Measuring food insecurity: An introduction to tools for human biologists and ecologists

OBJECTIVE

Food insecurity is a significant and growing concern undermining the wellbeing of 30% of the global population. Food in/security is a complex construct consisting of four dimensions: availability, access, utilization, and stability, making it challenging to measure. We provide a toolkit human biologists/ecologists can use to advance research on this topic.

METHODS

We review the strengths and limitations of common tools used to measure food access and utilization, the two dimensions most proximate to people's lived experience, and emphasize tools that provide data needed to best link food security with human biological outcomes. We also discuss methods that provide contextual data human biologists/ecologists will find useful for study design, ensuring instrument validity, and improving data quality.

RESULTS

Food access is principally measured using experience-based instruments that emphasize economic access. Social access, such as food sharing, is under-studied and we recommend using social network analysis to explore this dimension. In terms of utilization, emphasis has been on food choice measured as dietary diversity. Food preparation and intrahousehold distribution, also part of the utilization dimension, are less studied and standardized instruments for measuring both are lacking. The embodiment of food insecurity has focused on child growth, although a growing literature addresses adult mental wellbeing and chronic and infectious disease risk.

CONCLUSIONS

We see the potential to expand outcomes to include reproductive and immune function, physical activity, and the gut microbiome. Human biologists/ecologists are well-positioned to advance understanding of the human health impacts of food insecurity and provide data to support intervention efforts.

Determinants of maternal, infant, and young child nutrition during the 1,000-day window of opportunity in Solomon Islands: A focused ethnographic study

Introduction

This focused ethnographic study used qualitative, ethnographic, and participatory methods to explore determinants of maternal, infant, and young child nutrition (MIYCN) during the first 1,000 days of life as part of efforts to address the double burden of malnutrition in Solomon Islands.

Methods

An iterative study design was used to first explore and then confirm findings related to food and nutrition security and social and behavioral determinants of MIYCN in urban and rural settings. The first phase included in-depth interviews, household observations, free lists, and seasonal food availability calendar workshops while the second phase included focus group discussions, pile sorts, participatory community workshops, and repeated household observations.

Results and discussion

We found that MIYCN is shaped by a complex interaction of factors at the macro- and micro-levels. At the macro-level, globalization of the food system, a shifting economy, and climate change are driving a shift toward a delocalized food system based on imported processed foods. This shift has contributed to a food environment that leaves Solomon Islanders vulnerable to food and nutrition insecurity, which we found to be the primary determinant of MIYCN in this context. At the micro-level, this food environment leads to household- and individual-level food decisions that often do not support adequate MIYCN. Multi-sectoral interventions that address the macro- and micro-level factors shaping this nutrition situation may help to improve MIYCN in Solomon Islands.

Consumer willingness to pay for healthier food products: A systematic review

Food retail strategies to improve the healthiness of food and beverage options may increase purchasing of healthier options and improve diets. Consumer demand for healthier options is an important determinant of the successful implementation and maintenance of healthy food retail interventions. A systematic review of peer-reviewed literature was undertaken to explore whether consumers are willing to pay more for healthier foods and to determine the key factors that influence willingness to pay. Fifteen studies reported the results of 26 experiments providing willingness to pay estimates for healthier food products across a range of food retail environments. Twenty three out of the 26 experiments included in this review (88.5%) found consumers would pay a 5.6% to 91.5% (mean 30.7%) price premium for healthier foods. Studies consistently found a positive willingness to pay for foods with reduced fat and wholegrains with additional fruit and vegetables, while willingness to pay for foods with reduced salt or a combination of low fat and sugar, or salt showed mixed results. Adults over 60 years, females, those living with obesity, and consumers who aim to maintain a healthy lifestyle were more likely to pay a price premium for healthier food, whereas younger consumers, consumers with healthy weight, and consumers with higher levels of education were less likely to pay higher prices. The results of this review contribute to our understanding of consumer preferences for healthier products and provide information to retailers on consumer surplus (benefits) associated with the provision of healthier food alternatives.

Co-creation of healthier food retail environments: A systematic review to explore the type of stakeholders and their motivations and stage of engagement

OBJECTIVE

To synthesize peer-reviewed literature that utilize co-creation principles in healthy food retail initiatives.

METHODS

Systematic review of six databases from inception to September 2021. Screening and quality assessment were carried out by two authors independently. Studies were included if they were conducted in food retail stores, used a collaborative model, and aimed to improve the healthiness of the food retail environment. Studies excluded were implemented in restaurants, fast food chains, or similar or did not utilize some form of collaboration. Extracted data included the type of stakeholders engaged, level of engagement, stakeholder motivation, and barriers and enablers of the co-creation process.

FINDINGS

After screening 6951 articles by title and abstract, 131 by full text, 23 manuscripts that describe 20 separate studies from six countries were included. Six were implemented in low-income communities and eight among Indigenous people groups. A common aim was to increase access to, and availability of, healthy products. A diverse range of co-creation approaches, theoretical perspectives, and study designs were observed. The three most common stakeholders involved were researchers, corporate representatives or store owners, and governments.

CONCLUSIONS

Some evidence exists of the benefits of co-creation to improve the healthiness of food retail environments. The field may benefit from structured guidance on the theory and practice of co-creation.

The Baltimore Urban Food Distribution (BUD) App: Study Protocol to Assess the Feasibility of a Food Systems Intervention

Low-income urban communities in the United States commonly lack ready access to healthy foods. This is due in part to a food distribution system that favors the provision of high-fat, high-sugar, high-sodium processed foods to small retail food stores, and impedes their healthier alternatives, such as fresh produce. The Baltimore Urban food Distribution (BUD) study is a multilevel, multicomponent systems intervention that aims to improve healthy food access in low-income neighborhoods of Baltimore, Maryland. The primary intervention is the BUD application (app), which uses the power of collective purchasing and delivery to affordably move foods from local producers and wholesalers to the city's many corner stores. We will implement the BUD app in a sample of 38 corner stores, randomized to intervention and comparison. Extensive evaluation will be conducted at each level of the intervention to assess overall feasibility and effectiveness via mixed methods, including app usage data, and process and impact measures on suppliers, corner stores, and consumers. BUD represents one of the first attempts to implement an intervention that engages multiple levels of a local food system. We anticipate that the app will provide a financially viable alternative for Baltimore corner stores to increase their stocking and sales of healthier foods, subsequently increasing healthy food access and improving diet-related health outcomes for under-resourced consumers. The design of the intervention and the evaluation plan of the BUD project are documented here, including future steps for scale-up. Trial registration #: NCT05010018.

Association Between a Policy to Subsidize Supermarkets in Underserved Areas and Childhood Obesity Risk

IMPORTANCE

The establishment and renovation of supermarkets may promote healthy diet practices among youth by increasing retail infrastructure for fresh foods.

OBJECTIVE

To estimate the association between the Food Retail Expansion to Support Health (FRESH) program and the weight status of children and adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Using a difference-in-differences (DiD) design and including 12 months before and after a FRESH supermarket opened, data were analyzed for residentially stable public school students in kindergarten through 12th grade with objectively measured height and weight data from the academic years 2009 through 2016. Of the 8 FRESH-subsidized supermarkets in residential neighborhoods in New York City, New York, 5 were new and 3 were renovation projects between December 2011 and June 2014. Data were analyzed from June 2021 to January 2022.

INTERVENTIONS

The treatment group included students who resided within 0.50 miles of a FRESH-subsidized supermarket and had at least 1 body mass index (BMI) measurement within 12 months before and 3 to 12 months after the month a FRESH supermarket opened (n = 22 712 student-year observations). A 2-stage matching-weighting approach was used to construct a control group of students who resided more than 0.50 miles from a FRESH supermarket in a FRESH-eligible area (n = 86 744 student-year observations).

MAIN OUTCOMES AND MEASURES

BMI z score was calculated using objectively measured height and weight data from FITNESSGRAM, an annual, school-based, standardized fitness assessment of every New York City public school student. Obesity was defined as 95th percentile or greater of the BMI z score using Centers for Disease Control and Prevention growth charts.

RESULTS

The treatment group in the analytic sample had 11 356 students (22 712 student-year observations), and the control group had 43 372 students (86 744 student-year observations). The students were predominately Black (18.8%) and Hispanic and Latino (68.5%) and eligible for free or reduced-priced lunch (84.6%). There was a significant decrease in BMI z score among students who resided within 0.50 miles of a FRESH supermarket (vs control group students) in the 3- to 12-month follow-up period (DiD, -0.04; 95% CI, -0.06 to -0.02). This was true for those exposed to supermarkets that were either new (DiD, -0.07; 95% CI, -0.11 to -0.03) or renovated (DiD, -0.03; 95% CI, -0.06 to -0.01). A statistically significant decrease was also observed in the likelihood of obesity (DiD, -0.01; 95% CI, -0.02 to -0.002).

CONCLUSIONS AND RELEVANCE

Government-subsidized supermarkets may contribute to a small decrease in obesity risk among children residing near those supermarkets, if part of a comprehensive policy approach.

Parents' awareness and perceptions of the Change4Life 100 cal snack campaign, and perceived impact on snack consumption by children under 11 years

Background

Childhood obesity is a pertinent public health problem in the UK. Consumption of free sugars has been associated with the development of obesity. In 2018, the Change 4Life (C4L) 100 cal snack campaign was launched with the slogan ‘100 calorie snacks, two a day max’, aiming to encourage parents to choose lower sugar, fat and calorie snacks for their children. This study aimed to examine how the campaign has been perceived by parents.

Methods

An online survey was developed to explore parent awareness, perceptions and understanding of the C4L 100 cal snack campaign. Respondents were recruited via Leeds City Council, posters displayed at primary schools and children’s centres across Leeds and via social media. Paper surveys were also shared with voluntarily led playgroups. Survey data was analysed using descriptive statistics. Thematic analysis was performed on open text responses.

Results

Three hundred forty-two 342 respondents completed the survey. Just over half of the respondents had come across the campaign, most seeing the leaflet or a television advert. Over two-thirds of respondents ‘agreed’ or ‘strongly agreed’ that the campaign caught their attention. A similar proportion ‘agreed’ or ‘strongly agreed’ that the campaign informed them about 100 cal snacks and just over a half thought it was memorable. Most respondents used positive language to describe the campaign, but there was no clear consensus of a perceived positive impact on healthier snack purchasing, nor preparing more 100 cal snacks at home. Respondents provided examples of how the campaign could be improved to positively impact eating behaviours: better publicity and information delivery; healthier snack examples made more visible; improved nutritional labelling and access to healthier products in supermarkets (availability, promotion, display, choice).

Conclusions

The C4L 100 cal snack campaign was perceived positively by parents and carers, with many agreeing that the campaign was informative and memorable. However, there was no agreement in terms of the parents reporting an impact of the campaign on behaviour change and healthier snack habits. Future social marketing campaigns could be improved through more formal pilot testing to assess the understanding and acceptance of the campaign amongst the target audience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12789-7.

An Investigation of Social Ecological Barriers to and Facilitators of WIC Farmers Market Nutrition Program Voucher Redemption

In the United States, many communities lack sufficient access to fresh produce. To improve access to fresh fruits and vegetables, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides eligible participants vouchers through the Farmers Market Nutrition Program (FMNP) that can be redeemed directly from farmers at markets or farm stands. However, FMNP voucher redemption rates in New Jersey remain lower than those in neighboring states. This article used the social ecological model to examine differences between FMNP participants who redeem vouchers (Redeemers) and those who do not (non-Redeemers) in the areas of: produce procurement practices and consumption frequency, and barriers to and facilitators of FMNP voucher redemption. This cross-sectional study included WIC FMNP participants (N = 329) in northern New Jersey, USA. Analyses were conducted using descriptive statistics, independent sample t-tests, and one-way ANOVA. Compared to Redeemers, non-Redeemers consumed fewer average daily vegetable servings, were more likely to shop at small grocery/corner stores, and encountered significant barriers to FMNP redemption, e.g., difficulty finding time to redeem vouchers.

Exploring the Impact of Policies to Improve Geographic and Economic Access to Vegetables among Low-Income, Predominantly Latino Urban Residents: An Agent-Based Model

Modifying the food environment of cities is a promising strategy for improving dietary behaviors, but using traditional empirical methods to test the effectiveness of these strategies remains challenging. We developed an agent-based model to simulate the food environment of Austin, Texas, USA, and to test the impact of different food access policies on vegetable consumption among low-income, predominantly Latino residents. The model was developed and calibrated using empirical data from the FRESH-Austin Study, a natural experiment. We simulated five policy scenarios: (1) business as usual; (2)−(4) expanding geographic and/or economic healthy food access via the Fresh for Less program (i.e., through farm stands, mobile markets, and healthy corner stores); and (5) expanding economic access to vegetables in supermarkets and small grocers. The model predicted that increasing geographic and/or economic access to healthy corner stores will not meaningfully improve vegetable intake, whilst implementing high discounts (>85%) on the cost of vegetables, or jointly increasing geographic and economic access to mobile markets or farm stands, will increase vegetable intake among low-income groups. Implementing discounts at supermarkets and small grocers is also predicted to be an effective policy for increasing vegetable consumption. This work highlights the utility of agent-based modeling for informing food access policies.

Factors Influencing Implementation, Sustainability and Scalability of Healthy Food Retail Interventions: A Systematic Review of Reviews

The aim of this systematic review of reviews was to synthesise the evidence on factors influencing the implementation, sustainability and scalability of food retail interventions to improve the healthiness of food purchased by consumers. A search strategy to identify reviews published up until June 2020 was applied to four databases. The Risk of Bias in Systematic Review tool was used. Review findings were synthesised narratively using the socio-ecological model. A total of 25 reviews met the inclusion criteria. A number of factors influenced implementation; these included retailers' and consumers' knowledge and preferences regarding healthy food; establishing trust and relationships; perceived consumer demand for healthy food; profitability; store infrastructure; organizational support, including resources; and enabling policies that promote health. Few reviews reported on factors influencing sustainability or scalability of the interventions. While there is a large and rapidly growing body of evidence on factors influencing implementation of interventions, more work is needed to identify factors associated with their sustainability and scalability. These findings can be used to develop implementation strategies that consider the multiple levels of influence (individual, intrapersonal and environmental) to better support implementation of healthy food retail interventions.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

A Market Basket Assessment: Prices and Availability of Healthy Foods Across SNAP-Authorized Food Outlets in Counties With High Obesity Rates in Mississippi

Introduction

The Mississippi Delta is predominantly rural and ranks among the US regions with the highest obesity rates. Throughout the US, rural and low-income communities have limited access to healthy foods. Given the interrelation between the quality of the food environment and the healthfulness of diets and obesity rates, the food environment is an important public health concern in these communities.

Methods

We conducted a retail assessment in July 2019 in the Delta region of Mississippi and evaluated prices and availability of healthy foods at Supplemental Nutrition Assistance Program–accepting retail establishments using the validated Market Basket Assessment Tool. We used regression analysis to identify differences in prices and availability of healthy foods across food retail formats.

Results

The healthy foods availability and quality score for convenience stores, which comprise the highest proportion of store formats in the region, was 70% lower than for supermarkets. Compared with the prices at supermarkets, the prices at convenience stores were 48% higher for grains, 35% higher for fruit and vegetables, 73% higher for meats, and 95% higher for beans, seeds, and nuts. The healthfulness of foods available at dollar stores was also lower than the healthfulness at supermarkets, but prices were generally similar.

Conclusion

The availability of supermarkets and grocery stores was limited in the study area, but the concentration of convenience stores was high. Overall, access and affordability of healthy foods were restricted in the counties studied; these findings are useful for intervention development.

A Multi-Pronged Evaluation of a Healthy Food Access Initiative in Central Texas: Study Design, Methods, and Baseline Findings of the FRESH-Austin Evaluation Study

Food insecurity and limited healthy food access are complex public health issues and warrant multi-level evaluations. The purpose of this paper was to present the overall study design and baseline results of the multi-pronged evaluation of a healthy food access (i.e., Fresh for Less (FFL)) initiative in Central Texas. The 2018-2021 FRESH-Austin study was a natural experiment that utilized a cluster random sampling strategy to recruit three groups of participants (total n = 400): (1) customers at FFL assets, (2) residents that lived within 1.5 miles of an FFL asset, and (3) residents from a comparison community. Evaluation measures included annual cohort surveys, accelerometers and GPS devices, store-level audits, and built environment assessments. Data are being used to inform and validate an agent-based model (ABM) to predict food shopping and consumption behaviors. Sociodemographic factors and food shopping and consumption behaviors were similar across the three groups; however, customers recruited at FFL assets were lower income and had a higher prevalence of food insecurity. The baseline findings demonstrate the need for multi-level food access interventions, such as FFL, in low-income communities. In the future, ABM can be used as a cost-effective way to determine potential impacts of future large-scale food environment programs and policies.

U.S. Adolescents' Diet Consumption Patterns Differ between Grocery and Convenience Stores: National Health and Nutrition Examination Survey 2011-2018

Among U.S. adolescents, foods/beverages that are store-bought (i.e., from grocery and convenience stores) are significant contributors of energy intake. However, it remains unclear (1) what foods/beverages are consumed by U.S. adolescents from grocery and convenience stores and (2) if there are differences in foods/beverages consumed by store type. Therefore, we analyzed 29,216 eating occasions from adolescents (12–19 years; n = 4065) in the National Health and Nutrition Examination Survey 2011–2018 to report food/beverage groups and nutrients consumed from grocery and convenience stores. Differences in food/beverage groups and nutrient densities by store type were calculated using multiple logistic and linear regressions. Adolescents were more likely to consume “Beverages” and “Snacks and Sweets” and less likely to consume “Grains”, “Protein”, “Milk and Dairy”, “Condiments and Sauces”, and “Fruits” from convenience compared to grocery stores (all p < 0.0025). Foods/beverages from convenience stores were higher in carbohydrates, total sugar, and added sugar and lower in protein, fat, saturated fat, sodium, and fiber than those from grocery stores (all p < 0.0025). In conclusion, while foods/beverages from convenience stores are more energy-dense and nutrient-poor, there is a critical need to increase the availability, accessibility, and affordability of healthier foods/beverages in both store types to encourage healthier dietary behaviors among U.S. adolescents.

Healthy Eating Index-2015 Scores Vary by Types of Food Outlets in the United States

Diet quality in the United States is improving over time but remains poor. Food outlets influence diet quality and represent the environments in which individuals make choices about food purchases and intake. The objective of this study was to use the Healthy Eating Index-2015 (HEI-2015) to evaluate the quality of foods consumed from the four major outlets where food is obtained—stores, full-service restaurants, quick-services restaurants, and schools—and to assess changes over time. This cross-sectional study used 24 h dietary recall data from eight cycles (2003–2004 to 2017–2018) of the National Health and Nutrition Examination Survey (NHANES). Linear trend estimation was used to test for changes in HEI scores over time, and balanced repeated replicate weighted linear regression was used to test for differences in total and component scores between types of food outlets. Overall, Americans are not consuming a mix of foods from any major category of food outlet that aligns with dietary guidelines. The total score for schools (65/100 points) and stores (62/100 points) was significantly higher than full-service (51/100 points) and quick-service (39/100 points) restaurants (p < 0.0001). HEI scores significantly improved over time for schools (p < 0.001), including an increase in whole grains from less than 1 point in 2003–2004 to 7 out of 10 points in 2017–2018. In 2017–2018, schools received the maximum score for total fruits, whole fruits, and dairy. Continued research on strategies for improving the quality of foods consumed from restaurants and stores is warranted.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts

BACKGROUND

The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers.

METHODS

Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code.

RESULTS

Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases.

CONCLUSIONS

Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Street Food Stand Availability, Density, and Distribution Across Income Levels in Mexico City

Street food stands (SFS) are an understudied element of the food environment. Previous SFS studies have not used a rigorous approach to document the availability, density, and distribution of SFS across neighborhood income levels and points of access in Mexico City. A random sample (n = 761) of street segments representing 20 low-, middle-, and high-income neighborhoods were assessed using geographic information system (GIS) and ground-truthing methods. All three income levels contained SFS. However, SFS availability and density were higher in middle-income neighborhoods. The distribution of SFS showed that SFS were most often found near homes, transportation centers, and worksites. SFS availability near schools may have been limited by local school policies. Additional studies are needed to further document relationships between SFS availability, density, and distribution, and current structures and processes.

Influence of the Socio-Cultural Environment and External Factors in Following Plant-Based Diets

A general transition to plant-based diets is recommended for improved human and planetary health. The information about why people opt for plant-based diets can be used to profile future health promotion initiatives. We studied the reasons that encouraged the adoption and maintenance of plant-based diets and the influence of the socio-cultural environment and other external factors. Through the use of a specifically designed questionnaire, we evaluated two different populations. Interpreting data from 229 participants, we observed the relevance of adapting strategies to motivate people to embrace plant-based diets according to their socio-cultural environment. External factors facilitating access to plant-based products appeared to be essential in both populations.

Improving Consumption and Purchases of Healthier Foods in Retail Environments: A Systematic Review

This review examines current research on manipulations of U.S. food retail environments to promote healthier food purchasing and consumption. Studies reviewed use marketing strategies defined as the 4Ps (product, price, placement, promotion) to examine results based on single- and multi-component interventions by study design, outcome, and which of the “Ps” was targeted. Nine electronic databases were searched for publications from 2010 to 2019, followed by forward and backward searches. Studies were included if the intervention was initiated by a researcher or retailer, conducted in-store, and manipulated the retail environment. Of the unique 596 studies initially identified, 64 studies met inclusion criteria. Findings show that 56 studies had at least one positive effect related to healthier food consumption or purchasing. Thirty studies used single-component interventions, while 34 were multi-component. Promotion was the most commonly utilized marketing strategy, while manipulating promotion, placement, and product was the most common for multi-component interventions. Only 14 of the 64 studies were experimental and included objective outcome data. Future research should emphasize rigorous designs and objective outcomes. Research is also needed to understand individual and additive effects of multi-component interventions on sales outcomes, substitution effects of healthy food purchases, and sustainability of impacts.

The Retail Food Environment, Store Foods, and Diet and Health among Indigenous Populations: a Scoping Review

PURPOSE OF THE REVIEW

Describe the state of knowledge on how the retail food environment contributes to diet-related health and obesity among Indigenous populations, and assess how the literature incorporates Indigenous perspectives, methodologies and engagement throughout the research process. Outcomes included dietary behaviour (purchasing, intakes and diet quality) and diet-related health outcomes (weight-related outcomes, non-communicable diseases and holistic health or definitions of health as defined by Indigenous populations involved in the study).

RECENT FINDINGS

Of fifty included articles (1996-2019), the largest proportions described Indigenous communities in Canada (20 studies, 40%), the USA (16, 32%) and Australia (9, 18%). Among articles that specified the Indigenous population of focus (42 studies, 84%), the largest proportion (11 studies, 26%) took place in Inuit communities, followed by Aboriginal and Torres Strait Islander communities (8 studies, 19%). The included literature encompassed four main study designs: type A, dietary intakes of store foods (14 studies, 28%), and type B, store food environments (16, 32%), comprised the greatest proportion of articles; the remainder were type C, store food environments and diet (7, 14%), and type D, store food environment interventions (13, 26%). Of the studies that assessed diet or health outcomes (36, 72%), 22 (61%) assessed dietary intakes; 16 (44%) sales/purchasing; and 8 (22%) weight-related outcomes. Store foods tended to contribute the greatest amount of dietary energy to the diets of Indigenous peoples and increased non-communicable disease risk as compared to traditional foods. Multi-pronged interventions appeared to have positive impacts on dietary behaviours, food purchasing and nutrition knowledge; promotion and nutrition education alone had more mixed effects. Of the nine studies which were found to have strong engagement with Indigenous populations, eight had moderate or high methodological quality. Eighteen studies (36%) did not mention any engagement with Indigenous populations. The literature confirmed the importance of store foods to the total energy intake of the contemporary diets of Indigenous people, the gaps in accessing both retail food environments and traditional foods and the potential for both new dietary assessment research and retail food environment intervention strategies to better align with and privilege Indigenous Ways of Knowing.

A Systematic Review of the Effect of Retail Food Environment Interventions on Diet and Health with a Focus on the Enabling Role of Public Policies

Purpose of Review

Update the state of evidence on the effectiveness of retail food environment interventions in influencing diet and explore the underlying role of public policy, through a systematic review of population-level interventions to promote health in the retail food environment, including community and consumer environments. Diet-related outcomes included purchasing, dietary intakes, diet quality, and health including weight. We coded studies for enabling public policy levers underpinning the intervention, using two widely used conceptual frameworks.

Recent Findings

Of 86 articles (1974–2018), the majority (58 articles, 67%) showed at least one positive effect on diet. Thirteen articles (15%) discussed natural experiments, 27 articles (31%) used a design involving comparison groups including 23 articles (27%) specifically describing randomized controlled trials, and 46 (53%) were quasi-experimental (cross-sectional) evaluations. Across the “4Ps” of marketing (product, promotion, placement, and price), promotion comprised the greatest proportion of intervention strategies, especially in earlier literature (pre-2008). Few studies combined geographic access interventions with 4P strategies, and few used robust dietary intake assessments. Behavior change communication remains an intervention mainstay, but recent work has also incorporated environmental and social planning, and fiscal strategies. More recent interventions were multi-component.

Summary

The retail food environment intervention literature continues to grow and has become more robust overall, with clearer evidence of the effect of interventions on diet-related outcomes, including consumer purchasing, dietary intakes, and health. There is still much scope for development in the field. Attention to enabling public policy could help to strengthen intervention implementation and evaluation in the retail food environment.

Longitudinal Fruit and Vegetable Sales in Small Food Retailers: Response to a Novel Local Food Policy and Variation by Neighborhood Socioeconomic Status

Small food retailers, including corner/convenience stores, pharmacies, gas-marts, and dollar stores, have historically stocked limited fruits and vegetables, though this may be changing. We examined increases in sales, customer purchasing, and stocking of fresh and/or frozen fruits and vegetables in small food stores over time and in relation to: (a) a local food policy (the Minneapolis Staple Foods Ordinance) and (b) neighborhood socioeconomic status (SES). We used longitudinal data (2014–2017) from 147 randomly-sampled stores in Minneapolis/St. Paul, USA, collected using interviewer-administered manager surveys (measuring sales and stocking) and customer intercepts/observations (measuring purchasing, n = 3039). The local policy required Minneapolis stores to meet minimum stocking standards for fresh/frozen produce and other healthy foods. No ordinance existed in St. Paul. Mixed regression models examined overall change over time and change by city and neighborhood SES. We observed significant increases over time (p < 0.05) in sales and purchasing of fresh fruit and in stocking of fresh fruit, frozen fruit, and frozen vegetables. We did not identify consistent statistical evidence for differential change in sales, purchasing, or stocking by city or neighborhood SES. Key study findings suggest limited differential effects of the local ordinance and/or neighborhood SES. However, findings also indicate significant time trends for some products, including consistent improvements in sales, customer purchasing, and stocking of fresh fruit. Given the ready-to-eat convenience of many fresh fruits and their broad appeal, fresh fruit appears a promising target for advancing the healthfulness of small food retailers.

Kids in a Candy Store: An Objective Analysis of Children's Interactions with Food in Convenience Stores

Increasing rates of childhood obesity worldwide has focused attention on the obesogenic food environment. This paper reports an analysis of children's interactions with food in convenience stores. Kids'Cam was a cross-sectional study conducted from July 2014 to June 2015 in New Zealand in which 168 randomly selected children aged 11-14 years old wore a wearable camera for a 4-day period. In this ancillary study, images from children who visited a convenience store were manually coded for food and drink availability. Twenty-two percent of children (n = 37) visited convenience stores on 62 occasions during the 4-day data collection period. Noncore items dominated the food and drinks available to children at a rate of 8.3 to 1 (means were 300 noncore and 36 core, respectively). The food and drinks marketed in-store were overwhelmingly noncore and promoted using accessible placement, price offers, product packaging, and signage. Most of the 70 items purchased by children were noncore foods or drinks (94.6%), and all of the purchased food or drink subsequently consumed was noncore. This research highlights convenience stores as a key source of unhealthy food and drink for children, and policies are needed to reduce the role of convenience stores in the obesogenic food environment.

Neighborhood Influences on Physical Activity Among Low-Income African American Adults With Type 2 Diabetes Mellitus

PURPOSE

The purpose of the study was to explore the influences of the neighborhood environment on physical activity (PA) among people living with type 2 diabetes mellitus (T2DM) in a community with limited resources.

METHODS

Participants were adults with T2DM and their family members or friends who help in the management of T2DM and who were living in a low-income African American (AA) community. Health care providers working in the neighborhood were also included. Using an emergent design, qualitative data were collected through 7 focus group discussions (N = 63) and 13 in-depth interviews. Verbatim transcriptions were analyzed via thematic coding to explore contextual factors that limit PA and meaning around neighborhood features that promote or discourage PA.

RESULTS

Levels of PA were strongly limited by neighborhood insecurity and a lack of recreational facilities in the neighborhood. People with T2DM and physical/mobility disabilities were more affected by the neighborhood environment than those without disabilities, particularly due to perceived safety concerns and social stigma. Despite socioeconomic inequalities within neighborhoods, participants showed resilience and made efforts to overcome social-environmental barriers to PA, applied various coping strategies, and received social support.

CONCLUSIONS

Results suggested that in an underserved neighborhood, individual barriers to physical activity were amplified by neighborhood-level factors such as crime, especially among individuals who have T2DM and disabilities. Socioeconomic inequalities should be addressed further to improve management of T2DM and its complications.

Crowdsourced Mapping for Healthy Food Accessibility in Dallas, Texas: A Feasibility Study

Since its first use for describing a neighborhood lacking access to food in the 1990's, “food deserts” has been widely addressed by researchers and adopted as an indicator of neighborhood-level food insecurity by governmental agencies, such as USDA. However, mostly due to cost and difficulty in collecting georeferenced data and characteristics of grocery stores, the USDA Food Access Research Atlas is infrequently released, and considers only income, vehicle ownership, and distance to the nearest grocery store. In this paper, we explored the feasibility of a crowdsourced geospatial data source, coupled with additional measures, in supplementing the USDA's current designation of food deserts. We used Yelp data to map food deserts in the city of Dallas and compared them with those based on the 2015 USDA food retailer database. Although direct comparison was not possible due to time mismatch between the two data sources, the discrepancies highlighted the need of a more frequent identification of food deserts for timely policy intervention. Furthermore, we extended mapping to reveal other potential areas of concerns, by adding the Transit Score metric and Yelp's price descriptor of businesses. The resulting maps illustrated the areas with grocery stores nearby but with limited accessibility due to lack of public transit or potential financial barriers in purchasing foods due to high prices. Our findings demonstrate the current status and future potential of up-to-date crowdsourced, georeferenced data as a complement of official government data, which could serve to extend food access research and guide health policies.

Participatory Methods to Identify Perceived Healthy and Sustainable Traditional Culinary Preparations across Three Generations of Adults: Results from Chile's Metropolitan Region and Region of La Araucanía

Traditional diets reflect different cultures and geographical locations, and may provide healthy diet options. In Chile, it is unknown whether traditional culinary preparations are still remembered, let alone consumed. Therefore, we adapted methods to identify traditional culinary preparations for healthy and sustainable dietary interventions. In Chile's Metropolitan Region and the Region of La Araucanía, we collected data on the variety of traditional diets through cultural domain analyses: direct participant observation (n = 5); free listing in community workshops (n = 10); and pile sort activities within semi-structured individual interviews (n = 40). Each method was stratified by age (25-45 year, 46-65 year and ≥ 65 year) and ethnic group (first nations or not). About 600 preparations and single-ingredient foods were identified that differed both in frequency and variety by region. The foods most consumed and liked (n = 24-27) were ranked in terms of sustainability for public nutrition purposes. Methods originally designed to collect information about plants of indigenous peoples can be extended to collect data on the variety of existing traditional culinary preparations, globally. Context, both geographical and cultural, matters for understanding food variety, and its subsequent use in the design of healthy and sustainable diet interventions.

A Geospatial Analysis of Access to Ethnic Food Retailers in Two Michigan Cities: Investigating the Importance of Outlet Type within Active Travel Neighborhoods

To date, the research that examines food accessibility has tended to ignore ethnic food outlets. This void leaves us with a limited understanding of how such food stores may, or may not, impact food security. The study discussed herein addressed this by conducting a geospatial assessment of ethnic food outlet accessibility in two U.S. cities: Flint and Grand Rapids, Michigan. We used Geographic Information Systems (GIS) tools to create a revealed accessibility index for each food outlet, and used the index to determine access within active travel service areas. We utilized an ordinary least squares regression (OLS), and two local models: spatial autoregression (SAR) and geographically weighted regression (GWR) to enhance our understanding of global and localized relationships between outlet accessibility and type (while controlling for known covariates). The results show that the local models outperformed (R² max = 0.938) the OLS model. The study found that there was reduced access to ethnic restaurants in all service areas of Grand Rapids. However, in Flint, we observed this association in the bicycling areas only. Also notable were the influences that demographic characteristics had on access in each city. Ultimately, the findings tell us that nuanced planning and policy approaches are needed in order to promote greater access to ethnic food outlets and reduce overall food insecurity.

Evaluation of Store Environment Changes of an In-Store Intervention to Promote Fruits and Vegetables in Latino/Hispanic-Focused Food Stores

Implementing interventions that manipulate food store environments are one potential strategy for improving dietary behaviors. The present study evaluated intervention effects, from the El Valor de Nuestra Salud (The Value of Our Health) study, on in-store environmental changes within Latino/Hispanic-focused food stores (tiendas). Sixteen tiendas were randomly assigned to either: a six-month structural and social food store intervention or a wait-list control condition. Store-level environmental measures of product availability, placement, and promotion were assessed monthly from baseline through six-months post-baseline using store audits. Linear mixed effects models tested for condition-by-time interactions in store-level environmental measures. Results demonstrated that the intervention was successful at increasing the total number of fruit and vegetable (FV) promotions (p < 0.001) and the number of FV promotions outside the produce department (p < 0.001) among tiendas in the intervention versus control condition. No changes in product availability or placement were observed. Results suggests changing the marketing mix element of promotions within small stores is measurable and feasible in an in-store intervention. Difficulties in capturing changes in product availability and placement may be due to intervention implementation methods chosen by tiendas. It is important to build upon the lessons learned from these types of interventions to disseminate evidence-based in-store interventions.

Corner Store Owners as Health Promotion Agents in Low-Income Communities

Reports of small business owner motivations for participation in health promotion interventions are rarely reported in the literature, particularly in relation to healthy eating interventions. This study explicates and defines the development of healthy corner stores as community-based enterprises (CBEs) within eight low-income, suburban communities. CBEs are defined as community-oriented small businesses with a common goal to improve population health. The corner stores assessed in this study were participants in Healthy HotSpot (HH), a corner store initiative of the Cook County Department of Public Health. To determine store alignment with the CBE construct, a case study design was used for qualitative inquiry. Participant narratives from store owners (n = 21), community-based organizations (CBOs; n = 8) and consumer focus groups (n = 51) were analyzed using an iterative process to determine how store owners aligned with the CBE construct, and how this influenced continuation of health promotion activities. Several key factors influenced the strength of store owners' alignment with the CBE construct. They included the following: (a) shared ethno-cultural identities and residential area as consumers; (b) positive, trustworthy relationships with consumers; (c) store owners valuing and prioritizing community health, often over profits; and (d) collaboration with a highly engaged CBO in the HH project. Results can assist in theory development and intervention design in working with corner store owners, and other small business owners, as health promotion agents to improve and sustain health outcomes and help ensure the economic vitality of low-income communities.

Evaluation of the first U.S. staple foods ordinance: impact on nutritional quality of food store offerings, customer purchases and home food environments

Background

Many lower-income and racially diverse communities in the U.S. have limited access to healthy foods, with few supermarkets and many small convenience stores, which tend to stock limited quantities and varieties of healthy foods. To address food access, in 2015 the Minneapolis Staple Foods Ordinance became the first policy requiring food stores to stock minimum quantities and varieties of 10 categories of healthy foods/beverages, including fruits, vegetables, whole grains and other staples, through licensing. This study examined whether: (a) stores complied, (b) overall healthfulness of store environments improved, (c) healthy customer purchases increased, and (d) healthfulness of home food environments improved among frequent small store shoppers.

Methods

Data for this natural (or quasi) experiment were collected at four times: pre-policy (2014), implementation only (no enforcement, 2015), enforcement initiation (2016) and continued monitoring (2017). In-person store assessments were conducted to evaluate food availability, price, quality, marketing and placement in randomly sampled food retailers in Minneapolis (n = 84) and compared to those in a nearby control city, St. Paul, Minnesota (n = 71). Stores were excluded that were: supermarkets, authorized through WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), and specialty stores (e.g., spice shops). Customer intercept interviews were conducted with 3,039 customers exiting stores. Home visits, including administration of home food inventories, were conducted with a sub-sample of frequent shoppers (n = 88).

Results

Overall, findings indicated significant improvements in healthy food offerings by retailers over time in both Minneapolis and St. Paul, with no significant differences in change between the two cities. Compliance was low; in 2017 only 10% of Minneapolis retailers in the sample were fully compliant, and 51% of participating Minneapolis retailers met at least 8 of the 10 required standards. Few changes were observed in the healthfulness of customer purchases or the healthfulness of home food environments among frequent shoppers, and changes were not different between cities.

Conclusions

This study is the first evaluation a local staple foods ordinance in the U.S. and reflects the challenges and time required for implementing such policies.

Trial registration

NCT02774330.

Youth Willingness to Purchase Whole Grain Snack Packs from New York City Corner Stores Participating in a Healthy Retail Program

Corners stores in low-income communities are a promising setting to intervene in youth whole grain intake. One strategy that may encourage whole grain intake is if corner stores were to pair and sell whole grain snacks in combination with either a liked fruit or vegetable and an optional condiment (i.e., a whole grain snack pack). This study examined youth in terms of their (1) liking of fruits, vegetables, and whole grain snacks; (2) perceptions about which fruits and vegetables pair best with whole grain snacks; and (3) willingness to pay for a whole grain snack pack. One-time intercept surveys were conducted with 10-18-year-olds (n = 402) who visited a New York City (NYC) corner store (n = 34) participating in the City Harvest Healthy Retail Program. On average, youth were willing to spend $2.38 (SD $4.32) on a whole grain snack pack. Higher overall liking scores for vegetables and whole grain snacks were associated with willingness to spend 24.4% (95% confidence interval (CI): 11.5-38.7%) and 21.6% (95%CI: 5.2-40.6%) more on whole grain snack packs, respectively. In conclusion, youth are receptive to purchasing whole grain snack packs from NYC corner stores participating in a healthy retail program.

Opportunities and Challenges Addressing Access to Healthy Food in Five Rural Louisiana Food Stores

The prevalence of high obesity in rural communities may result from low access to healthy foods. To improve the local food environment, a multicomponent environmental food store intervention was implemented in 3 Louisiana parishes where obesity prevalence was greater than 40%. The intervention consisted of healthy-food demonstrations, in-store marketing, and encouraging store owners to stock healthy items. We documented aspects of the rural food store climate, such as store size and the store owner’s willingness to stock healthy items, that affect improving access to healthy food. We found that although the intervention was not effective in shifting purchasing or dietary habits of customers, positive changes in some food store environments did occur. To maximize the effect that rural food store interventions can have on reducing obesity, it is essential to understand aspects of the rural food store climate.

Socioeconomic Inequalities in the Retail Food Environment around Schools in a Southern European Context

Across Europe, excess body weight rates are particularly high among children and adolescents living in Southern European contexts. In Spain, current food policies appeal to voluntary self-regulation of the food industry and parents’ responsibility. However, there is no research (within Spain) assessing the food environment surrounding schools. We examined the association between neighborhood-level socioeconomic status (NSES) and the spatial access to an unhealthy food environment around schools using both counts and distance measures, across the city of Madrid. We conducted a cross-sectional study citywide (n = 2443 census tracts). In 2017, we identified all schools (n = 1321) and all food retailers offering unhealthy food and beverages surrounding them (n = 6530) using publicly available data. We examined both the counts of retailers (within 400 m) and the distance (in meters) from the schools to the closest retailer. We used multilevel regressions to model the association of neighborhood-level socioeconomic status (NSES) with both measures, adjusting both models for population density. Almost all schools (95%) were surrounded by unhealthy retailers within 400 m (median = 17 retailers; interquartile range = 8–34). After adjusting for population density, NSES remained inversely associated with unhealthy food availability. Schools located in low-NSES areas (two lowest quintiles) showed, on average, 29% (IRR (Incidence Rate Ratio) = 1.29; 95% CI (Confidence Interval) = 1.12, 1.50) and 62% (IRR = 1.62; 95% CI = 1.35, 1.95) more counts of unhealthy retailers compared with schools in middle-NSES areas (ref.). Schools in high-NSES areas were farther from unhealthy food sources than those schools located in middle-NSES areas (β = 0.35; 95% CI = 0.14, 0.47). Regulating the school food environment (within and beyond school boundaries) may be a promising direction to prevent and reduce childhood obesity.

A systematic review of factors that influence food store owner and manager decision making and ability or willingness to use choice architecture and marketing mix strategies to encourage healthy consumer purchases in the United States, 2005-2017

Background

Altering food store environments is a promising approach to encourage healthy product purchases by consumers to improve their diet quality and health. Food store owners and managers are intermediaries to ensure that environmental changes are enacted. Despite their role as gatekeepers to implement and sustain healthy food environment changes, no systematic review has been published that examines food store owner and manager (retailer) data. Thus a review of retailer information available within the expansive United States (US) food environment literature was the purpose of this research.

Methods

The PRISMA protocol was used. A search strategy, including published articles from years 1980–2017, was applied to six databases to locate relevant articles that addressed the perspective of food store retailers in the US. Data were extracted, organized, and agreed upon between two authors based on pre-designed constructs: (1) a social-ecological model to capture factors that influence retailer decision making; and (2) a marketing-mix and choice-architecture framework to examine perspectives of applied (or the prospective application of) strategies at the store-level. Study quality was assessed using quality criteria checklists for qualitative and quantitative research.

Results

Thirty-one articles met inclusion criteria and most studies (n = 22) were qualitative and conducted in urban food stores (n = 23). Multiple social-ecological factors influenced retailer decision making and ability or willingness to use marketing-mix and choice-architecture strategies to improve consumers’ healthy choices to support dietary quality. These factors included: conflicting training outcomes to enhance retailers’ knowledge and skills (individual, n = 9); the importance of trust (interpersonal, n = 8); views about marketing-mix and choice-architecture strategies in the food environment (n = 25); consumer demand or demographics (community, n = 19); supplier and food store management variables (systems or sectors, n = 18); local and federal policy (n = 8); and support for community health (norms/values, n = 8).

Conclusions

Research partnerships can support favorable business and public health outcomes to align with retailers’ business models and available resources. A participatory and translational approach to food environment research will likely maximize public health impact. Urban and rural food store retailers are important actors for future research to inform the feasibility of store retailers to apply MMCA strategies that are profitable and promote health.

Electronic supplementary material

The online version of this article (10.1186/s12966-019-0767-8) contains supplementary material, which is available to authorized users.

One-Year Follow-Up Examination of the Impact of the North Carolina Healthy Food Small Retailer Program on Healthy Food Availability, Purchases, and Consumption

We examined the short-term impact of the North Carolina Healthy Food Small Retailer Program (HFSRP), a legislatively appropriated bill providing funding up to $25,000 to small food retailers for equipment to stock and promote healthier foods, on store-level availability and purchase of healthy foods and beverages, as well as customer dietary patterns, one year post-policy implementation. We evaluated healthy food availability using a validated audit tool, purchases using customer bag-checks, and diet using self-reported questionnaires and skin carotenoid levels, assessed via Veggie Meter™, a non-invasive tool to objectively measure fruit and vegetable consumption. Difference-in-difference analyses were used to examine changes in HFSRP stores versus control stores after 1 year. There were statistically significant improvements in healthy food supply scores (availability), with the Healthy Food Supply HFS score being -0.44 points lower in control stores and 3.13 points higher in HFSRP stores pre/post HFSRP (p = 0.04). However, there were no statistically significant changes in purchases or self-reported consumption or skin carotenoids among customers in HFSRP versus control stores. Additional time or other supports for retailers (e.g., marketing and promotional materials) may be needed for HFSRP implementation to influence purchase and consumption.

Multilevel Structural Equation Modeling of Students' Dietary Intentions/Behaviors, BMI, and the Healthfulness of Convenience Stores

Background: When dietary behaviors are habitual, intentions are low, and environmental cues, such as the consumer food environment, might guide behavior. How might intentions to eat healthily and ultimately actual dietary behaviors, be influenced by the consumer food environment (including the availability and affordability of healthy foods) in convenience stores? This study will determine pathways between the healthfulness of convenience stores and college students’ dietary intentions/behaviors, and body mass index (BMI). Methods: Through multilevel structural equation modeling, a comparison was made of students’ healthful meal intentions (HMI); intake (fruits/vegetables, %kcal/fat, sugar-sweetened beverages (SSBs) and whole-grains); and measured BMI; as well as the healthfulness of convenience stores (fruits/vegetables availability/quality, healthy food availability/affordability). Data was collected on 1401 students and 41 convenience stores across 13 US college campuses. Results: Controlling for gender, HMI was negatively associated with SSBs (β = −0.859) and %kcal/fat (β = −1.057) and positively with whole-grains (β = 0.186) and fruits/vegetables intake (β = 0.267); %Kcal/fat was positively (β = 0.098) and fruits/vegetables intake (β = −0.055) negatively associated with BMI. Campus level, fruits/vegetables availability were positively associated to HMI (β = 0.214, β = 0.129) and directly/negatively to BMI (β = −2.657, β = −1.124). Conclusions: HMI modifies dietary behaviors, with energy from fat and fruit/vegetable intake the most predictive of weight. Availability of fruit/vegetables in convenience stores make it easier for young adults to eat well.

You Can't Find Healthy Food in the Bush: Poor Accessibility, Availability and Adequacy of Food in Rural Australia

In high-income countries, obesity disproportionately affects those from disadvantaged and rural areas. Poor diet is a modifiable risk factor for obesity and the food environment a primary driver of poor diet. In rural and disadvantaged communities, it is harder to access affordable and nutritious food, affecting both food insecurity and the health of rural residents. This paper aims to describe the food environment in a rural Australian community (approx. 7000 km² in size) to inform the development of community-relevant food supply interventions. We conducted a census audit of the food environment (ground truthing) of a local government area (LGA). We used the Nutrition Environment Measurement tools (NEMS-S and NEMS-R) to identify availability of a range of food and non-alcoholic beverages, the relative price of a healthy compared to a less healthy option of a similar food type (e.g., bread), the quality of fresh produce and any in-store nutrition promotion. Thirty-eight food retail outlets operated at the time of our study and all were included, 11 food stores (NEMS-S) and 27 food service outlets (NEMS-R). The mean NEMS-S score for all food stores was 21/54 points (39%) and mean NEMS-R score for all food service outlets was 3/23 points (13%); indicative of limited healthier options at relatively higher prices. It is difficult to buy healthy food beyond the supermarkets and one (of seven) cafés across the LGA. Residents demonstrate strong loyalty to local food outlets, providing scope to work with this existing infrastructure to positively impact poor diet and improve food security.

Best Practices and Innovative Solutions to Overcome Barriers to Delivering Policy, Systems and Environmental Changes in Rural Communities

To better understand the barriers to implementing policy; systems; and environmental (PSE) change initiatives within Supplemental Nutrition Assistance Program-Education (SNAP-Ed) programming in U.S. rural communities; as well as strategies to overcome these barriers, this study identifies: (1) the types of nutrition-related PSE SNAP-Ed programming currently being implemented in rural communities; (2) barriers to implementing PSE in rural communities; and (3) common best practices and innovative solutions to overcoming SNAP-Ed PSE implementation barriers. This mixed-methods study included online surveys and interviews across fifteen states. Participants were eligible if they: (1) were SNAP-Ed staff that were intimately aware of facilitators and barriers to implementing programs, (2) implemented at least 50% of their programming in rural communities, and (3) worked in their role for at least 12 months. Sixty-five staff completed the online survey and 27 participated in interviews. Barriers to PSE included obtaining community buy-in, the need for relationship building, and PSE education. Facilitators included finding community champions; identifying early "wins" so that community members could easily see PSE benefits. Partnerships between SNAP-Ed programs and non-SNAP-Ed organizations are essential to implementing PSE. SNAP-Ed staff should get buy-in from local leaders before implementing PSE. Technical assistance for rural SNAP-Ed programs would be helpful in promoting PSE.

Designing Place-Based Interventions for Sustainability and Replicability: The Case of GO! Austin/VAMOS! Austin

Place-based health efforts account for the role of the community environment in shaping decisions and circumstances that affect population well-being. Such efforts, rooted as they are in the theory that health is socially determined, mobilize resources for health promotion that are not typically used, and offer a more informed and robust way of promoting health outcomes within a community. Common criticisms of place-based work include the difficulty of replication, since engagement is so specific to a place, and limited sustainability of the work, in the absence of continued institutional structures, both within the community and supporting structures outside the community, to keep these initiatives resilient. This paper describes a place-based initiative, GO! Austin/VAMOS! Austin (GAVA), which was designed to harness the strengths of place-based work-namely, its specificity to place and community. From the start, the project was designed to balance this specificity with a focus on developing and utilizing a standardized set of evidence-informed implementation and evaluation approaches and tools that were flexible enough to be modified for specific settings. This was accompanied by an emphasis on leadership and capacity building within resident leaders, which provided for informed intervention and demand building capacity, but also for longevity as partners, philanthropic, and otherwise, moved in and out of the work.

Leveraging Citizen Science for Healthier Food Environments: A Pilot Study to Evaluate Corner Stores in Camden, New Jersey

Over the last 6 years, a coordinated “healthy corner store” network has helped an increasing number of local storeowners stock healthy, affordable foods in Camden, New Jersey, a city with high rates of poverty and unemployment, and where most residents have little or no access to large food retailers. The initiative’s funders and stakeholders wanted to directly engage Camden residents in evaluating this effort to increase healthy food access. In a departure from traditional survey- or focus group-based evaluations, we used an evidence-based community-engaged citizen science research model (called Our Voice) that has been deployed in a variety of neighborhood settings to assess how different features of the built environment both affect community health and wellbeing, and empower participants to create change. Employing the Our Voice model, participants documented neighborhood features in and around Camden corner stores through geo-located photos and audio narratives. Eight adult participants who lived and/or worked in a predefined neighborhood of Camden were recruited by convenience sample and visited two corner stores participating in the healthy corner store initiative (one highly-engaged in the initiative and the other less-engaged), as well as an optional third corner store of their choosing. Facilitators then helped participants use their collected data (in total, 134 images and 96 audio recordings) to identify and prioritize issues as a group, and brainstorm and advocate for potential solutions. Three priority themes were selected by participants from the full theme list (n = 9) based on perceived importance and feasibility: healthy product selection and display, store environment, and store outdoor appearance and cleanliness. Participants devised and presented a set of action steps to community leaders, and stakeholders have begun to incorporate these ideas into plans for the future of the healthy corner store network. Key elements of healthy corner stores were identified as positive, and other priorities, such as improvements to safety, exterior facades, and physical accessibility, may find common ground with other community development initiatives in Camden. Ultimately, this pilot study demonstrated the potential of citizen science to provide a systematic and data-driven process for public health stakeholders to authentically engage community residents in program evaluation.

Examination of the Relationship between In-Store Environmental Factors and Fruit and Vegetable Purchasing among Hispanics

Retail food environments have received attention for their influence on dietary behaviors and for their nutrition intervention potential. To improve diet-related behaviors, such as fruit and vegetable (FV) purchasing, it is important to examine its relationship with in-store environmental characteristics. This study used baseline data from the “El Valor de Nuestra Salud” study to examine how in-store environmental characteristics, such as product availability, placement and promotion, were associated with FV purchasing among Hispanic customers in San Diego County. Mixed linear regression models indicated that greater availability of fresh FVs was associated with a $0.36 increase in FV purchasing (p = 0.01). Placement variables, specifically each additional square foot of display space dedicated to FVs (p = 0.01) and each additional fresh FV display (p = 0.01), were associated with a $0.02 increase and $0.29 decrease, respectively, in FV purchasing. Introducing FV promotions in the final model was not related to FV purchasing. Exploratory analyses indicated that men reported spending $3.69 fewer dollars on FVs compared to women, controlling for covariates (p = 0.02). These results can help inform interventions targeting in-store environmental characteristics to encourage FV purchasing among Hispanics.

Baseline Assessment of a Healthy Corner Store Initiative: Associations between Food Store Environments, Shopping Patterns, Customer Purchases, and Dietary Intake in Eastern North Carolina

In 2016, the North Carolina (NC) Legislature allocated $250,000 to the NC Department of Agriculture, to identify and equip small food retailers to stock healthier foods and beverages in eastern NC food deserts (the NC Healthy Food Small Retailer Program, HFSRP). The purpose of this study was to examine associations between food store environments, shopping patterns, customer purchases, and dietary consumption among corner store customers. We surveyed 479 customers in 16 corner stores regarding demographics, food purchased, shopping patterns, and self-reported fruit, vegetable, and soda consumption. We objectively assessed fruit and vegetable consumption using a non-invasive reflection spectroscopy device to measure skin carotenoids. We examined associations between variables of interest, using Pearson's correlation coefficients and adjusted linear regression analyses. A majority (66%) of participants were African American, with a mean age of 43 years, and a mean body mass index (BMI) of 30.0 kg/m². There were no significant associations between the healthfulness of food store offerings, customer purchases, or dietary consumption. Participants who said they had purchased fruits and vegetables at the store previously reported higher produce intake (5.70 (4.29) vs. 4.60 (3.28) servings per day, p = 0.021) versus those who had not previously purchased fresh produce. The NC Legislature has allocated another $250,000 to the HFSRP for the 2018 fiscal year. Thus, evaluation results will be important to inform future healthy corner store policies and initiatives.

Association between store food environment and customer purchases in small grocery stores, gas-marts, pharmacies and dollar stores

Background

Purchases at small/non-traditional food stores tend to have poor nutritional quality, and have been associated with poor health outcomes, including increased obesity risk The purpose of this study was to examine whether customers who shop at small/non-traditional food stores with more health promoting features make healthier purchases.

Methods

In a cross-sectional design, data collectors assessed store features in a sample of 99 small and non-traditional food stores not participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Minneapolis/St. Paul, MN in 2014. Customer intercept interviews (n = 594) collected purchase data from a bag check and demographics from a survey. Store measures included fruit/vegetable and whole grain availability, an overall Healthy Food Supply Score (HFSS), healthy food advertisements and in-store placement, and shelf space of key items. Customer nutritional measures were analyzed using Nutrient Databases System for Research (NDSR), and included the purchase of ≥1 serving of fruits/vegetables; ≥1 serving of whole grains; and overall Healthy Eating Index-2010 (HEI-2010) score for foods/beverages purchased. Associations between store and customer measures were estimated in multilevel linear and logistic regression models, controlling for customer characteristics and store type.

Results

Few customers purchased fruits and vegetables (8%) or whole grains (8%). In fully adjusted models, purchase HEI-2010 scores were associated with fruit/vegetable shelf space (p = 0.002) and the ratio of shelf space devoted to healthy vs. less healthy items (p = 0.0002). Offering ≥14 varieties of fruit/vegetables was associated with produce purchases (OR 3.9, 95% CI 1.2–12.3), as was having produce visible from the store entrance (OR 2.3 95% CI 1.0 to 5.8), but whole grain availability measures were not associated with whole grain purchases.

Conclusions

Strategies addressing both customer demand and the availability of healthy food may be necessary to improve customer purchases.

Trial registration

ClinialTrials.gov: NCT02774330. Registered May 4, 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0531-x) contains supplementary material, which is available to authorized users.

Longitudinal Associations between Change in Neighborhood Social Disorder and Change in Food Swamps in an Urban Setting

Few studies have examined how neighborhood contextual features may influence the food outlet mix. We evaluated the relationship between changes in neighborhood crime and changes in the food environment, namely the relative density of unhealthy (or intermediate) food outlets out of total food outlets, or food swamp score, in Baltimore City from 2000 to 2012, using neighborhood fixed-effects linear regression models. Comparing neighborhoods to themselves over time, each unit increase in crime rate was associated with an increase in the food swamp score (b = 0.13; 95% CI, -0.00017 to 0.25). The association with food swamp score was in the same direction for violent crime and in the inverse direction for arrests related to juvenile crimes (proxy of reduced crime), but did not reach statistical significance when examined separately. Unfavorable conditions, such as crime, may deter a critical consumer base, diminishing the capacity of a community to attract businesses that are perceived to be neighborhood enhancing. Addressing these more distal drivers may be important for policies and programs to improve these food environments.

Proyecto MercadoFRESCO: a multi-level, community-engaged corner store intervention in East Los Angeles and Boyle Heights

Urban food swamps are typically situated in low-income, minority communities and contribute to overweight and obesity. Changing the food landscape in low income and underserved communities is one strategy to combat the negative health consequences associated with the lack of access to healthy food resources and an abundance of unhealthy food venues. In this paper, we describe Proyecto MercadoFRESCO (Fresh Market Project), a corner store intervention project in East Los Angeles and Boyle Heights in California that used a multi-level approach with a broad range of community, business, and academic partners. These are two neighboring, predominantly Latino communities that have high rates of overweight and obesity. Located in these two communities are approximately 150 corner stores. The project used a community-engaged approach to select, recruit, and convert four corner stores, so that they could become healthy community assets in order to improve residents' access to and awareness of fresh and affordable fruits and vegetables in their immediate neighborhoods. We describe the study framework for the multi-level intervention, which includes having multiple stakeholders, expertise in corner store operations, community and youth engagement strategies, and social marketing campaigns. We also describe the evaluation and survey methodology to determine community and patron impact of the intervention. This paper provides a framework useful to a variety of public health stakeholders for implementing a community-engaged corner store conversion, particularly in an urban food swamp.