Which of the following is not a major factor impacting a persons food choices?

The committee examined evidence for the impact of various environmental factors on the feasibility of defining the adequacy of SNAP allotments. The range of available evidence included specific environmental factors affecting food choices: food prices; access to food outlets offering a wide range of healthy foods; and disparities in access, particularly in transportation. The committee notes that relevant data collection is ongoing but the data are not yet available through the ERS National Household Food Acquisition and Purchase Survey. When completed, this survey will provide detailed information on household food purchases and acquisitions, including foods purchased for consumption at and away from home and foods acquired through public and private food and nutrition assistance programs. This dataset will be useful for a broad range of economic analyses of food choices and for understanding the implications of food choices for diet quality.

Access to Food Outlets

As described above, choosing foods that make up a diet consistent with the recommendations of the 2010 DGA, such as increased consumption of fruits and vegetables and whole-grain-rich foods and decreased consumption of solid fats and added sugars (), can be challenging for populations with limited resources as a result of factors affecting food prices both regionally and locally. In light of this evidence, the committee examined additional evidence for an impact of the ability of low-income populations to access affordable healthy foods on the purchasing power of SNAP allotments under the assumptions of the TFP.

Access to Food Outlets and Purchasing Behavior

The committee identified a number of observational studies showing correlations between various means of access to food outlets and purchasing behavior. Personal transportation was previously discussed as an individual factor. The following discussion focuses on other barriers to access to healthy foods.

Urban or rural locale In a survey of the availability of fruits and vegetables in urban and rural areas of upstate New York, identified one urban minority neighborhood among those surveyed that, in this respect, was the most disadvantaged site within an urban locale, as measured by the population density of stores selling these products. This community was found to be lacking not in the number of food stores but in an accessible high-impact super produce store. By contrast, such stores were available in a higher-income urban mixed neighborhood in the same locale, illustrating that disparity in access to fresh produce was associated with a single disadvantaged area within a larger locale.

A recent example of associations between access to healthy food and consumption is a cross-sectional community survey, conducted in 2002–2003, which was used as a data source for analyzing associations between neighborhood availability and consumption of dark green and orange vegetables in an ethnically diverse low- to moderate-income population in Detroit (). Data derived from the survey included the frequency of consumption of these vegetables and their availability in all food stores in the communities studied. The mean intake of dark green and orange vegetables among all participants was found to be 0.61 servings per day. The lowest intake was among participants living in neighborhoods where no store carried five or more varieties of such vegetables; residents in those neighborhoods consumed 0.17 fewer servings per day than those in neighborhoods where at least two stores provided more variety. The results of this study suggest a direct relationship between the availability of vegetables and consumption patterns within a locale.

conducted a telephone survey to (1) determine whether there is an association between the availability and consumption of low-fat milk, and (2) assess whether the availability of low-fat milk is associated with household income and racial composition. The study was carried out in three different geographic settings in New York: large metropolitan, midsize urban, and rural. Household interviews were conducted in each setting to determine the type of milk consumed. In each store surveyed within a corresponding zip code, containers of whole, 2 percent, 1 percent, and skim milk were counted for each container size (quart, half gallon, and gallon). The percentage of low-fat milk in the store and the average percentage across all stores in a zip code were then determined. A direct correlation was found among the percentage of low-fat milk in stores, consumption of low-fat milk in the household, and income level by zip code. In particular, low-fat milk tended to be less common in the stores located in rural or low-income areas and areas in which the majority of the population was nonwhite. The authors note, however, that only 51 percent of survey respondents reported usually purchasing milk within their residential zip code.

conducted a similar study using a survey of healthful food choices in different grocery store environments to assess the relationship between individual dietary choices and the grocery store environment. They carried out a telephone survey in 12 different communities, including the corresponding larger zip code area, to obtain self-reported dietary intake data on low-fat and high-fiber foods, as well as the availability of health information in the community stores. They found a significant correlation between the availability of healthful foods in the community and zip code area stores and the self-reported healthfulness of participants' diets. In a review of cross-sectional studies on associations between food environment and consumption, identified a number of studies that combined in-store measures with mapping of store location and found significant direct associations between neighborhood food environment and measures of consumption.

These studies are important because they suggest a link between purchasing power and access to food. A general conclusion that can be drawn from this work is that although associated with income, access to food outlets and healthy foods needs to be considered in the context of how certain factors within the food environment affect the cost of healthier food options. Overall, the evidence suggests that limited access to healthy food may influence food shopping and spending behavior by reducing choices.

Farm-to-consumer venues Farm-to-consumer venues show promise in improving dietary intake among all people in the United States, including low-income groups (). However there are few such venues, especially in low-income communities (). In addition, many farmers' markets do not accept SNAP. Although USDA figures indicate that the number of farmers' markets accepting SNAP has increased by 16 percent since 2010, more needs to be done to increase the number of these venues authorized as retailers by the program (). The lack of awareness of farm-to-consumer venues, the lack of farmers' markets and farm stands close to home, the lack of transportation to these venues, inconvenient hours, and affordability concerns are additional barriers to use of farm-to-consumer venues among those receiving federal food assistance ().

Disparities in Access and Geographic Proximity to Food Outlets

According to a 2009 USDA report, 23.5 million people lack access to a supermarket within a mile of their home (). Limited access to food stores is not unique to urban areas; about 20 percent of rural counties across the United States (418 counties) also have been identified as areas where half the population lives more than 10 miles from a large food store (). The disparate distribution of grocery stores and supermarkets in low-income neighborhoods or geographic areas is especially notable in light of the distribution of racial/ethnic groups within these tracts. For example, found that “a large majority of low-income households are in close proximity to a full-line grocery store or supermarket” (p. iv), but minority households in rural areas live farther from these types of food stores than nonminority households.

Disparities in Access by Type of Food Outlet

Apart from the question of distance from a food store is that of where SNAP participants are more likely to shop. analyzed data from the National Food Stamp Program Survey, conducted between June 1996 and January 1997. The analysis examined the food shopping opportunities of low-income households, including SNAP participants and eligible nonparticipants. The study found that most low-income households shopped at supermarkets but tended to supplement their purchases by shopping at neighborhood grocery stores, convenience stores, bakeries, and produce markets. They also engaged in “careful” shopping practices, including making bargain purchases, taking advantage of special offers, and using shopping lists to extend their food dollars. and also found that most SNAP participants redeemed their benefits at supermarkets, and their purchase patterns were similar to those identified by .

As noted by , minority low-income groups may experience disparities in access that are not seen across the low-income population as a whole. In a study examining associations between local food environments and neighborhood racial/ethnic and socioeconomic composition, analyzed census tract demographics as well as food store characteristics in selected study areas in Maryland, New York, and North Carolina. Their comparison across study areas and across racial/ethnic composition revealed that the predominantly minority and racially mixed areas had at least twice as many grocery stores but fewer than half the number of supermarkets compared with predominantly white areas. The low-income and nonwhite areas also had fewer fruit and vegetable markets, bakeries, specialty stores, and natural food stores.

A cross-sectional survey in Michigan () assessed the availability, quality, and price of fresh produce in various types of stores—large and small grocery stores, “mom and pop” stores, and convenience and specialty stores—in three Detroit communities and an adjacent suburb. The communities surveyed varied in racial/ethnic composition and socioeconomic characteristics and exhibited different health profiles for diet and obesity-related diseases. Among the findings was that produce quality was lower in low-income African American communities than in more affluent or racially mixed neighborhoods. Moreover, the low-income African American communities had more than four times more liquor stores and fewer grocery stores per 100,000 residents compared with the racially mixed communities.

Overall, this body of evidence suggests that supermarket access is poorer among low-income and minority populations, and that individuals without ready access to supermarkets have more difficulty finding fruits and vegetables in their neighborhood. In addition, individuals with supermarkets in their neighborhood are more likely than those lacking nearby supermarkets to eat more fruits and vegetables.

Disparities in the Quality of Food Available for Purchase

In a cross-sectional study of 25 stores in South San Diego County, California, examined associations between the availability, quality, and cost of healthy and unhealthy food items and store location—specifically, non-ethnically based supermarkets and Latino grocery stores (tiendas) in low-income areas. They found no difference in the availability of fresh produce by store type and quality differences for only one fruit item. Further, the price per pound for fresh produce was lower in the tiendas than in the supermarkets. However, the cost of skim milk was significantly higher in the tiendas and lean ground beef was significantly less available than in the supermarkets surveyed. Similarly, , conducted two studies examining changes in price differences between large grocery stores and small neighborhood markets over the past 35 years (study 1), and price and nutritional quality as a function of income and neighborhood (study 2) in New Haven, Connecticut. In assessing the results of both studies, they concluded that the availability of many healthful food items was lower and produce quality was worse in lower-income than in higher-income areas even though average prices were not significantly different between the two types of neighborhoods. In Baltimore, Maryland, conducted a small observational study to determine the availability and price of food in 240 stores in area neighborhoods. In the neighborhoods surveyed, 94.4 percent of residents were African American; 64.4 percent of family households were female headed; the unemployment rate of residents was 23.5 percent, with a median household income of $15,493; and only 53.6 percent of adults had completed high school. Of the 187 food stores located within the city, 17 were classified as supermarkets, 136 as grocery stores, and 34 as convenience stores. No fresh fruits or vegetables, whole-wheat bread, or skim milk was found in the city's grocery stores; other food items, such as whole milk, soda, chips, and canned foods, were typically available. Further, the price of whole milk, cereal, and white bread at a representative store was 20 percent higher than in the closest supermarket, 0.9 miles away. Overall, food outlets in lower-income and minority neighborhoods tend to stock lower-quality items than food outlets in predominantly higher-income, white neighborhoods.

Disparities in Access to and Availability of Public Transportation

Residents in many urban areas have few transportation options to reach supermarkets. To examine whether access to transportation plays a role in risk factors for food insecurity and access to food outlets, developed and mapped a number of food insecurity index values, including income, ethnicity, employment, and education. Analysis of the indices identified a number of high-risk areas lacking food access in Seattle, King County, Washington. Many of the high-risk lower-income neighborhoods assessed were racially and ethnically diverse. For some of these areas, transportation access was a major barrier to food security. Households in the areas at risk of food insecurity were more vulnerable to economic and social as well as geographic barriers that may have made them dependent on local convenience stores and/or required long trips to distant grocery stores.

Inadequate transportation can also be a major challenge for rural residents, given the long distances to stores. examined associations between neighborhood needs, as measured by socioeconomic deprivation and vehicle availability, and two criteria for food environment access: distance to the nearest food store and fast-food restaurant, and number of food stores and fast-food restaurants within a specified network distance of neighborhood areas. The authors analyzed data from the 2006–2007 Colonias Food Environment Project and the decennial 2000 U.S. Census Summary File 3. They found that the rural neighborhoods studied had better access to convenience stores and fast-food restaurants in terms of both distance and shopping opportunity compared with access to supermarkets. Supermarkets provided greater proximity and coverage than traditional grocery stores, but when neighborhood deprivation was taken into account, the neighborhoods with higher deprivation had the least access to supermarkets and grocery stores but the greatest access to convenience stores. When transportation access was considered, limited availability of a vehicle was correlated with greater proximity to a supermarket as well as other store types, but higher deprivation was associated with greater distance to supermarkets as well as other store types. Collectively, these results indicate an association between high-deprivation neighborhoods and both low access and limited transportation to supermarkets in a rural area.

In response to a request from Congress, USDA conducted a comprehensive 1-year study to assess the impact of limited access to food on local populations and outline recommendations for addressing the problem (). The study included two conferences on food deserts and a set of commissioned studies carried out in cooperation with the National Poverty Center at the University of Michigan, as well as reviews of the existing literature, a national-level assessment of access to supermarkets and large grocery stores, analysis of the economic and public health effects of limited access, and a discussion of existing policy interventions. shows the study findings on access to supermarkets according to individual factors of low-income and underserved population groups in the United States. Data in the table indicate that the median distance to a supermarket for low-income, minority, and elderly populations is comparable to that for higher-income populations. However, as data in indicate, the percentage of households without a vehicle is higher in low-income areas. For example, 2.5 to 3.3 percent of urban and 7.4 percent of rural low-income households live more than a mile from a supermarket and lack access to a vehicle. Research has shown that inadequate transportation is a significant barrier to access to supermarkets for residents of economically disadvantaged African American neighborhoods ().

TABLE 4-5

Supermarket Access by Household Income, Race/Ethnicity, Age, and Vehicle Access.

TABLE 4-6

Household Vehicle Access and Supermarket Access.

Impact of Disparities in Access on Health Outcomes

The committee identified a number of studies examining associations between disparities in access to healthy foods and food insecurity, obesity, and obesity-related chronic disease. On the whole, the evidence supports a positive relationship between food insecurity and risk for obesity that is strongest among women (; ; ; ; ; ) and stronger among African American and Hispanic groups than whites (; ). The evidence reviewed was inconsistent as to significant associations between food insecurity and obesity in children ().

A review of 54 studies examining associations between neighborhood differences in access to healthy food and risk for obesity identified an association between better access to convenience stores and higher risk for obesity (). An observational study that analyzed data collected from a telephone survey found increased odds of obesity associated with distance to a supermarket in metropolitan but not in nonmetropolitan areas (). In contrast, another analysis of data collected on more than 21,000 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants in Kansas failed to find an association between the availability of grocery stores and supermarkets within a census tract and body mass index (BMI) (). A recent ERS report () suggests that access to a supermarket or large grocery store is a problem for a small percentage of households.

Other observational evidence supports a reduced risk for obesity and related conditions associated with better access to healthy foods. analyzed cross-sectional data collected from men and women participating in the third visit (1993–1995) of the Atherosclerosis Risk in Communities Study to determine whether characteristics of the local food environment were associated with the prevalence of cardiovascular disease risk factors. They found that people with access only to supermarkets or to supermarkets and grocery stores had the lowest rates of obesity and overweight, while those with access only to convenience stores had the highest rates. However, associations for diabetes, high serum cholesterol, and hypertension were not consistently observed.

To examine the association of retail food environments with obesity and diabetes, the California Center for Public Health Advocacy, PolicyLink, and the University of California, Los Angeles, Center for Health Policy Research combined individual-level demographic and health outcome data from the 2005 California Health Interview Survey () with the locations of retail food outlets. Geographic information system software was used to calculate a Retail Food Environment Index for each adult CHIS respondent within a given radius around his/her home address. It was found that in California, rates of obesity and diabetes were 20 percent higher for those living in the least healthy food environments after controlling for household income, race/ethnicity, age, gender, and physical activity levels ().

Evidence that access to food has a direct impact on pregnancy outcomes is limited. In a study examining associations between diet quality, measured by a Diet Quality Index, among pregnant women and distance from a supermarket, found that women living more than 4 miles from a supermarket had a twofold increased risk for being in the lowest quartile of the DQI. In another study on access to food and birth outcomes, found that women living in food deserts without access to healthy foods had significantly more low-birth-weight infants than women who had access to supermarkets and a variety of foods.

Although diet is integral to the treatment of diabetes and maintenance of glycemic control, evidence now exists that foods recommended as part of a healthy diabetic diet are in short supply in low-income, nonwhite neighborhoods. To illustrate, documented and compared the availability and cost of foods recommended for people with diabetes in East Harlem and the adjacent more affluent and predominantly white Upper East Side neighborhood. They found that the East Harlem neighborhood had a shortage of food markets, and some stores did not carry foods needed for a healthy diabetic diet. Additionally, the neighborhood had few large stores with a variety of foods and fewer stores that carried recommended food items. Further, East Harlem had many more undesirable stores than the more affluent Upper East Side neighborhood. These disparities in availability of healthy foods many be a barrier to diabetes self-management for East Harlem residents.

As described above, limited access to healthy food can influence purchasing behavior. Therefore, it is possible that the availability of food outlets and costs of food items may impact the purchasing power of SNAP allotments for healthy foods under the assumptions of the TFP, which in turn may affect diet-related health outcomes for SNAP participants.

Effectiveness of Addressing Environmental Challenges to Food Access

Environmental interventions to address challenges to food access show some promise. A recent study evaluating the impact of the first full-service supermarket to locate in Harlem in New York City found that the store allocated the same amount of space to fresh fruits, vegetables, fish, and meat as a typical suburban market, at similar prices (). The Pennsylvania Fresh Food Financing Initiative—a statewide financing program designed to increase supermarket development in underserved areas—has funded 78 fresh-food outlets in Pennsylvania, which have increased food access for 500,000 children and adults (). More research is need to understand what changes might improve access to food outlets. Approaches at the environmental level might include transportation policies that address both affordability and routes, and incentive/financing programs to increase the number of and quality of supermarkets in low-income, minority communities.

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