Grand Rapids was one factor
that initially prompted this needs assessment. Concern over dietary quality – which may play a role in
chronic disease prevention, risk, and management – was another factor motivating this assessment, and
thus the next section will explore the dietary quality of the Grand Rapids population.

Table 6. Age-adjusted Mortality Rates per 100,000 People for the Ten Leading Causes of Death,
Grand Rapids City and Michigan and United States Residents, 2019

Source: Michigan Department of Health and Human Services, Community Health Information 2019; data available
at: https://vitalstats.michigan.gov/osr/CHI/deaths/frame.asp

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Table 7. Age-adjusted Mortality Rates per 100,000 People for Ten Leading Causes by Sex and
Race, Grand Rapids City, Kent County, Michigan Residents, 2019

Source: Michigan Department of Health and Human Services, Community Health Information 2019; data available
at: https://vitalstats.michigan.gov/osr/CHI/deaths/frame.asp

Table 8. Crude Discharge Rates of Chronic Disease per 100,000 People in Kent County and
Michigan in 2019
Kent County Michigan
Acute Myocardial Infarction 133.9 253.2
Congestive Heart Failure
All Ages 38.6 47.5
Ages 65 & Over 186.0 188.6
Stroke
All Ages 262.9 331.9
Ages 65 & Over 1,270.8 1,288.7
Arthritis (Ages 45 & Over) 1,147.4 1,093.6
Asthma 46.6 60.8
Diabetes
All 144.3 229.5
With Lower Extremity Amputation 12.3 15.7
Hip Fractures (Ages 65 & Over) 257.5 241.3
Osteoporosis Any Mention (Ages 65 & Over) 1,896.6 1,752.4
Source: Michigan Department of Health and Human Services, Community Health Information 2019; data available
at: https://vitalstats.michigan.gov/osr/chi/profiles/frame.html

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Figure 3. Prevalence of Obese, Overweight, and Healthy Weight Conditions in Kent County and
Michigan, 2018-2020
36
Kent
35
Michigan
34

33

32
Percentage

31

30

29

28

27

26
Obese Overweight Healthy Weight

Source: Michigan Department of Health and Human Services, 2018-2020 Michigan Behavioral Risk Factor Survey;
data available at: https://www.michigan.gov/documents/mdhhs/2018-
2020_MiBRFSS_Reg_LHD_Tables_737681_7.pdf

Table 9. Crude Prevalence Estimates of Obesity, CVD, and Diabetes by Race in Michigan by
Race/Ethnicity, 2018-2020
Obese (%) Cardiovascular Diabetes
Disease (%) (%)
Overall (Kent County) 33.3 6.4 11.0
Overall (Michigan) 34.7 9.7 11.7
Race/Ethnicity (state level)
Hispanic 43.1 7.2 9.4
Non-Hispanic:
White 34.0 10.0 11.4
Black 42.5 10.2 15.5
Asian/Pacific Islander 8.9 - 5.3
American Indian/Alaska Native 34.8 22.3 19.3
Other/Multi-Racial 36.1 10.2 11.0
Arab 24.9 5.0 5.7
Source: Michigan Department of Health and Human Services, 2018-2020 Michigan Behavioral Risk Factor Survey;
data available at: https://www.michigan.gov/documents/mdhhs/2018-
2020_MiBRFSS_Expanded_Race_Tables_736727_7.pdf

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Figure 4. Prevalence Estimates of Overweight, Obesity, and Diabetes in Kent County by
Race/Ethnicity, 2017-2019

Source: Grand Rapids African American Health Institute, Health Equity Index; data available at:
https://hei.graahi.org/Profile?Tab=Summary

Figure 5. Prevalence Estimates of CVD-Related Characteristics in Kent County by Race/Ethnicity,

2017-2019

Source: Grand Rapids African American Health Institute, Health Equity Index; data available at:
https://hei.graahi.org/Profile?Tab=Summary

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Table 10. Percent of Population with Health Insurance in Grand Rapids and Kent County, 2015-
2019
Grand Rapids (%) Kent County (%)
Overall 91.4 94.2
Race/Ethnicity
One race:
White 92.9 95.2
Black/African American 91.3 92.4
American Indian/Alaska Native 91.6 90.2
Asian 91.0 94.3
Native Hawaiian/Other Pacific Islander 100.0 100.0
Some other race 74.5 76.2
Two or more races 92.3 94.0
Hispanic/Latino origin (any race) 79.1 82.4
White alone, not Hispanic/Latino 94.7 96.1
Source: US Census Bureau, 2015-2019 American Community Survey 5-yr estimate; data available at:
https://data.census.gov/cedsci/table?q=Grand%20Rapids%20city,%20Michigan%20Health&g=0500000US26081&t
id=ACSST5Y2019.S2701&hidePreview=true

Nutrition Data

Concerns regarding dietary quality in Grand Rapids initially prompted this needs assessment, and
two metrics that can be used to assess dietary quality are fruit and vegetable consumption (Table 11). The
Grand Rapids-Wyoming Metro area has proportions of the population that consumed at least one fruit or
vegetable per day similar to those of Michigan. Fruit and vegetable consumption data by race/ethnicity
and household income were available at only the state level. Clear disparities exist by race/ethnicity with
Hispanics having the lowest fruit consumption and non-Hispanic Blacks having the lowest vegetable
consumption. Further disparities exist by income, as those who make less than $15,000 a year have
prevalence of fruit and vegetable consumption more than 10% lower than the that of those who make
$50,000 or more a year.
Dietary quality can also be assessed by percentage of energy intake (% EI) from quick-service
restaurants for which only national data were available (Table 12). While the % EI from quick-service
restaurants is the same for all individuals at 37% in both 2015-2016 and 2017-2018, Hispanics and non-
Hispanic Blacks tend to have higher % EI from quick-service restaurants compared to non-Hispanic
Whites and Asians. In addition, those who make less than $24,999 a year have a greater % EI from quick-
service restaurants than does any other income group. These disparities are present in both survey years
included in Table 12.
Beverage consumption among adults in US in 2017-2018 are shown in Figures 6 and 7 stratified
by sex and race, respectively. Consumption of sugar-sweetened beverages (SSB) is concerning given that
a single serving of a sugar-sweetened beverage per day was found to confer an 18% increased risk of type
2 diabetes (1). Daily sweetened beverage consumption is lower than water and diet beverage consumption
for each sex when looked at individually, but males consume about one cup of a SSB more than do
females. Particularly concerning are the disparities in SSB consumption by race: nearly 20% more Blacks
and Hispanics drink SSBs compared to Whites and Asians. Blacks and Hispanics also tend to drink less
milk and diet beverages.
A more robust metric for dietary quality is the Healthy Eating Index (HEI) for Americans, which
numerically represents how closely aligned dietary patterns are with recommended ones. Since the
definition of the HEI was last updated in 2015, only one set of scores from 2015 are available and are
presented in Tables 13 and 14. Note also that HEI scores at only the national level were available. The
HEI of females is four points higher than that of males (61 versus 57) (2). Moreover, the HEI scores for

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those aged 2-19 years, 20-64 years, or 65 or older years are 53, 59, and 64 (2). Further disparities exist by
race/ethnicity (Table 12), for non-Hispanic Blacks and Hispanics have HEI scores nearly ten points lower
than the HEI of non-Hispanic Asians. Those who make less than 131% of poverty or between 131% and
350% poverty per year also have HEI scores four points lower than that of those who make 350% poverty
or more a year. Clear differences in dietary quality exist among sexes, age groups, races/ethnicities, and
income levels, which is concerning given that dietary quality and risk for chronic diseases such as type 2
diabetes may be closely linked.
Food access and insecurity are additional factors that contribute to dietary quality since inability
to access a grocery store with nutritious food may hinder one’s ability to eat a healthful diet. Table 15
highlights metrics for these two factors in Kent County by comparing the percent change in different
variables between two years. The prevalence of low access to stores in Kent County decreased between
2010 and 2015, and although the number of grocery stores diminished between 2011 and 2016, the
number of supercenters and club stores, convenience stores, and specialized food stores all increased.
Thus, food access overall seemed to improve between 2010 and 2016 in Kent County. Food insecurity
seemed to moderately improve as well since the number of Supplemental Nutrition Assistance Program
(SNAP) participants decreased between 2012 and 2017 while the number of SNAP-authorized stores
increased.
More specific food insecurity data were available for Kent County in 2017 and 2019 and are
shown in Table 16. The number of food insecure people decreased between 2017 and 2019, but the
proportion of the food-insecure population that was above the income threshold of SNAP increased by
3%, indicating that food insecurity may be exacerbated for this 3% of the food-insecure population. This
change in income and SNAP status may explain why the number of SNAP participants decreased
between 2012 and 2017 (Table 15). Also, the average meal cost and additional money required to meet
food needs both increased from 2017 to 2019, which may in part be due to inflation. Taken together, the
data on food access and insecurity for Kent County suggest that while food access may be slightly
improving, both issues still exist within the community and may continue to impair people’s ability to eat
a nutritious diet.

Table 11. Crude Prevalence of Fruit and Vegetable Consumption in Grand Rapids-Wyoming
Metro and Michigan in 2019
At least one fruit per At least one vegetable
day (%) per day (%)
Grand Rapids-Wyoming Metropolitan 61.7 77.7
Michigan 59.9 79.3
Race/Ethnicity (state level)
Hispanic 53.8 76.8
Non-Hispanic:
White 60.4 80.5
Black 58.7 70.6
American Indian/Alaska Native 63.4 76.5
Asian 59.4 86.4
Multiracial 58.4 84.7
Other 59.4 90.2
Household Income (state level)
Less than $15,000 51.2 68.7
$15,000-$24,999 54.6 77.0
$25,000-$34,999 58.7 73.7
$35,000-$49,999 58.3 80.6
$50,000+ 63.2 83.3
Source: Centers for Disease Control and Prevention, 2019 Behavioral Risk Factor Surveillance System; data
available at: https://www.cdc.gov/brfss/index.html

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Table 12. Percentage of Energy Intake for Americans Aged 20 Years and Older from Quick Service
Restaurants or Away from Home by Race/Ethnicity and Family Income, 2017-2018
Quick Service Restaurants (%)
Years 2015-2016 2017-2018
All Individuals 37 37
Race/Ethnicity
Hispanic 39 39
Non-Hispanic:
White 36 36
Black 42 41
Asian 33 34
Income
Less than $24,999 38 39
$25,000 - $74,999 37 36
$75,000 or more 37 36
Source: United States Department of Agriculture, 2015-2016 and 2017-2018 National Health and Nutrition
Examination Survey; data available at: https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-
human-nutrition-research-center/food-surveys-research-group/docs/wweia-data-tables/

Figure 6. Mean Daily Beverage Intake Among Adults Consuming Each Type, 2017-2018

Source: United States Department of Agriculture, 2017-2018 National Health and Nutrition Examination Survey;
data available at: https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-
center/food-surveys-research-group/docs/wweia-data-briefs/

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Figure 7. Percentage of American Adults Consuming Beverages by Race/Ethnicity, 2017-2018

Source: United States Department of Agriculture, 2017-2018 National Health and Nutrition Examination Survey;
data available at: https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-
center/food-surveys-research-group/docs/wweia-data-briefs/

Table 13. Average Healthy Eating Index Scores for Americans Aged 2 Years and Older in 2015 by
Race/Ethnicity

Source: United States Department of Agriculture, 2015-2016 National Health and Nutrition Examination Survey;
data available at: https://fns-
prod.azureedge.net/sites/default/files/media/file/FinalE_Draft_HEI_web_table_by_Race_Ethnicity_jf_citation_rev.p
df

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Table 14. Average Healthy Eating Index Scores for Americans Aged 2 Years and Older in 2015 by
Poverty Income Ratio (PIR)

Source: United States Department of Agriculture, 2015-2016 What We Eat in America/National Health and
Nutrition Examination Survey; data available at: https://fns-
prod.azureedge.net/sites/default/files/media/file/FinalE_Draft_HEI_web_table_by_PIR_jf_citation_rev.pdf

Table 15. Food Access and Insecurity Metrics in Kent County, Michigan
Years Compared Percent Change (%)
Low access to store 2010 and 2015 -5.34
Grocery stores 2011 and 2016 -18.26
Supercenters & club stores 2011 and 2016 5.26
Convenience stores 2011 and 2016 1.14
Specialized Food Stores 2011 and 2016 2.78
SNAP-authorized stores 2012 and 2017 3.60
SNAP participants 2012 and 2017 -4.69
WIC women participants 2014 and 2016 -0.30
Source: United States Department of Agriculture, Food Environment Atlas; data available at:
https://www.ers.usda.gov/data-products/food-environment-atlas/

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Table 16. Food Insecurity Metrics in 2017 and 2019 in Kent County, Michigan
2017 2019
Food Insecure People 71,970 68,860
SNAP (% of food-insecure population)
Above SNAP, Other Nutrition Programs 25% 28%
Threshold of 200% Poverty

Below SNAP, Other Nutrition Programs 75% 72%

Threshold of 200% Poverty
Average Meal Cost $2.99 $3.16
Additional Money Required to Meet Food Needs $36,742,000 $37,148,000
Source: Feeding America, 2017 and 2019 Map the Meal Gap; data available at:
https://map.feedingamerica.org/county/2019/overall/michigan/county/kent

Community Assets and Resources

Several resources exist in Grand Rapids that provide nutrition-related services to the local
population. Resources such as the ones listed below may be able to address poor dietary quality and aid
those with chronic disease within the community.

• Spectrum Health
o https://www.spectrumhealth.org/patient-care/nutrition-services
• Downtown Food Pantry
o https://foodpantry.westminstergr.org/
• Health Net of West Michigan
o https://healthnetwm.org/
• Heart of West Michigan United Way
o https://www.hwmuw.org/

Priorities

The goal of this needs assessment was to evaluate dietary quality and chronic disease among
adults in Grand Rapids, Michigan. This goal was accomplished by examining demographic, economic,
health, and nutrition data for the community. Several key findings will be discussed to highlight priorities
for the community.
Education may impact dietary quality, since those with a higher education may have greater
nutrition knowledge, and nutrition knowledge is positively associated with dietary quality (6). A
nutritious diet in turn may be preventative against chronic disease development (1). Disparities in
Education exist in Grand Rapids: those of Hispanic origin or some other race than the ones listed in Table
3 have the lowest proportions of high-school graduates. In addition, Blacks, American Indians and Alaska
Natives, those of some other race, and those of two or more races have the lowest proportions of a having
at least a bachelor’s degree. Blacks in Grand Rapids also have the highest unemployment rates and lowest
median incomes, and American Indians/Alaska Natives, those of some other race, those of two or more
races, and Hispanics/Latinos have the highest proportions of those below the poverty level (Table 4).
These disparities are concerning given that lower-income groups more frequently selected lower-quality
diets, and energy-dense diets were generally cheaper than nutrient-dense ones in one meta-analysis (7). In
addition to income, access to transportation may play a role in dietary quality since those without
transportation may be unable to shop at stores with a diverse offering of fresh produce and other

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nutritious foods. Disparities in transportation access exist in Grand Rapids, for non-Hispanic Blacks and
Hispanics are more likely to take public transportation and carpool, respectively (Table 5).
The burden of chronic disease reveals further disparities at the state level given that non-Hispanic
Blacks and Hispanics in Michigan have the highest prevalence of obesity (Table 9). American Indians and
Alaska Natives have the highest prevalence of both cardiovascular disease and diabetes. County data
further support the presence of disparities since Blacks in Kent County have higher prevalence of obesity,
diabetes, and high blood pressure and a higher rate of heart disease deaths (Figures 4 and 5). Chronic
disease is a nutrition concern since dietary quality can be preventative against or a risk factor for chronic
disease development (1).
Dietary quality in Grand Rapids was assessed by fruit and vegetable consumption, percent of
energy intake from quick-service restaurants, sugar-sweetened beverage (SSB) consumption, and HEI
scores. The metrics together highlight clear differences in dietary quality by race/ethnicity and income.
Specifically, non-Hispanic Blacks have the lowest vegetable consumption, highest % EI from quick-
service restaurants, highest SSB consumption, and lowest HEI compared to other races and ethnicities
(Table 11, Table 12, Figure 7, Table 13). Hispanics also have low vegetable consumption, high SSB
consumption, and a low HEI. Furthermore, low-income groups have low fruit and vegetable consumption,
higher % EI from quick-service restaurants, and a lower HEI (Table 14) compared to higher-income
groups.
Fortunately, food access seems to be improving in Kent County (Table 15), though food
insecurity seems to have slightly been exacerbated between 2017 and 2019 (Table 16). Food access and
insecurity play critical roles in dietary quality since having both food access and security enables one to
choose nutrient-dense foods.
Based on this needs assessment, priorities for Grand Rapids should be focused on improving the
disparities in dietary quality and chronic disease present among different races/ethnicities and/or income
groups. Blacks, American Indians/Alaska Natives, those of some other race, those of two or more races,
and Hispanics should be groups on which to center attention. Blacks are particularly vulnerable to chronic
disease risk, one study finding that Blacks were at a higher risk for diabetes than were whites (1). Blacks
in Grand Rapids indeed have a higher prevalence of diabetes as compared to Whites as well as higher
prevalence of obesity and CVD. Non-Hispanic Blacks in the United States also generally have poorer
diets than do other races and ethnicities.
Though there is room for improvement in terms of dietary quality and chronic disease burden at
the population level in Grand Rapids, aiding minority groups and low-income groups should be
prioritized by the community. Addressing the racial and socioeconomic disparities in Grand Rapids by
taking dietary-quality and chronic-disease approaches would be one step towards improving nutrition and
health equity in the community.

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https://www.ahajournals.org/doi/10.1161/CIR.0000000000000950 (accessed 24 September
2021).
2. USDA Food and Nutrition Service. Healthy Eating Index (HEI). Version current 21 July 2020.
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3. County Health Rankings and Roadmaps. Kent County, Michigan. Version current 2021. Internet:
https://www.countyhealthrankings.org/app/michigan/2021/rankings/kent/county/outcomes/overa
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an (accessed 27 September 2021).
6. Spronk I, Kullen C, Burdon C, O'Connor H. Relationship between nutrition knowledge and
dietary intake. Br J Nutr 2014;111(10):1713-26. Internet:
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disparities in diet quality and health: a systematic review and analysis. Nutr Rev
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November 2021).
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https://www.michigan.gov/mdhhs/0,5885,7-339-73970_2944_4669---,00.html (accessed 24
October 2021).

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