Health Policy$ense

Healthy Food Choice in the Inner City

Latest Studies Show It's Not Just About 'Food Deserts'

Two new studies challenge the assumption that simply building supermarkets in so-called ‘food deserts’ will yield nutritional and health benefits. These ‘deserts’ are geographic areas, usually urban and poor, that lack full-service grocery stores and fresh produce. LDI Senior Fellow Carolyn Cannuscio and colleagues suggest that social considerations shape peoples’ choices on where to shop, and Victoria Mayer and Penn colleagues stress that improving peoples’ diets requires not only improved access but also greater affordability.

Just building supermarkets does not boost the 
health of a neighborhood.

 Research and policy have focused on the physical ‘food environment’ as a determinant of health, and on interventions that make nutritious food more readily available. This approach assumes a relatively passive response to the local food environment, e.g., defaulting to shopping at the stores closest to home. However, strategies to improve food retail environments have not yet produced the expected health benefits. These new studies dig deeper into other forces at play.

Philadelphia as a case study
The studies use survey and interview data from Philadelphia, a city with high levels of poverty (26.9%), obesity (32% of adults) and diabetes (11% of adults). It is also a city that is experimenting with eradicating ‘food deserts’ with a focus on turning local corner stores into greengrocers.

Affordability is key
In the Journal of Urban Health, Mayer and PennLDI colleagues Amy Hillier, Marcus Bachhuber, and Judith Long study how neighborhood food access and receipt of food assistance affect ‘food insecurity’-- when people are unable to obtain enough food for an active and healthy life. Food insecurity has been linked to increased risk of poor physical and mental health, and diet-related diseases such as obesity, hypertension, and diabetes. In this study, food insecurity was measured by whether survey respondents had skipped or reduced meal size because of budgetary constraints in the previous 12 months.

The authors used data from the 2008, 2010, and 2012 waves of the Southeastern Pennsylvania Household Health Survey. They analyzed responses to questions about the difficulty of finding fruits and vegetables in the neighborhood, the overall quality of neighborhood grocery stores, and participation in government-funded food assistance programs. Not surprisingly, better neighborhood food access was associated with lower risk of food insecurity. However, most food- insecure individuals reported good access to food but found it too expensive to buy. More than half of food-insecure individuals received no food assistance benefits. The authors suggest that economic constraints may create a ceiling beyond which improved food access cannot improve diet or health. They write:

While those living in higher access areas were at lower risk of food insecurity, even after controlling for neighborhood-level factors, most of those who were food insecure reported easy or very easy access to fruits and vegetables and excellent or good quality grocery stores in their neighborhood. Therefore, in the absence of policies and programs that allow families living in poverty to afford healthy foods, interventions that increase food access may not improve diet and decrease risk of diet-related diseases. Programs aimed at improving diet in low-income communities with high rates of food insecurity should focus not only on location but also on affordability, especially as cuts to food assistance programs threaten to increase food insecurity and poverty.

Consider the social dynamics
In Social Science & Medicine, Carolyn Cannuscio, Amy Hillier, Allison Karpyn, and Karen Glanz look more deeply at the social dynamics of healthy food shopping and store choice in an urban environment. They suggest an ecological approach, which incorporates relationships within the social environment into its considerations, as an alternative to the focus on only the physical environment. In this model, geographical proximity is just one of many forces that shape human behaviour.

Through door-to-door surveys and follow-up semi-structured interviews, the authors find that people chose to shop at stores that met a range of social needs, not necessarily the closest. Interviews focused on participants’ typical food-shopping patterns with questions regarding where they chose to shop, their shopping experiences in those stores, what foods they typically purchased, and their own understanding of why they made the decisions that they did regarding food shopping. The ‘needs’ expressed by interviewees ranged from:

…practical financial considerations, to fundamental issues of safety, to mundane concerns about convenience, and juggling multiple work and family responsibilities. The majority of participants were highly motivated to adapt their shopping patterns to accommodate personal financial constraints. In addition, they selectively shopped at stores frequented by people who shared their race/ethnicity, income and education, and they sought stores where they had positive interactions with personnel and proprietors…participants adapted their routines to avoid unsafe places and the threat of violence.

Cannuscio and colleagues suggest that the appeal of the ‘food deserts’ or the ‘supermarket proximity and health’ framework is that the problem of food access is framed in a way that proposes an actionable solution -- food deserts need supermarkets. But this approach may not go far enough to address the social dynamics of the urban food environment, nor the affordability of the food that may be within reach.