Topic :Food Deserts: Some low-income neighborhoods have limited access to healthy and affordable foods, known as food deserts. Food deserts may have plenty of fast

Judith Bell, MPA

Gabriella Mora, MPH

Erin Hagan, MBA, PhD

Victor Rubin, MCP, PhD

Allison Karpyn, PhD

PolicyLink

6 Access to Healthy Food and Why It Matters

The Food Trust

Healthy food retailers—grocery stores; farmers’ markets; cooperatives; mobile markets; and other vendors of fresh, affordable, nutritious food—are critical components of healthy, thriving communities. As the country inches its way out of the Great Rec- ession and seeks to grow a more sustainable and equitable economy, ensuring that healthy food is accessible to all is crucial. Without access to healthy foods, a nutritious diet and good health are out of reach. And without grocery stores and other fresh food retailers, communities are also missing the commercial vitality that makes neighborhoods livable and helps local economies thrive.

Moreover, the challenge of access to healthy food has been a persistent one for communities of color. Beginning in the 1960s and 1970s, white, middle-class and working-class families left urban centers for homes in the suburbs, and supermarket chains went with them, leaving many inner- city neighborhoods with few or no full-service markets—often for decades. Limited access to healthy food also plagues many rural communities and small towns, where population losses and economic changes have diminished food retail options. Even in agricultural centers where fruits and vegetables are being grown, residents may not have a retail outlet nearby. Many of the communities that lack healthy food retailers are also oversaturated with fast-food restaurants, liquor stores, and other sources of inexpensive, processed food with little to no nutritional value. For decades, community activists have organized around the lack of access to healthy foods as an economic, health, and social justice issue.

Healthy food retailers can generate significant economic stimulus by serving as anchors for further commercial revitalization, creating local jobs, gen- erating tax revenues, and capturing local dollars within the community, among other economic and community development outcomes.1, 2 For example, it is estimated that 24 new jobs are created for

every 10,000 square feet of retail grocery space,3 so a very large market can generate between 150 and 200 full- and part-time jobs.1 Attracting and incentivizing new or improved healthy food retail in communities of color and low-income, urban, and rural communities is an important component of a comprehensive strategy to revitalize disinvested areas by improving health and economic outcomes in the places that need it most.

As concerns have grown over the worsening obesity epidemic, access to healthy and affordable food has moved to the forefront of community, civic, and policymakers’ agendas. A shared recognition of the role that healthy food access plays in promoting stronger local economies, vibrant neighborhoods, and healthy people has sparked support for diff- erent projects and initiatives, bringing an array of approaches from grocery stores to farmers’ markets, mobile markets, food hubs, and community gardens.

Even as recognition of the problem is growing and progress is being made, between 6 and 9 percent of all U.S. households are still without access to healthy food. Nearly 30 million people live in low- income areas with limited access to supermarkets (defined as the closest store being more than a mile away).4 The problem is particularly acute in low- income communities of color. People living in these neighborhoods must either make do with the foods available in smaller local stores, which are very often less healthy and more expensive, or spend nearly 20 minutes traveling to the nearest large retailer or even more time in rural communities where a full-service grocery store may be more than 20 miles away.5

There has been a proliferation of innovative approaches to bringing healthy food retail into underserved communities in recent years. The best- known large-scale innovation is the highly successful Pennsylvania Fresh Food Financing Initiative—a statewide public-private effort that helped develop

Introduction

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or improve 88 supermarkets, smaller independently owned grocery stores, farmers’ markets, and other fresh food outlets in underserved urban communities, small towns, and rural areas throughout Pennsylvania. Launched in 2004, the initiative leveraged more than $190 million in healthy food retail projects over six years and is responsible for creating or retaining more than 5,000 jobs in Pennsylvania communities.6, b This program has so far been adapted and funded in six other states and cities, bringing much-needed financial resources and development know-how to communities seeking to improve healthy food access. Several more jurisdictions are in the process of starting funding for similar initiatives.

The federal Healthy Food Financing Initiative (HFFI), established in 2011, has, in three years, distributed more than $500 million in grants and tax credits to improve access to healthy food in communities across the country. The President has proposed to expand the program further in 2014. In total, more than $1 billion in private capital has already been lev- eraged to support an array of different projects and approaches—not only full-scale grocery stores but also consumer co-operatives, farmers’ markets, mobile markets, and food hubs. Thousands of jobs have been created, and hundreds of thousands of people have new access to healthy food.

The local and state-level efforts confirm that sup- port for healthy food retail can come in many forms and that new models are emerging at a fast pace. Improving offerings at corner stores and bodegas, starting or expanding farmers’ markets and mobile markets, enhancing community gardens and other forms of urban agriculture, and initiating new forms of wholesale distribution through food hubs are among the promising strategies that bring economic and health benefits to neighborhoods. The local economy, development resources, community leadership and support, political will, and other factors determine what is possible and viable.

In 2010, PolicyLink and The Food Trust published The Grocery Gap: Who Has Access to Healthy Food and Why It Matters, a comprehensive review of the previous two decades’ worth of food access research. The review found overwhelming evidence that access to healthy food was particularly limited for low- income communities, communities of color, and rural

b In addition to state legislative leadership, the initiative arose from the work of Pennsylvania-based nonprofit organizations including The Food Trust and The Reinvestment Fund, with strong support from the food retailing industry.

communities. The research also suggested that access to healthy food corresponds with a good diet and lower risk for obesity and other diet-related chronic diseases. A third, more emergent, theme in the literature was that new and improved healthy food retail in underserved communities creates jobs and helps to revitalize low-income neighborhoods.

Given the proliferation of research since the 2010 Grocery Gap publication, it was determined important to systematically review the new studies and reevaluate the evidence base. This new report does that, pro- viding an up-to-date summary of what is known about access to healthy food and why it matters. The majority of the evidence continues to support—or strengthen—three primary findings:

• Accessing healthy food is still a challenge for many families, particularly those living in low- income neighborhoods, communities of color, and rural areas.

• Living closer to healthy food retail is among the factors associated with better eating habits and decreased risk for obesity and diet-related diseases.

• Healthy food retail stimulates economic activity.

While most of the newer research continues to point to positive health and economic impacts, some contradicting results have also surfaced. As this report documents, however, the majority of research still indicates that in order for people to improve their diets they need to have convenient access to good quality, healthy food.

The proliferation of local efforts to provide access to healthy food has drawn attention to the factors that can determine the impact of these innovations, including transportation access and the quality, price, and cultural appropriateness of the offerings. As more studies of local circumstances are published, a more complete picture is emerging of the realities for people living in low-income urban neighborhoods, communities of color, and rural areas with limited access. There is also more clarity about what happens to purchasing, consumption, health outcomes, and the local economy when access changes. The following summary of the state of the research can inform policymakers, advocates, researchers, philanthropic organizations, and others in identifying, designing, and implementing strategies to ensure all people have access to healthy food.

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The field of healthy food access research has benefited from rapid growth and wider attention in the last three years. The result of this increased scrutiny and documentation is a more well-rounded understanding of the problems and the emergence of a literature that describes impacts at both the individual and community levels. The results from the review of the literature are organized by the three main findings described in the introduction and elaborated upon in this section.

1. Accessing healthy food is a challenge for many families, particularly those living in low- income neighborhoods, commu- nities of color, and rural areas.

An overwhelming body of evidence over 20 years indicates that accessing affordable, high-quality, and healthy food is a challenge for many families; this challenge is most pronounced in low-income neighborhoods of color.4, 7-170 Recent national-scale studies conducted by the United States Department of Agriculture’s Economic Research Service (USDA ERS) and The Reinvestment Fund have found that 25 to 30 million Americans—about 9 percent of the total population—are living in communities that do not provide adequate access to healthy food retailers, such as supermarkets or grocery stores, within a reasonable distancec from their home.4, 142 Both

c The Reinvestment Fund (TRF) considers a “reasonable distance” to be one that is “comparatively acceptable” to the distance traveled by residents in well-served areas. TRF defines “comparatively acceptable” as the distance that residents of well- served areas (block groups with incomes greater than 120 percent of the area’s median income) travel to the nearest supermarket. The USDA defines “reasonable distance” as the presence of a supermarket within one mile of a person’s residence.

studies found that the populations living in these communities are more likely to be low-income and to be people of color.

Where Are Food Deserts Located?

In an effort to help identify the communities that can most benefit from targeted resources and strategies to improve healthy food access, the United States Department of Agriculture (USDA) and The Reinvestment Fund have developed and launched free data sources that assist in the identification of areas lacking healthy food access, or food deserts.171 The Food Access Research Atlas (USDA) and PolicyMap (The Reinvestment Fund) both, with varying levels of complexity, visually depict gaps in healthy food access across the country.

From 1990 through February 2013, many studies have documented how low-income communities and communities of color have less access to healthy food than higher-income and less diverse communities.

• A national cross-sectional study found that low-income, urban neighborhoods of color have the least availability of grocery stores and supermarkets compared with both low- and high-income white communities.172

• A 2012 comprehensive review of published literature about the role of the retail food environment in shaping racial, ethnic, and socioeconomic disparities in obesity risk con- cluded that the retail environments of comm- unities of color lack accessibility to healthy food, while the opportunities to purchase processed, convenience foods and alcohol are great.100

• In an assessment of nearly 1,200 residents in Baltimore, Maryland, white, college-educated, and higher-income households have significantly higher availability of healthy food options

Findings

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The Food Trust

compared with black, less-educated, low- income households.99

• In New York City, one-third of all predominantly black census tracts and one-third of the lowest- poverty tracts lack walking or subway access to supermarkets. Further, of all neighborhoods in the city, the predominantly black neighborhoods have the lowest access to healthy food.158

• A study examining the relative changes in availability of various food stores by race and socioeconomic status, from 1997 to 2008, found that predominantly African American neighborhoods and low-income neighborhoods had the smallest increase in food store availability and the greatest reduction in the number of available grocery stores.95

Not only is access lacking in low-income commu- nities and communities of color, but disparities exist in the quality, variety, quantity, and price of healthy foods as well.107, 109, 112, 113, 123, 129, 168, 170 Together, the barriers inhibiting access to fresh foods and the plethora of inexpensive fast-food outlets can make it more difficult for people living in low-income neighborhoods and communities of color to eat a healthy diet.159

• In an assessment comparing low- and high- income food environments in Kansas City, Kansas, and Kansas City, Missouri, low-income neighborhoods have less availability and lower-quality produce than higher-income neighborhoods.168

• Supermarkets serving African American communities in Pittsburgh, Pennsylvania, are perceived by residents to offer produce and meats of poorer quality than branches of the same supermarkets serving white neighborhoods.107 Women in a low-income African American community in Chicago, Illinois, reported numerous environmental

barriers to acquiring healthy food, including store availability and upkeep; food availability, placement, and quality; high food prices; and safety concerns, among other issues.109

Rural Food Access

Lack of access to healthy foods in rural communities, especially within Native American reservations, is a significant concern.24, 32, 35, 36, 39, 47, 50, 54, 55, 75, 80, 95, 135, 138, 173-181 In rural areas, 10 miles is typically considered an acceptable distance to travel to a grocery store, supermarket, or other retail food outlet. However, it is not uncommon for the closest grocery store to be much farther away, and people living in low- income, rural communities typically have the farthest distances to travel to access healthy food.5

• A national study identified nearly 8 percent of the total rural population in the United States as living in communities lacking access to healthy food, and nearly 35 percent of those lacking access are also low income.142

• One study evaluating the food accessibility on 22 Native American reservations in Washington State observed physical and financial barriers to accessing healthy food: 15 reservations do not have an on-reservation supermarket or grocery store, yet the cost of shopping at off-reservation supermarkets is about 7 percent higher than the national reference cost.182

• On one reservation in South Dakota, nearly 40 percent of families with young children experience hunger and food insecurity.183, d

d Food insecurity is defined by the USDA as follows: “Food insecurity—the condition assessed in the food security survey and represented in USDA food security reports—is a household- level economic and social condition of limited or uncertain access to adequate food.” 263

Predominantly African American neighborhoods and low-income neighborhoods had the smallest increase in food store availability and the greatest reduction in the number of available grocery stores.95

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Other considerations associated with accessibility— such as perceptions of quality, price, and pref- erence—may also be more pronounced in rural areas where the density of food retail outlets is much lower than in urban areas. Even if a rural community’s access is not considered limited based on the standard geographic definition, residents may still experience challenges meeting their dietary needs and preferences. For example, two separate studies conducted in rural areas in Maine tell a different story about the rural food landscape.

• A study assessing proximity to fresh food retail within a rural community in Maine found that most residents are within acceptable distances (defined as within 10 miles) of stores offering healthy food options, although these stores may not be supermarkets.184

• A qualitative study examining the rural food environment in Maine found that cost, travel distance, and food quality are all factors that emerge as influential in rural, low-income families’ efforts to get food and families often travel up to 80 miles to purchase affordable, high-quality food.105

Transportation

Lack of transportation to grocery stores presents a serious problem for many people. About 2.1 million households do not own a vehicle and live more than one mile from the nearest supermarket. While this figure has been improving (down from 2.4 million households in 2006), the lowest vehicle ownership occurs among low-income people, further exacerbating the challenges to accessing healthy food in low-income communities.4 Although rural residents generally tend to have higher rates of vehicle ownership, lack of access to reliable transportation in rural communities can pose an acute added barrier

for accessing healthy food given the lack of transit systems in most rural areas.47, 55, 105, 180, 181, 185

Similar studies have looked at the impact of trans- portation in urban, low-income communities as well.14, 15, 36, 74, 112, 113, 128, 139, 140, 181, 186 Lack of trans- portation is frequently cited as a barrier to access- ing a full-service supermarket or grocery store, and recent results have reinforced an older body of literature, including congressional reports.127, 148, 153, 169, 187

School Settings

While research has more frequently examined access to healthy food relative to the home, some recent studies have sought to explore the food environment around schools.156, 188-190 The food environment in many low-income urban communities often com- prises primarily convenience stores and smaller markets. Convenience stores located in close proximity to middle and high schools represent an important—yet predominantly unhealthy—source of food for youth, and can have a substantial impact on diets regardless of the quality of food provided in schools.

• The findings of two studies indicate that stu- dents in low-income, urban neighborhoods in Oakland, California, and Minneapolis, Minnesota, have greater access to convenience food sources around their schools, lower access to healthy snack options, and greater access to unhealthy snack options compared with their counterparts in more affluent areas.189, 190

• Conversely, students in higher-income neighbor- hoods have less access to convenience food sources compared with students attending low-income schools, and when they do, their options are healthier.189

Convenience stores located in close proximity to middle and high schools represent an important—yet predominantly unhealthy—

source of food for youth, and can have a substantial impact on diets regardless of the quality of food provided in schools.

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12 Access to Healthy Food and Why It Matters

The Food Trust

2. Living closer to healthy food retail is associated with better eating habits and decreased risk for obesity and diet-related diseases.

Obesity and overweight affects two in every three adults and one-third of children ages 6 to 19. These rates are even more striking for children of color, with more than half of Hispanic and African American children classified as overweight or obese. For the first time in history, American children are projected to live shorter lives than their parents.191-193

The dire circumstances and projections have created urgency about the need to reduce obesity rates and widespread interest in changes in food environments. Healthy food access has been recognized by national agencies and associations including the Centers for Disease Control and Prevention (CDC), the Institute of Medicine (IOM), and the American Heart Association (AHA) as a necessary strategy to reduce obesity and improve the public’s health. While not the sole solution to the complexities of the obesity epidemic, access to nutritious and affordable food is an important factor enabling community residents to make easy, healthy choices about their diets.

More than 75 studies in the past three years have examined the direct health impacts of access to healthy food on diet and on the risk of obesity or overweight, as measured by fruit and vegetable consumption and body mass index (BMI)e respectively.8, 10, 16, 17, 24, 27-30, 34, 37, 45, 46, 49, 51, 76-78, 80, 83, 84, 94-96, 100, 101, 106, 110, 120, 128, 131, 137, 159, 175, 187, 188, 194-237

The latest research both reinforces and challenges previous research outcomes. Healthy eating and positive health outcomes were associated with access to healthy food in the following studies.

• A study of nearly 600 rural seniors found that increased distance to the nearest supermarket or other healthy food retail outlet is associated with decreased daily consumption of fruits and vegetables.200

e Body mass index (BMI) is a calculation of an individual’s weight-for-height ratio. According to the Centers for Disease Control and Prevention (CDC), BMI provides a reliable indicator of body fatness for most people and is used to screen for weight categories that may lead to health problems.264

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CHALLENGES OF ACCESS ///////////////

30 million live in low-income areas with limited access to supermarkets.4

one-third of all predominantly black census tracts in New York City lack walking or subway access to supermarkets.158

RURAL FOOD ACCESS //////////////////

8% of the total rural population in the United States live in communities lacking access to healthy food.4

35% of those lacking access are also low income.142

15 out of 22 Native American reservations in Washington State do not have an on-reservation supermarket or grocery store.182

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• Another study examining the relationship between healthy food access and produce consumption in a large metropolitan area found that better geographic accessibility to multiple grocery stores is associated with increased fruit and vegetable consumption. The model utilized in this study predicted that an additional 10 stores located within a mile of a person’s residence would correspond with a 15 percent increase in the likelihood of eating four or more servings of fruits and vegetables per day.208

• A study using a sample of national, secondary data found that lower produce prices, higher fast-food prices, and greater access to super- markets are related to increased fruit and vegetable consumption and lower BMI, especially among low-income teenagers.95

• A study of nearly 4,000 adults living in New Orleans found that each additional supermarket in a participant’s neighborhood is associated with reduced risk for obesity, while fast-food and convenience store access are predictive of greater odds of obesity.94

• Data from more than 300 food stores and more than 1,200 telephone interviews in one region found that higher-quality food environments—not specific food retail types— are associated with a decreased risk of obesity and overweight.202

While numerous studies support a direct connection between access to healthy food, a healthy diet, and health outcomes, there is also a smaller body of studies with findings that question the strength of that connection.

• A study assessing the density of both healthy and unhealthy food retail in relationship to childhood obesity risk found that low-income neighborhoods of color have greater access to all sources of food retail (both healthy and unhealthy) as measured by the number of outlets of all kinds. This measure of proximity does not independently explain weight gain over time in this sample of elementary school- aged children. The author concluded that accurate understanding of the ease of access requires better measurement of transportation and store inventories, and that factors such as pricing and the “psychology of food purchase patterns” can influence childhood obesity.199

TRANSPORTATION ///////////////////////

2.1 million households do not own a vehicle and live more than one mile from the nearest supermarket.4

ECONOMIC IMPACT OF HEALTHY FOOD //////////////////////

$540 billion in grocery store sales in 2011, translated to a…

$50 billion payroll for two million Americans working in food retailing.241

13,780 jobs were directly created by the food industry, generating…

$3 billion in economic activity in Vermont.119

150-200 full- and part-time jobs can be generated by a large retail grocery market.1

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• A 2012 analysis of 19,000 children and ado- lescents in California found no relationship between the home and school neighborhood food environments and youth diet quality. This exploratory study was the first to examine the impact of neighborhood food environments using BMI and measures of dietary intake from a statewide health interview survey, an approach limited by relatively low response rates, small sample sizes, and reliance on self- reporting. These researchers also recommended examination of other factors that can influence food purchasing and would sharpen the measurement of access.188

• A 2011 systematic literature review reported that mixed associations were found between greater accessibility to supermarkets or grocery stores and fruit and vegetable consumption, with five out of six studies showing no association between the two measures.195

Studies showing mixed results are reminders that community-level factors influencing healthy eating, such as distance to the store, or the prevalence of fast-food outlets, will have different degrees of salience to distinct local populations. In one published report, contrasting results were observed for different types of communities. A county-level analysis of metropolitan areas, utilizing a national data set of individual behaviors, found that as distance to a supermarket increased, consumers are less likely to eat five or more servings of fruits and vegetables per day and are more likely to be obese. However, this study also found that distance to the supermarket has no associations with obesity or fruit and vegetable consumption in nonmetropolitan (e.g., rural and small town) areas.96

Studies questioning the extent to which the avail- ability of healthy food impacts eating behaviors and overall health reveal that access is embedded in a complex set of relationships and factors in which the presence of a store is a necessary factor, but not necessarily the only factor, to ensure healthy eating. A more complete understanding of the impacts of access can be obtained by including assessments

ECONOMIC IMPACT OF HEALTHY FOOD /////////////////////////

Every $5.00 in new SNAP benefits generates…

$9.00 in local spending at supermarkets, grocery stores, and other approved SNAP-accepting retailers.253, 254

$1 billion of SNAP benefits generates anywhere from…

8,900-17,900 full-time-equivalent jobs.256

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of additional factors that influence the ability of neighborhood residents to eat healthy diets. These factors include the following:

• Transportation options: The overwhelming majority of people travel by car to shop for groceries, but some people use public transportation or walk, and a better under- standing could be gained about the reliability and feasibility of the modes of transportation people use to access healthy food. For example, a February 2013 town hall call-in survey of 127 Detroit city residents found that 22 percent of participants identified lack of transportation as the primary limitation to providing healthy food to their families.169

• Quality and price of produce and other healthy food options: Some studies looking at the relationship between the food environment and health outcomes use the simple presence of a store as a proxy for the availability of healthy foods. However, without a store assessment, this sort of analysis does not take into account the quality or price of the foods stocked in these stores. For example, a study of low-income, urban, food-desert consumers of color living in Detroit found that consumer income plays a significant role in determining purchasing behaviors and that increasing income or lowering price leads to increased fruit consumption.129

• Cultural appropriateness of neighborhood food choices: A store will have appeal and relevance in meeting its community’s needs if it stocks the foods in which the shoppers are interested at reasonable prices and treats them with respect. There is a need for more research regarding how the unique economic conditions, history, and cultural mix of neighborhoods affect food availability.238 Recent efforts in many cities to bridge the cultural gaps between small-store owners and residents of different ethnicities suggest that more successful healthy retailing can be attained when these issues are addressed directly.

ECONOMIC IMPACT OF HEALTHY FOOD (CONT’D) ////////////////

$190 million has been leveraged in healthy

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