It’s a uniquely modern problem. We have the most obese impoverished population in the history of the planet and its been called the “hunger-obesity paradox.” Even the homeless are now more than likely to be overweight with over 32% being officially obese. Think about that.

Then think about every single picture you have ever seen from the Great Depression when 1 of every 4 Americans were out of work and millions were drastically affected by starvation and hunger.  The subject in Dorothea Lange’s iconic 1936 picture “Migrant Mother” appears bizarrely healthy by today’s standards even though her family was reduced to scavenging for vegetables and killing birds for food on their way to California.

The hunger-obesity paradox appears to be a tailor-made Conservative argument against the excesses of government social programs akin to the myths about “welfare queens” driving around in Cadillacs. The truth is far more complex though it does not exonerate social welfare programs from being culpable at least in part.

Far from being a case of fraud or gluttony on the public dime, most of the cause appears to be one of surprisingly rational economics. Contrary to standard belief, eating healthy and nutritional food actually costs more than eating so-called “junk food”.  This is not by accident. The food industry has become very good at producing high caloric and high energy but low cost processed food that is of low nutritional value. I.e. they include things like saturated fats and high carbohydrate amounts that make the food taste great while eliminating more costly and less tasty nutritional ingredients.

For people with limited means it makes economic sense to maximize the energy content of the food while minimizing costs. Junk food has other advantages as well including minimizing preparation time and effort, being easily stored, and usually being easily available in poorer neighborhoods that typically lack grocery stores.  The net result is long term poor dietary habits such as increased meal portions and massive weight gain. Impoverished Americans are no longer “hungry” or “starving” but have become “food insecure” meaning that they do not have the financial resources to have regular access to nutritional food.

It also makes sense for the poor to utilize subsidies for such essentials as food and housing in order to maximize disposable income to purchase nonessential items. This could come in the form of consumer electronics or even and frequently alcohol and cigarettes which cannot be purchased with food stamps.  Disposable income can even be used for home food delivery services which Texas food stamp beneficiaries pay for in cash. Almost 100% of delivery customers of Randy’s Fine Foods in Houston Texas are food stamp beneficiaries and junk food is a top seller.

Pop Tarts, Famous Amos and Oreo cookies. Honey buns, candy bars and corn dogs. Laffy Taffy and cheesecake. Pickles are the only vegetable listed on a Randy’s menu.

Terrible dietary habits and obesity are certainly not limited to people poor enough to be eligible for food stamps but there is evidence that links food stamp use with greater rates of obesity (at least among non-elderly women).  And obesity increases the risk of diabetes, high blood pressure and cholesterol, all of which increase the rates of serious and chronic disease and can easily lead to a downward spiral of arthritis, mobility limitations, sedentary lifestyle, deconditioning, and depression. Such health issues are devastating for any hope of gaining economic security in a population that is heavily dependent on jobs involving unskilled manual labor. Certainly the last thing food assistance programs want to do is to contribute to the rates of obesity and obesity related diseases in susceptible and dependent populations. First, do no harm.

There have been efforts in several states to ban the use of food stamps for junk food but many of the companies that make these types of food contribute heavily to political campaigns and frequently these efforts go nowhere. The other approach is limit food stamp use to an approved list of healthy foods like what the Women, Infants, and Children program (WIC) does. But again, these efforts are frequently opposed by the food industry which stands to lose billions – 46 million Americans spend an average of $135 a month in food stamps –  and opposed by liberals who fear that significant restrictions will deter use by those who need these programs. There are educational programs about good nutrition as part of many food stamp programs but there is no significant data that shows that education alone is able to overcome economic reality, convenience, and entitlement that are parts of the junk food culture.

The only other option is to individually monitor food stamp recipients similar to how welfare recipients are monitored for continued economic need and an inability to find a job. After all, hunger, nutrition, and obesity are all public health issues. Why shouldn’t food stamp recipients be regularly monitored by medical professionals? These populations are at risk both for malnutrition as well as obesity and frequently are complicated with substance abuse and poor dietary habits. I would never consider treating a patient with a chronic health problem without regularly monitoring them. And I am a firm believer in establishing fairly rigorous but reasonable requirements for anyone who seeks government assistance.

But significant barriers to such a common sense approach exist. There is as of yet no data to suggest that regular monitoring of the health of food stamp recipients would make any difference in health outcomes and though there are no indications that such requirements would significantly deter participation in these programs for those who truly need them, liberals would still oppose such legislation based on these concerns.  And even though many food stamp beneficiaries would be eligible for Medicaid benefits under “Obamacare” it’s far from certain that enough primary care providers would be available to regularly see all of these new patients.  And who would pay for those not eligible for Medicaid? And what if a beneficiary is morbidly obese? Or smokes? Are they to be kicked out of the program? Much more thought and work on this needs to be done.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.