Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S.

doi:10.1016/j.amepre.2008.09.025

American Journal of Preventive Medicine

Volume 36, Issue 1, January 2009, Pages 74-81.e10

https://doi.org/10.1016/j.amepre.2008.09.025 Get rights and content

Background

Poor dietary patterns and obesity, established risk factors for chronic disease, have been linked to neighborhood deprivation, neighborhood minority composition, and low area population density. Neighborhood differences in access to food may have an important influence on these relationships and health disparities in the U.S. This article reviews research relating to the presence, nature, and implications of neighborhood differences in access to food.

Methods

A snowball strategy was used to identify relevant research studies (n=54) completed in the U.S. and published between 1985 and April 2008.

Results

Research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity. Results from studies examining the accessibility of restaurants are less consistent, but there is some evidence to suggest that residents with limited access to fast-food restaurants have healthier diets and lower levels of obesity. National and local studies across the U.S. suggest that residents of low-income, minority, and rural neighborhoods are most often affected by poor access to supermarkets and healthful food. In contrast, the availability of fast-food restaurants and energy-dense foods has been found to be greater in lower-income and minority neighborhoods.

Conclusions

Neighborhood disparities in access to food are of great concern because of their potential to influence dietary intake and obesity. Additional research is needed to address various limitations of current studies, identify effective policy actions, and evaluate intervention strategies designed to promote more equitable access to healthy foods.

Introduction

A growing body of evidence indicates that residential segregation by income, race, and ethnicity contributes to health disparities in the U.S. 1, 2, 3, 4, 5, 6, 7 In addition, substantial research shows disparities in health between urban and rural areas. ⁸ Poor dietary patterns and obesity, established risk factors for chronic disease, have been linked to neighborhood deprivation, neighborhood minority composition, and low area population density (as found in more rural areas). 9, 10, 11, 12, 13, 14, 15 Neighborhood differences in access to foods may be an important influence on these relationships. Establishing the presence, nature, and implications of neighborhood differences in the physical availability of more- and less-healthy foods is necessary to properly inform the development of responsive public health policies and interventions that may help reduce inequalities in health.

Recent reviews have drawn attention to relationships among neighborhood food availability, dietary intake, and obesity, but to our knowledge, a detailed review of disparities in food access has not been completed. 16, 17 For this review, neighborhood is broadly defined to be “the area around one's place of residence,” and research relating to both micro- (e.g., stores within walking distance from home) and macro-level characteristics (e.g., restaurants within county boundaries) of the physical food environment are considered. This article briefly reviews the current evidence base regarding (1) the relationship between neighborhood access to more- and less-healthy foods and dietary intake and (2) the relationship between neighborhood access to foods and weight status. In addition, this article presents a comprehensive review of disparities across the U.S. according to income, race, ethnicity, and urbanization in neighborhood access to more- and less-healthy foods. Studies relating to both food stores and restaurants are summarized separately and discussed in terms of their limitations and implications for future research and practice.

Section snippets

Methods

A snowball strategy was used to identify relevant research studies completed in the U.S. and published between 1985 and April 2008. Searches were completed in PubMed and MEDLINE using the following key words: neighborhood; environment; food store; supermarket; restaurant; dietary intake; obesity; overweight; disparity; inequality; deprivation; income; poverty; rural; race; and ethnicity. The references cited in articles (n=43) indexed in these search engines were also checked; and all

Retail Food Stores and Dietary Intake

Supermarkets, as compared to other food stores, tend to offer the greatest variety of high-quality products at the lowest cost. 18, 19, 20, 21, 22, 23 In contrast, convenience stores sell mostly prepared, high-calorie foods and little fresh produce, at higher prices. ²⁴ Studies of adults 18, 25, 26, 27, 28, 29 and adolescents ³⁰ have examined associations between neighborhood access to food stores and intake of fruits and vegetables, calories from dietary fat, and overall diet quality. The

Discussion

The aim of this review is to describe and evaluate research relating to neighborhood differences in the physical availability of food stores, restaurants, and healthy foods. Associations of neighborhood food access with dietary intake and obesity were found to vary according to the type of food store or restaurant. In general, research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower

References (110)

A. Diez Roux et al.
Neighborhood of residence and incidence of coronary heart disease
N Engl J Med
(2001)
T. LaVeist
Racial segregation and longevity among African Americans: an individual-level analysis
Health Serv Res
(2003)
S. Grady
Racial disparities in low birthweight and the contribution of residential segregation: a multilevel analysis
Soc Sci Med
(2006)
J. Bell et al.
Birth outcomes among urban African-American women: a multilevel analysis of the role of racial residential segregation
Soc Sci Med
(2006)
S. Jackson et al.
The relation of residential segregation to all-cause mortality: a study in black and white
Am J Public Health
(2000)
P. Lobmayer et al.
Inequality, residential segregation by income, and mortality in U.S. cities
J Epidemiol Community Health
(2002)
K. Hart et al.
Metropolitan governance, residential segregation, and mortality among African Americans
Am J Public Health
(1998)
L. Gamm et al.
Rural Healthy People 2010: a companion document to Healthy People 2010. Volume 2
(2003)
A. Rundle et al.
The urban built environment and obesity in New York City: a multilevel analysis
Am J Health Promot
(2007)
M. Nelson et al.
Built and social environments: associations with adolescent overweight and activity
Am J Prev Med
(2006)

J. Stimpson et al.

Neighborhood deprivation is associated with lower levels of serum carotenoids among adults participating in the Third National Health and Nutrition Examination Survey

J Am Diet Assoc

(2007)

V. Chang

Racial residential segregation and weight status among U.S. adults

Soc Sci Med

(2006)

S. Robert et al.

A multilevel analysis of race, community disadvantage, and body mass index among adults in the U.S.

Soc Sci Med

(2004)

A. Diez Roux et al.

Neighborhood differences in diet: the atherosclerosis risk in communities (ARIC) study

J Epidemiol Community Health

(1999)

R. Lopez

Neighborhood risk factors for obesity

Obesity

(2007)

M. Story et al.

Creating healthy food and eating environments: policy and environmental approaches

Annu Rev Public Health

(2008)

J. Black et al.

Neighborhoods and obesity

Nutr Rev

(2008)

J. Bodor et al.

Neighborhood fruit and vegetable availability and consumption: the role of small food stores in an urban environment

Public Health Nutr

(2008)

J. Sallis et al.

San Diego surveyed for heart healthy foods and exercise facilities

Public Health Rep

(1986)

K. Glanz et al.

Nutrition environment measures survey in stores (NEMS-S): development and evaluation

Am J Prev Med

(2007)

D. Block et al.

A comparison of the availability and affordability of a market basket in two communities in the Chicago area

Public Health Nutr

(2006)

C. Chung et al.

Do the poor pay more for food?An analysis of grocery store availability and food price disparities

J Consum Aff

(1999)

C. Connell et al.

Food supply adequacy in the lower Mississippi delta

J Nutr Educ Behav

(2007)

S.N. Zenk et al.

Fruit and vegetable access differs by community racial composition and socioeconomic position in Detroit, Michigan

Ethn Dis

(2006)

K. Morland et al.

The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study

Am J Public Health

(2002)

B.A. Laraia et al.

Proximity of supermarkets is positively associated with diet quality index for pregnancy

Prev Med

(2004)

D. Rose et al.

Food store access and household fruit and vegetable use among participants in the U.S. food stamp program

Public Health Nutr

(2004)

L. Moore et al.

Associations of the local food environment with diet quality—a comparison of assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis

Am J Epidemiol

(2008)

M. Wang et al.

Changes in neighborhood food store environment, food behaviour and body mass index, 1981–1990

Public Health Nutr

(2008)

R. Jago et al.

Distance to food stores and adolescent male fruit and vegetable consumption: mediation effects

Int J Behav Nutr Phys Act

(2007)

A. Cheadle et al.

Community-level comparisons between the grocery store environment and individual dietary practices

Prev Med

(1991)

S. Zenk et al.

Fruit and vegetable intake in African Americans: income and store characteristics

Am J Prev Med

(2005)

J. Edmonds et al.

Ecological and socioeconomic correlates of fruit, juice, and vegetable consumption among African-American boys

Prev Med

(2001)

B.D. Fisher et al.

Community measures of low-fat milk consumption: comparing store shelves with households

Am J Public Health

(1999)

A. Auchincloss et al.

Neighborhood resources for physical activity and healthy foods and their association with insulin resistance

Epidemiol

(2008)

M. Wang et al.

Socioeconomic and food-related physical characteristics of the neighborhood environment are associated with body mass index

J Epidemiol Community Health

(2007)

K. Morland et al.

Supermarkets, other food stores, and obesity: the atherosclerosis risk in communities study

Am J Prev Med

(2006)

S. Inagami et al.

You are where you shopGrocery store locations, weight, and neighborhoods

Am J Prev Med

(2006)

L. Powell et al.

Associations between access to food stores and adolescent body mass index

Am J Prev Med

(2007)

G. Liu et al.

Green neighborhoods, food retail and childhood overweight: differences by population density

Am J Health Promot

(2007)

R. Sturm et al.

Body mass index in elementary school children, metropolitan area food prices and food outlet density

Public Health

(2005)

L. Powell et al.

Food store availability and neighborhood characteristics in the United States

Prev Med

(2007)

L. Morton et al.

Starved for access: life in rural America's food deserts

Rural Realities

(2007)

P. Kaufman

Rural poor have less access to supermarkets, large grocery stores

Rural Development Perspectives

(1998)

A. Liese et al.

Food store types, availability, and cost of foods in a rural environment

J Am Diet Assoc

(2007)

J. Sharkey et al.

Neighborhood socioeconomic deprivation and minority composition are associated with better potential spatial access to the ground-truthed food environment in a large rural area

J Nutr

(2008)

E. Baker et al.

The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines

Prev Chronic Dis

(2006)

C.R. Horowitz et al.

Barriers to buying healthy foods for people with diabetes: evidence of environmental disparities

Am J Public Health

(2004)

A. Shaffer

The persistence of L.A.'s grocery gap: the need for a new food policy and approach to market development. Center for Food and Justice, Urban and Environmental Policy Institute (UEPI), Occidental College

L. Alwitt et al.

Retail stores in poor urban neighborhoods

J Consum Aff

(1997)

Cited by (1472)

Local retail food environment exposure and diet quality in rural and urban adults: A longitudinal analysis of the ORISCAV-LUX cohort study
2024, Health and Place
Despite growing interest in understanding how food environments shape dietary behaviors, European longitudinal evidence is scarce. We aimed to investigate the associations of 9-year average and change in exposure to local retail food environments with the diet quality of residents in Luxembourg. We used data from 566 adults enrolled in both waves of the nationwide ORISCAV-LUX study (2007–2017). Dietary quality was assessed by the Diet Quality Index-International (DQI-I). Exposure to “healthy” and “less healthy” food outlets was assessed by both absolute and relative GIS-based measurements. The results showed a 56.3% increase in less healthy food outlets over the period. In adjusted linear mixed models, high (vs. low) 9-year average exposure to less healthy food outlets was associated with lower DQI-I, when examining spatial access (β = −1.25, 95% CI: −2.29, −0.22) and proportions (β = −1.24, 95% CI: −2.15, −0.33). Stratified analyses showed these associations to be significant only among urban residents. There was no association between change in exposure to less healthy food outlets and DQI-I. Increased exposure to healthy outlets in rural areas, using absolute measurements, was associated with worsened DQI-I. Neighborhood socioeconomic status did not moderate the above associations. Findings suggest that the proliferation of less healthy food outlets may have contributed to the deterioration of the diet quality of urban residents, and support the use of relative measurements to fully capture the healthiness of food environments.
New insights into grocery store visits among east Los Angeles residents using mobility data
2024, Health and Place
In this study, we employed spatially aggregated population mobility data, generated from mobile phone locations in 2021, to investigate patterns of grocery store visits among residents east and northeast of Downtown Los Angeles, in which 60% of the census tracts had previously been designated as “food deserts”. Further, we examined whether the store visits varied with neighborhood sociodemographics and grocery store accessibility. We found that residents averaged 0.4 trips to grocery stores per week, with only 13% of these visits within home census tracts, and 40% within home and neighboring census tracts. The mean distance from home to grocery stores was 2.2 miles. We found that people visited grocery stores more frequently when they lived in neighborhoods with higher percentages of Hispanics/Latinos, renters and foreign-born residents, and a greater number of grocery stores. This research highlights the utility of mobility data in elucidating grocery store use, and factors that may facilitate or be a barrier to store access. The results point to limitations of using geographically constrained metrics of food access like food deserts.
Environmental-, Climate-, and Health-Related Dietary Motivations Are Associated With Higher Diet Quality in a National Sample of US Adults With Lower Incomes
2024, Journal of the Academy of Nutrition and Dietetics
Plant-based diets can have co-benefits for human and planetary health. Associations between environmental, climate, and health concerns and dietary intake in US adults are understudied, particularly in underserved populations.
The study objectives were to assess how dietary choices motivated by the environment, climate, and health vary by sociodemographic characteristics and how they relate to diet quality and intake frequency of different food groups in US adults with lower incomes.
The study design was cross-sectional.
A web-based survey was fielded in December 2022 to 1,798 US adults with lower incomes (<250% of federal poverty guidelines).
Environmental-, climate-, and health-related dietary motivations and diet quality and dietary food group intake frequency were assessed.
Differences in mean dietary outcomes and dietary motivation ratings by sociodemographic characteristics were evaluated using analysis of variance and Kruskal–Wallis tests. Associations between dietary motivations and diet quality scores and dietary intake frequency were examined using generalized linear models adjusted for sociodemographic covariates.
Younger adults, women, nonbinary people, racial and ethnic minoritized groups, and adults experiencing food insecurity reported higher environmental and climate dietary motivations; older adults, higher-income adults, and food-secure adults reported higher health motivations. Agreeing with environmental- (β = 2.28, 95% CI 1.09 to 3.47), climate- (β = 2.15, 95% CI 0.90 to 3.40), and health-related (β = 5.27, 95% CI 3.98 to 6.56) dietary motivations was associated with higher diet quality scores compared with those with neutral rankings. Similarly, agreement with environmental-, climate-, and health-related dietary motivations was associated with higher intake frequency of fish, fruits and vegetables, and plant proteins, but not with red and processed meat intake frequency. Of several climate-mitigation behaviors presented, participants perceived meat reduction as least effective (P < .001).
Environment, climate, and health were positive motivators of several healthy dietary choices in US adults with lower incomes. Such motivators did not translate to lower intake frequency of red and processed meat.
Sodium Intake and Sodium to Potassium Ratio among New York City Adults in the 2018 Heart Follow-Up Study
2024, Current Developments in Nutrition
High sodium and low potassium intake are positively associated with blood pressure, a significant risk factor for cardiovascular disease. The mean intake of sodium among United States adults exceeds the chronic disease risk reduction level of 2300 mg/d, whereas potassium intake remains lower than the recommended levels. From 2008 through 2019, there were several local and national initiatives to reduce sodium in New York City (NYC).
We aimed to update and compare estimates of sodium intake among NYC adults overall and by covariates from the 2010 Heart Follow-Up Study (HFUS) with the 2018 HFUS. We also estimated the 2018 sodium-to-potassium ratio to understand overall diet quality among demographic groups.
This cross-sectional study used sodium and potassium measurements from 24-h urine collection and self-reported data from 2509 and 1656 participants in the 2018 and 2010 HFUS, respectively. The weighted mean daily intake of sodium and the sodium-to-potassium ratio were estimated. T-tests and multivariable linear regression models with tests for interactions were used to compare changes in sodium intake.
The mean sodium intake of adult New Yorkers in 2018 was 3292 mg/d. Sodium intake did not change from 2010 (3234 mg/d, P = 0.45) to 2018 in the overall population, although there was a decrease in sodium intake among adults 18–24 y old (3445 mg/d to 2957 mg/d, P = 0.05). The daily mean sodium-to-potassium ratio was 1.7 mg/mg. The highest sodium-to-potassium ratios were among Black females 18–44 y old (2.0) and 45–64 y old (2.2) and Black (2.1) and Latino (2.1) males between 18 and 44 y old.
The lack of population-level changes in sodium intake and the high sodium-to-potassium ratios among Black females and younger Black and Latino males suggest that further efforts to reduce sodium in the food supply and address persistent inequities are needed.
Association of county-level food deserts and food swamps on postoperative outcomes among patients undergoing colorectal surgery
2024, Journal of Gastrointestinal Surgery
Although malnutrition has been linked to worse healthcare outcomes, the broader context of food environments has not been examined relative to surgical outcomes. We sought to define the impact of food environment on postoperative outcomes of patients undergoing resection for colorectal cancer (CRC).
Patients who underwent surgery for CRC between 2014 and 2020 were identified from the Medicare database. Patient-level data were linked to the United States Department of Agriculture data on food environment. Multivariable regression was used to examine the association between food environment and the likelihood of achieving a textbook outcome (TO). TO was defined as the absence of an extended length of stay (≥75th percentile), postoperative complications, readmission, and mortality within 90 days.
A total of 260,813 patients from 3017 counties were included in the study. Patients from unhealthy food environments were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with higher social vulnerability (all P < .01). Patients residing in unhealthy food environments were less likely to achieve a TO than that of patients residing in the healthiest food environments (food swamp: 48.8% vs 52.4%; food desert: 47.9% vs 53.7%; P < .05). On multivariable analysis, individuals residing in the unhealthy food environments had lower odds of achieving a TO than those of patients living in the healthiest food environments (food swamp: OR, 0.86; 95% CI, 0.83-0.90; food desert: OR, 0.79; 95% CI, 0.76-0.82); P < .05).
The surrounding food environment of patients may serve as a modifiable sociodemographic risk factor that contributes to disparities in postoperative CRC outcomes.
A tale of many neighborhoods: Latent profile analysis to derive a national neighborhood typology for the US
2024, Health and Place
Neighborhoods are complex and multi-faceted. Analytic strategies used to model neighborhoods should reflect this complexity, with the potential to better understand how neighborhood characteristics together impact health. We used latent profile analysis (LPA) to derive a residential neighborhood typology applicable for census tracts across the US.
From tract-level 2015–2019 American Community Survey (ACS) five-year estimates, we selected five indicators that represent four neighborhood domains: demographic composition, commuting, socioeconomic composition, and built environment. We compared model fit statistics for up to eight profiles to identify the optimal number of latent profiles of the selected neighborhood indicators for the entire US. We then examined differences in national tract-level 2019 prevalence estimates of physical and mental health derived from CDC's PLACES dataset between derived profiles using one-way analysis of variance (ANOVA).
The 6-profile LPA model was the optimal categorization of neighborhood profiles based on model fit statistics and interpretability. Neighborhood types were distinguished most by demographic composition, followed by commuting and built environment domains. Neighborhood profiles were associated with meaningful differences in the prevalence of health outcomes. Specifically, tracts characterized as “Less educated non-immigrant racial and ethnic minority active transiters” (n = 3,132, 4%) had the highest poor health prevalence (Mean poor physical health: 18.6 %, SD: 4.30; Mean poor mental health: 19.6 %, SD: 3.85), whereas tracts characterized as “More educated metro/micropolitans” (n = 15, 250, 21%) had the lowest prevalence of poor mental and physical health (Mean poor physical health: 10.6 %, SD: 2.41; Mean poor mental health: 12.4 %, SD: 2.67; p < 0.001).
LPA can be used to derive meaningful and standardized profiles of tracts sensitive to the spatial patterning of social and built conditions, with observed differences in mental and physical health by neighborhood type in the US.

View all citing articles on Scopus

: The full text of this article is available via AJPM Online at www.ajpm-online.net; 1 unit of Category-1 CME credit is also available, with details on the website.

View full text

Review and special articleNeighborhood Environments: Disparities in Access to Healthy Foods in the U.S.

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Retail Food Stores and Dietary Intake

Discussion

Neighborhood of residence and incidence of coronary heart disease

N Engl J Med

Racial segregation and longevity among African Americans: an individual-level analysis

Health Serv Res

Racial disparities in low birthweight and the contribution of residential segregation: a multilevel analysis

Soc Sci Med

Birth outcomes among urban African-American women: a multilevel analysis of the role of racial residential segregation

Soc Sci Med

The relation of residential segregation to all-cause mortality: a study in black and white

Am J Public Health

Inequality, residential segregation by income, and mortality in U.S. cities

J Epidemiol Community Health

Metropolitan governance, residential segregation, and mortality among African Americans

Am J Public Health

Rural Healthy People 2010: a companion document to Healthy People 2010. Volume 2

The urban built environment and obesity in New York City: a multilevel analysis

Am J Health Promot

Built and social environments: associations with adolescent overweight and activity

Am J Prev Med

Neighborhood deprivation is associated with lower levels of serum carotenoids among adults participating in the Third National Health and Nutrition Examination Survey

J Am Diet Assoc

Racial residential segregation and weight status among U.S. adults

Soc Sci Med

A multilevel analysis of race, community disadvantage, and body mass index among adults in the U.S.

Soc Sci Med

Neighborhood differences in diet: the atherosclerosis risk in communities (ARIC) study

J Epidemiol Community Health

Neighborhood risk factors for obesity

Obesity

Creating healthy food and eating environments: policy and environmental approaches

Annu Rev Public Health

Neighborhoods and obesity

Nutr Rev

Neighborhood fruit and vegetable availability and consumption: the role of small food stores in an urban environment

Public Health Nutr

San Diego surveyed for heart healthy foods and exercise facilities

Public Health Rep

Nutrition environment measures survey in stores (NEMS-S): development and evaluation

Am J Prev Med

A comparison of the availability and affordability of a market basket in two communities in the Chicago area

Public Health Nutr

Do the poor pay more for food?An analysis of grocery store availability and food price disparities

J Consum Aff

Food supply adequacy in the lower Mississippi delta

J Nutr Educ Behav

Fruit and vegetable access differs by community racial composition and socioeconomic position in Detroit, Michigan

Ethn Dis

The contextual effect of the local food environment on residents' diets: the atherosclerosis risk in communities study

Am J Public Health

Proximity of supermarkets is positively associated with diet quality index for pregnancy

Prev Med

Food store access and household fruit and vegetable use among participants in the U.S. food stamp program

Public Health Nutr

Associations of the local food environment with diet quality—a comparison of assessments based on surveys and geographic information systems: the multi-ethnic study of atherosclerosis

Am J Epidemiol

Changes in neighborhood food store environment, food behaviour and body mass index, 1981–1990

Public Health Nutr

Distance to food stores and adolescent male fruit and vegetable consumption: mediation effects

Int J Behav Nutr Phys Act

Community-level comparisons between the grocery store environment and individual dietary practices

Prev Med

Fruit and vegetable intake in African Americans: income and store characteristics

Am J Prev Med

Ecological and socioeconomic correlates of fruit, juice, and vegetable consumption among African-American boys

Prev Med

Community measures of low-fat milk consumption: comparing store shelves with households

Am J Public Health

Neighborhood resources for physical activity and healthy foods and their association with insulin resistance

Epidemiol

Socioeconomic and food-related physical characteristics of the neighborhood environment are associated with body mass index

Review and special article
Neighborhood Environments: Disparities in Access to Healthy Foods in the U.S.