DR. ANGELA ODOMS-YOUNG: Hello and welcome to day two of the NIH Food Insecurity, Neighborhood
Food Environment, and Nutrition Health Disparities: State of the Science Workshop. Yesterday,
we had several wonderful presentations that focused on food insecurity innovations and
strategies to inform policy and practice to specifically prevent diet-related health disparities,
as well as promote health equity. And I just want to do a brief recap. I'm Angela Odoms-Young.
I'm one of the co-chairs of the workshop. I'm an associate professor in the Division
of Nutritional Sciences at Cornell University. So, we had, as I mentioned, a series of wonderful
presentations that really focused in on the causes and consequences of food insecurity
and strategies and solutions to address food insecurity. So, just to hit the highlights,
several presentations focused on the multiple level…multi-level
determinants that impact food insecurity and the relationship between food insecurity and
health. The presentations highlighted the limited research and data that we have on
certain populations that are at risk of food insecurity, such as Indigenous populations,
young adults that are not in college. Several of the presentations explored methodological
challenges and how we need to look at multiple methodologies, including qualitative methods,
as well as policy studies. And then, it was highlighted by several presenters that we
need to further define and identify measures and metrics related to this concept of nutrition
security or nutrition insecurity. In the latter part of the session, we focused in
on strategies and solutions to address food insecurity. And there was a key point about
highlighting the lived experience and really barriers and facilitators that people experience,
both individuals and families experience, to food assistance program participation. There
was a discussion about the impact of restrictions and incentives in federal food assistance
programs and how those relate to diet and health outcomes and address food insecurity.
Implications of the broader policy context, not just the food policy context, but also
broader economic policy context that exists and that may impact solutions or strategies
when we want to address food insecurity. Again, methodological approaches to understand
program implementation and associated outcomes. And then what combination of intervention
strategies, particularly in health care settings, can produce reductions or result in reductions
in food insecurity, but also better diets and quality of life. There was some challenges
that were highlighted about the heterogeneity in program implementation that can make it
difficult to evaluate and look at the literature overall and understand what's happening when
it comes to the impact of these interventions on food insecurity. Other challenges include
a short-term funding or changes in priority populations. And then, one area for expansion
related to understanding the impact of structural interventions and moving more upstream, but
still considering downstream outcomes. And then lastly, we had a closing speaker that
emphasized the need to decolonize methodologies and to use theories, like Indigenous theories,
and ways of knowing critical race theory and using an intersectionality lens to understand
and address food insecurity. And we had, that was the emphasis of our closing
speaker, but that was highlighted by several speakers throughout. So, throughout the workshop
today we're, as I mentioned, we're going to focus on neighborhood food environments. And
you will have the opportunity to address questions to our speakers and panelists. You can simply
put your questions in the chat box, and please don't be shy. We want to hear from you. I
know it's, a virtual platform, but we want to make sure is as interactive as possible.
Now I have the pleasure of introducing next, Dr. Shannon Zenk, who's the Director of the
National Institute of Nursing Research, who will provide us with some opening remarks.
And so, Shannon, I'm going to turn it over to you.
DR. SHANNON ZENK: Thank you. Thank you, Angela. Good afternoon, everyone. I'm Shannon Zenk,
Director of the National Institute of Nursing Research. It's so nice to join my longtime
Chicago colleague, Dr. Angela Odoms-Young and welcoming you day two of the Food Insecurity,
Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science Workshop.
And I'm so thrilled that NINR co-sponsored this event with our NIH colleagues, and thank
you to our partners at the CDC and at the Department of Agriculture for your contributions
as well. Before I turn things over to Dr. Odoms-Young and Dr. Glanz, I'd like to share
a little bit about why I think this area of research is so important. Next slide. So,
I became interested in the health impacts of neighborhood environments while practicing
as a nurse. One of my first jobs as a nurse was as a home health care case manager. And
in this role, I visited the people in their homes, typically after a hospitalization,
to help with pain management, provide wound care, and teach about how to manage chronic
conditions. But spending time in people's homes and in
different neighborhoods, I was struck by the tremendous differences in the environments
of patients in my caseload, both in terms of privilege and poverty. I found it difficult
to talk to some patients about healthy eating, for example, when what they really needed
to restore their health was far more fundamental: decent stable housing, a safe environment,
access to affordable healthy foods nearby. Next slide, please. These observations inspired
me to go back to school to learn more and contribute to solutions. Ultimately, colleagues
and I conducted some of the early studies in Detroit on food deserts. And we know that
many of the inequities in neighborhood food environments that we see can be traced to
redlining and disinvestment from communities of color. Observational and intervention research
on neighborhood food environments, diet, and health have grown tremendously and evolved
over the past 15 to 20 years due to work of so many participating in this meeting. It's
a perfect time to reflect on the state of the science, what's been learned,
what are the gaps and opportunities, so that the most impactful science can move forward.
Next slide, please. We know that there are not only inequities in the neighborhood food
environment, but in food and nutrition security as well. The economic crisis that accompanied
the COVID-19 pandemic led to spiking rates of food insecurity as jobs were lost and schools
closed. People of color were among those hardest hit by this food crisis. And the levels of
food insecurity are down from their peak during the pandemic. We're not out of the woods yet.
We also need to acknowledge that the economic crisis we faced in 2020 is only the latest
economic crisis faced by many Americans. The racial wealth gap in our nation is well established,
with white household wealth at 10 times that of black households and seven times that of
Hispanic households. Not only does greater wealth allows some to weather storms like
COVID-19, but greater wealth also comes with better access to health care, education, child
care, and any number of resources in our society. While we need research to solve pressing problems
like food insecurity, we can't ignore the impact of policies that have perpetuated such
fundamental inequalities in our nation. Next slide, please. So, then how can we right the
historic and contemporary wrongs of racism that have produced and perpetuated persistent
health disparities, including nutrition health disparities? It's clear that we urgently need
practice and policy solutions for the challenging health problems we face and the disparities.
There is now a broader recognition of the many ways that racial and social injustice
have significant impacts on individual and community health, and the public is demanding
change. But in this landscape and to inform action, we need scientific evidence on what
policies and interventions are effective in increasing resources and improving the environment
in low income and communities of color, and improving health behaviors and health outcomes
in these communities. That's exactly why we're holding this event and why thousands of you
registered to attend. Next slide, please. At NINR we intend to do
our part. A major focus of our current research is prevention, and a third of NINR’s funding
already focuses on research to eliminate health disparities. As we look forward, we want to
ensure that our research tackles the nation's most pressing health challenges and discover
solutions in the wide variety of settings where nurses practice not only in hospitals
and clinics, but also in people's homes, schools, worksites, justice settings, and communities.
We want to ensure our research applies a holistic approach that includes addressing social determinants
of health. And we want to advance health equity. Next slide, please. Today, I'll share with
you just one example of NINR-supported research that examines the health impact of the food
environment and other social factors through a health equity lens. NINR grantee Dr. Suzan
Carmichael studies racial and ethnic disparities and severe maternal morbidity. Dr. Carmichael
has found severe maternal mortality is increasing among all racial and ethnic groups studied,
with the greatest increase among non-Hispanic black women.
She found that pre-pregnancy BMI and gestational weight gain are related to maternal morbidity.
And her latest NINR-funded study is examining the impact of neighborhood resources like
walkability, green space, and the food environment on severe maternal morbidity. I'm really proud
that NINR supports work like this, which is essential in determining what is driving such
disparities so that policy solutions can be developed. Before I turn the meeting back
over to Dr. Odoms-Young, I want to invite you to share your thoughts on NINR’s next
strategic plan. We'll soon post our strategic plan framework for public comment through
an RFI. We'll publicize this widely, and I hope you'll provide us with your comments
based on your very important perspective on economic and environmental factors, nutrition,
and health equity. So, thanks again for inviting me to help open the session. I also want to
thank our workshop co-chairs, Dr. Karen Glanz and Dr. Angela Odoms-Young; the workshop organizers,
Dr. Alison Brown and Dr. Tanya Agurs-Collins; as well as everyone who
worked with them to put together this outstanding program. Please enjoy today's session. Thanks again.
DR. ANGELA ODOMS-YOUNG: Thank you so much, Shannon, and thank you for your thoughtful
comments. I have the pleasure...again, I'm Angela Odoms-Young, faculty member at Cornell University
and co-chair for the workshop. I have the pleasure of introducing Session 4, where
we will focus on providing an Overview and Measurement of the Neighborhood Food Environment.
We're going to kick off this session with a State of the Science, Neighborhood Food
Environment and How It Influences Health by Dr. Karen Glanz, a faculty member at University
of Pennsylvania and then also co-chair of this NIH workshop. The objective of this session
is to discuss the current state of the science and disparities across food environments,
measurement, and the association of food environments with diet, obesity, and health. And so I'm
going to turn it over to you, Karen.
DR. KAREN GLANZ: Good afternoon. Karen Glanz, I'm back. Happy to provide an Overview on
Neighborhood Food Environments and Health as we kick off this part of the workshop.
Going to briefly talk about some of the driving forces for focusing research and practice
on neighborhood food environments, the complexity of food environments. Talk about a simple
model and what's changed, how COVID-19 pandemic is an inflection point in this area and give
you a very brief overview of the state of the science in observing, changing, and measuring
neighborhood food environments. And I'll finish with some thoughts about research gaps and
the road forward in this area. The idea that environments affect behavior is not new, in
fact, it's more than a century old in modern thinking, as B.F. Skinner developed the Skinner
Box to see if he could get a rat to push a lever by sounding speaker, signaling lights,
or running the shock generator. And found in many different ways that people could
be conditioned to respond to their environments as well.
However, I don't think he was thinking about the ecological perspective that's become so
prominent in our public health thinking nowadays. The idea that behavior is affected by and
affects multiple levels of influence and that there's reciprocal causation between individuals
and our environments. In 2008, Mary Story, Karen Kaphingst, Ramona Robinson-O'Brien and
I published this ecological framework depicting the multiple influences on what people eat
in the Annual Review of Public Health. And, to say the least, it's very complicated. It
focuses on all these different levels and many different environments. But let's see
what happens if we take away the individual level factors. Then the picture gets a bit
less complex but still has a lot of components that maybe we don't want to focus on if we're
focusing on neighborhood environments. So, let's take out the social environment, and
we still have a pretty complicated picture. But these are the things that we want to focus
on in today's workshop. Neighborhoods, restaurants, supermarkets, convenience stores, food pantries,
and many of the factors that may be influencing them.
Two of the driving forces for understanding and improving neighborhood food environments
and the burgeoning research in this area—this started about two decades ago—included
the recognition that the obesity and chronic disease epidemics were not just determined
by biology and psychology, but that multilevel determinants, as you've just seen, have been
recognized, and that our environments play a big part in our diet, risk factors, and diseases.
Secondly, there was a recognition of unequal access to healthful food, disparities, and
the need for more equity, that these also are linked to health outcomes. A good depiction
of the importance of neighborhoods as they relate to food and to health outcomes comes
in the form of some really provocative maps from New York City and also from the Seattle
King County area. And you can see by the variations in shading in each of these maps that there's
anywhere from a four to an eightfold difference in rates of obesity in neighborhoods within
these cities. So, we're not talking about climate differences,
we're not talking about geographic differences, but really neighborhood-level differences.
And New York has done a particularly good job of documenting many of the health-related
factors and determinants. And these maps at the bottom focus on tobacco use, poverty rates,
and the percentage of blacks living in these different neighborhoods. And isn't it interesting
that they also align pretty well with the rates of obesity in New York neighborhoods?
So, this is a simplified version of the food environment hypothesis: that there are factors
that influence the proximal food environments in stores, restaurants, and other sources,
including online sources, and that these affect our food intake, risk factors, and disease
profiles. This model of community nutrition environments overlaps with the ones that you've
already seen, but I wanted to show it because it's particularly important in clarifying
some distinctions about aspects of neighborhood nutrition environments.
We differentiate community nutrition environments from consumer nutrition environments, both
of which may affect organizational nutrition environments. And specifically, those definitions
are that community nutrition environments are where people get their food, where they
buy it, where it's prepared, etc., the type and location of supermarkets, restaurants,
and so on and their accessibility. Whereas consumer nutrition environments reflect the
availability of healthy food choices, pricing, promotion, placement, and information availability.
In other words, what is inside the stores and what is inside the restaurants. That's particularly
pertinent to this area of research because it gives us two different levels to look at,
two different levels at which interventions may be possible and at which understanding
occurs differentially. So, what's the biggest source of food? What's changing? What has
changed? Well, one thing that hasn't changed is that supermarkets are still the number
one source of retail food and provide the largest share of household calories.
Over 65 percent of our calories come from supermarkets and grocery stores. However,
over time, the links between retail and food service have increasingly become blurred.
And then non-supermarket sources have a large role, particularly a larger role in disadvantaged
communities, even though they're only this small little other sliver, they're a growing
sliver and an important sliver for the communities that are most needy. And online ordering and
purchasing and hybrids have grown, and particularly during the COVID pandemic. The COVID pandemic
is something of an inflection point for neighborhood food environments. It may raise new issues
that may be with us for years to come. People are making fewer shopping trips. Online grocery
ordering has jumped tremendously, yet still most people do less than a quarter of their
shopping online. There are hybrid models. Food delivery and takeout from restaurants
more than doubled, as people are eating at home but they're taking out food from restaurants
at a much higher pace than they were in the past.
And most recently, in 2021, we see supply chain issues, some foods in short supply, prices
going up, and shortages of some fresh foods caused by extreme weather yet another influence
on the food environment. So, what about food environments and policies? How do they go
together? Policies can shape environments, things like sugary beverage taxes, catering
policies, price supports and food assistance policies all can really determine what's
in the environment, where food sources are, and so forth. But oftentimes, environments
evolve in the absence of specific policies. They may be market-driven decisions. They
may be decisions made by city planners. They may be made by school boards. And policies
can be health promoting or not so health promoting. So, bear that in mind as a backdrop to our
understanding of the food environment. So, a quick overview of some of the things that
we know and how these have entered into the consciousness of people interested in understanding
and impacting food environments and health. Early food environment research was mostly
looking at associations between environments, behavior, and risk factors. And the key findings
were that supermarkets made for healthier food environments, that people who shopped
at supermarkets ate more fresh fruits and vegetables, and that fast food restaurants
were obesogenic, that the food was high in calories, salt, and fat that people got at
fast food restaurants. So, that was a big focus. Two pluses and minuses. There was early
recognition of disparities that there are more fast food restaurants in minority neighborhoods,
that some foods were less available, poorer quality in minority and low-income areas,
and that supermarkets were less accessible in poor and black neighborhoods. All this
research gave way to a lot more research. And one of the best, most in-depth reviews
is a systematic review conducted a few years ago by Cobb and others. And what do you know?
The most studied exposures were supermarket availability and fast food, restaurant availability.
But what about the findings? Did the findings replicate what we learned earlier? Not really.
Associations between the outlets and obesity was mostly null, and indeed, the review found
an overall low quality of studies, which is rather concerning. And again looking at supermarket,
fast food and small stores, some stores found positive findings, some negative, but more
than anything, the findings were null. Along with all this research there is an increasing
interest in how to measure food environments. And we talk about measurement often at the
community food environment, where are the stores? And at the consumer food environment, what's
in the stores? And the measures of what's in retail store food environments has become
of great interest and focus and a lot of focus on availability of healthy foods and unhealthy
foods, price, and quality. We increasingly see reports of reliability and validity of
measures and some intervention studies indications of whether the measures can pick up change
in the food environment. The Nutrition Environment Measures Survey
that I and my colleagues developed and first published in 2007, has been crafted in such
a way that many people could adapt it, use it, translate it, and a whole suite of tools
has been created. And up to now, 174 publications have used the NEMS tools. This is a little
social network analysis of the NEMS tools, starting with the NEMS restaurant and NEMS
store tools, and many spin-offs and many languages and many environments.
This is an indication of the eagerness for systematic observational tools to measure
the food environment. And also, this tool…these tools that were originally developed for research
can be and have been used for community assessment, advocacy, and intervention. You'll hear more
about the measurement of the food environment and the consumer food environment from Alison
Gustafson later on. So, what do we know about interventions? We have a body of intervention
research in supermarkets, small stores, and restaurants. And we also have some whole-community
interventions that have been conducted to help us see whether we can improve food environments.
So, the first question is, if it's helpful to have a supermarket in your neighborhood.
Does adding a new supermarket in a food desert improve diet and reduce obesity? A couple
of speakers will address this issue and talk about the Healthy Food Financing Initiative.
Two important published studies by Tamara Dubowitz and Stephen Matthews have both found
that with a new supermarket, there is increased awareness of food access, but healthful food
intake and lower BMI were not attributed to the new stores, and that there are positive
and negative changes in food availability found.
Perhaps not so surprisingly, Vaughn, Dubowitz, and others published a paper reporting that
residents of food deserts buy most of their junk food at supermarkets. After all, it's
probably cheaper in the supermarkets than in other smaller stores. There's also been
a fair bit of attention to interventions at supermarkets or in supermarkets as being potentially
efficacious for increasing purchase of healthy foods. And these are just a few of the reviews
that have been published on the topic. And you'll be hearing from Allison Karpyn at the
workshop also reporting on her review. We conducted a study called Healthy Retail Solutions
to use placement and promotion strategies to try to increase sales of healthier products
in supermarkets in low-income neighborhoods. This is one example of a beverage cooler, where
we made water more prominent and took the higher calorie, higher sugar beverages and
put them at the bottom. Results of that study found that there were greater sales of skim,
1 percent milk, water, and frozen entrees, but no change in sales in some other food
categories. So, some changes and not others. We've scaled
up the study and conducted it for a longer period of time, and the results will be forthcoming
soon. Small food store interventions have been of particular interest in disadvantaged
and minority neighborhoods, and there have been a number of studies. A nice review was
conducted and reported in 2012 by Joel Gittlelsohn and others, and you'll hear more from him
about small store interventions. Some of the highlights of the findings were that stocking
and availability of healthful foods tended to increase. The manager said they sold more
promoted or healthful foods, but that there were limited data on purchase or impact on
shopper consumption. And there are design and measurement limitations to many of these
studies. There were two large studies of urban corner store initiatives conducted in Philadelphia
about five, six years ago, and they did find, similar to what other studies have found,
that the food environment could be made healthier. But that changes in purchases, which were extensively
studied, did not change from baseline to follow-up in this natural experiment.
In a randomized trial of the Healthy Corner Store Initiative around schools, Gary Foster
and colleagues did not find any changes in energy content per purchase and no changes
in BMI Z-scores or obesity prevalence. So, some food for thought about why that perhaps
wasn't as successful as we would have hoped. There have been a lot of restaurant interventions
in recent years, in particular, those focusing on calorie menu labeling as calorie menu labeling,
policies have become more widespread. Some of those studies have found reduced energy
intake of orders, but others have found nonsignificant effect or no effect. Industry response to
the national requirement of calorie menu labeling in chain restaurants has shown an association
with small decreases in mean calorie and nutrient content of fast food meals one to two years
after the implementation of nationwide labeling. And another approach in restaurant interventions
is that of actually changing the menu. You'll hear a bit more about the Silver Diner study
from Chris Economos later on. It's been suggested that we need whole-of-community
interventions, not just in stores, not just in restaurants, to really make a dent in the
obesity problem. And there've been a number of intervention studies in whole communities,
lasting multiple years, and a couple of nice reviews of those studies. Wolfenden and others
looked at these programs in the U.S. and in some Pacific islands, and looked at eight
trials and found that seven of them had positive effects. However, the mean reduction in BMI
Z-scores were quite small. Ewart-Pierce, Ruiz, and Gittlelsohn also conducted a review with
some overlap and some different studies, and they found mixed findings: some significant,
some not significant findings, and concluded that multilevel, multi-community approaches
show promising results. The Healthy Eating Active Living Zones program, sponsored by
Kaiser Permanente in California, was a really ambitious intervention program of three years
in 12 low-income communities, guided by a very complex logic model that you can see
a simplified version of here, and with more than 230 different community change strategies.
The main bottom line findings reported by Cheadle and others in 2018 were that there
were positive population-level results for higher dose strategies. However, one thing
you can see here is that only a small proportion of the strategies in what they call strategy
clusters were higher dose. These studies are marked by research limitations, and it's hard
to assess the food environment changes, and there's practice limitations as well. We
don't know if these programs are sustainable or can be scaled up beyond the research. So,
a few points in closing. There's signal and there's noise. Signals of effectiveness, but
a lot of studies whose results we might consider disappointing. If environmental strategies
and change strategies aren't found effective, why is that? It could be research issues,
it could be strategy issues, and it could be that we're working from the wrong assumptions
and not addressing the key causes of the problems. We also need to broaden our thinking to think
about food justice, social justice, and unintended consequences.
I think most of us would agree that everyone has a right to healthy, affordable food and
that consumers have a right to know what's in their food when they buy a meal from a
restaurant. And communities can benefit from some of these strategies and policies. For
instance, a sugary beverage tax that produces tax revenue to improve preschool education
is a plus. But, if it raises taxes and sends people outside the city to buy their groceries,
it could result in job losses and net tax losses. So, we need to work constantly to
prevent the demand for short-term results from undermining long-term research and policy.
And we need to ask what we're doing that promotes or prevents change. The food environment is
complex, like the story of the blind man and the elephant. It's hard to see the whole picture
at once, and we need to remember that the real elephant is the sum of its parts. We
don't know how much environmental change is needed to achieve health improvement. We don't
know how long it will take to improve behavior in health, whether the changes can be sustained,
and who changes. Do only motivated people change? Do they reduce
health inequity? A few closing thoughts and a few things we know. Local policies and environments
can be powerful tools for changing behavior. We need to be cautious when we take associations
and try to turn them into interventions, because the strategies may not work if they're based
on an incomplete understanding of the causes. And targeted inequality-reducing strategies
may have more impact than population-based strategies spread across all groups. And last,
we need to consider the balance of social justice and goals to improve health and behavior.
I want to thank people whose input is important to this presentation and who've supported
and collaborated on my work over the years, and, of course, the funding institutions as
well. Thank you, and we'll have time for some questions.
DR. ANGELA ODOMS-YOUNG: Great. Thanks, Karen. That was really a good frame-in for the kick off
today and for the remaining sessions. We have a few questions that have come into the chat.
The first question is about types of stores. So, are there any findings regarding ethnic-focused
supermarkets versus large chain supermarkets?
DR. KAREN GLANZ: Sure, that's a great question. I am not aware of studies that have actually
compared ethnic supermarkets to large chain supermarkets, but there are quite a significant
number that have been done in ethnic supermarkets, and particularly in small stores. Joel Gittlesohn
will be talking about interventions in small stores. There have been a lot of studies in
bodegas that kind of fit in that small store category, and there have been a lot of case
studies that have been done in a whole range of ethnic-focused stores, such as Asian supermarkets,
Latino-Hispanic supermarkets in different regions of the country. So, and you know,
the findings of those are pretty very hard to summarize in a brief sentence. I would
say generally that in the smaller store studies, it's been shown that it's possible to increase
the availability of healthier food options, but that there hasn't been a lot of significant
change in many studies in terms of healthier diet or weight changes. And I would say from
my point of view, some of that has to do with the enormous challenge of reducing the plethora
of unhealthy items in some of the smaller stores.
So, that's a bit of a generalization, but there's quite a lot of literature out there in ethnic
supermarkets, just not compared to grocery stores.
DR. ANGELA ODOMS-YOUNG: Thanks, Karen. The next question is about prepared food sources.
Can you talk about any studies on prepared food sources and availability, with a focus
on cultural foods and utilization in the neighborhood food environment?
DR. KAREN GLANZ: So, yeah. There are a number of studies. I'm not sure if you're referring
to prepared foods that people get in supermarkets. That's one source. But in terms of small restaurants,
there are a number of studies and there are particularly some studies in Asian restaurants.
Grace Mai and colleagues in Philadelphia have done a study where they were aiming to reduce
the sodium content in small restaurants. And I know that Joel Gittlesohn and his team have
done some work in Baltimore, where they've worked with reformulating menu choices in
Asian restaurants, and I would refer you to look at those. They're interesting, and they're
also very well marked by community participation and retailer participation, which is really
key if we want to try to make an impact in those environments. There's also quite a bit
in some other regions of the country, but those are two that come to mind almost immediately.
DR. ANGELA ODOMS-YOUNG: Thanks, Karen. I know you didn't mention as much about some of the
margin areas. I know many people are interested in community-supported agriculture and food
hubs, and we have a question that is related to that. Are you aware of research on the
impact of community-supported agriculture or food hubs on dietary outcomes?
DR. KAREN GLANZ: I have to admit that I'm not. I'm aware of some case studies and descriptions
of programs, and I agree those are growing areas. And there may be some that I've missed,
but I'm not aware of any that have looked at dietary outcomes per se. They have looked…some
of them have looked at purchases. And of course, if you put more of something in the community,
there will be purchases. And I think that, also, that this is a place where things like
GusNIP and fruit and vegetable incentives and coupons have really infiltrated in large
ways, programmatically. We have less…we have a lot of information about the use of
these, but less information about their specific impact in those venues that you asked about.
DR. ANGELA ODOMS-YOUNG: The next question is about food marketing, where I know you
have some extensive work and have a good handle, probably on the literature in that area, thinking
about the [inaudible] and the marketing focus. Do you have any insights into the role of food
marketing? Is there evidence that promotion and marketing interfere with some of the interventions
in the local food retail space?
DR. KAREN GLANZ: Yeah, well, that could be a whole day's conference in itself. That’s
a great question. There is…we can look at food marketing in neighborhoods, so there's
really good evidence like, without even thinking about TV and media advertising, there's evidence
that there's more advertising for low nutritional value foods in poor and minority neighborhoods.
So, we know that there's a target audience. If you really want to read a story about that,
read the story of how Pepsi—there's a whole book on this—marketed in black neighborhoods,
a bigger foothold in there. Within stores, there is a range of things that we would consider
marketing and placement types of interventions that are driven by industry, where they want
certain products to be given more visibility. And there's quite a bit of research around
that. Not too much that's conclusive, it's a little bit difficult to do that. Jaclyn
Kerr and colleagues, and we collaborated with them, did a study where they used grocery
receipts as outcomes and found some associations between the in-store marketing, placement
of certain kinds of foods and the purchase of those foods by participants.
So, it doesn't interfere with other interventions. Sometimes it overwhelms, and I think that
is one of the challenges that we face in trying to create more healthful food environments.
DR. ANGELA ODOMS-YOUNG: Thanks, Karen. We have a question about ethnic culture, cultural
norms, and social norms. How do you suggest the research be designed to examine ethnic
and cultural norms, social norms intersecting with identifying effective interventions for
the neighborhood food environment?
DR. KAREN GLANZ: Well, I think the best way to go about that is to look at some of the
wonderful examples that are out there that have been already created with community involvement
in it. And again, the ones that I think of first, at least in the U.S., are those in
Hispanic communities in California, such as the work of Suchi Ayala, who'll be moderating
in our next session, and also in Texas and Florida and Arizona, there's been a ton of
work in this area adapted to Hispanic communities, ranging from immigrant communities to more,
you know, longer-term communities that are kind of more Americanized. There's been a
fair bit in the Asian community. Some of that’s been in California, but as I mentioned, the
work of people like Grace Mei and Joel Gittlelsohn, and there has been a lot of work done…oh.
DR. ANGELA ODOMS-YOUNG: OK, we…maybe we just have a few technological issues. So,
I think Karen froze for a bit. And I think she's back. Are you back, Karen?
DR. KAREN GLANZ: Yes. Sorry, I had a little something fall down here in my space. I am
back. I can't be seen. That's unusual, can you hear me?
DR. ANGELA ODOMS-YOUNG: Yes, we can hear you.
DR. KAREN GLANZ: I don't know what's going on here. Well, let's continue without my face
on the screen, sorry.
DR. ANGELA ODOMS-YOUNG: Yeah, and we have a lot of good questions. So, I'm sure that
everybody can hear the responses. And I know technology is great, and so at least we can
have the pleasure of hearing you. So, the next question is about community nutrition
education. The attendee said, "Thank you for the wonderful presentation. I am wondering
if community nutrition education alongside food environment interventions have been tested.
And if so, what are the results?"
DR. KAREN GLANZ: Sorry, can you repeat that? I was trying to fix my camera there. About
how nutrition education...
DR. ANGELA ODOMS-YOUNG: Yeah, nutrition education alongside food environment interventions.
Have those been tested? And if so, what are the results when you combine community nutrition
education with interventions in the food environment?
DR. KAREN GLANZ: Well, first, I would say that the dividing line between interventions
in the environment and education writ large. Education, motivation incentives, next to
things like choice architecture, which would be changes in the environment, have been tried.
In many cases, we've looked at the environment without combining the food environment into
it, and I would say that it's often been difficult to separate out the effect of the education
or the individual or group-focused intervention strategies from the environmental strategies,
for instance. I mean, many years ago in the Netherlands, I worked with Ingrid Stenhouse
and others to do supermarket tours and we found that those led to healthier food choices.
Another study that I worked on was using a simplified index of nutrient-rich foods in
supermarkets, and that also led people to…we gave people a bunch of tools and they were
more likely to use less in their supermarkets and purchased and ate healthier foods, had
higher scores on the healthy eating index. So, we have a number of these kind of educational
and behavioral strategies in food environments. When they've been tried together, they've
seldom been separated. And I think that one of the lessons that we need to think about
is whether some of the environmental change strategies that have not found significant
positive results on diet or food purchase might be more effective if we could bolster
them with education and behavioral or motivational strategies.
DR. ANGELA ODOMS-YOUNG: Thanks, Karen. We have one last question. In yesterday's talk
by Mariana Chilton, she talked about the one thing we need to change to address nutrition
equity with everything. What kind of theoretical framework for PSE change can make this happen?
DR. KAREN GLANZ: Well, you know, you've hit on a topic that's one of my favorite theoretical
frameworks. But one of the things I say about theoretical frameworks is that a framework
is like a coffee cup. It's just a framework until you fill it up with content. So, we
have to apply it. So, I think that, for instance, an ecological systems perspective is a great
framework, but it depends what you put in those different levels of the framework and
what we focus on that makes a difference. With reference to some of the really important
ideas related to structural racism and colonialism and so forth that Mariana brought up, we perhaps
have been leaving those out. And I think putting them back in—in thoughtful ways—not just
to kind of throw everything into the bucket or the coffee cup would be advances in what
we know now.
DR. ANGELA ODOMS-YOUNG: Thank you so much, Karen. And thank you to attendees for your
thoughtful questions. We're going to move into Session 5, which is focused on the
state of the science in neighborhood food environments, and explore research gaps and
opportunities. And I'm going to turn it over…back over to Karen so can introduce our next
panel.
DR. KAREN GLANZ: Thank you so much and thanks, everyone, for the thoughtful questions that
you gave. I think I'm still not going to be visible. Might have to get my camera fixed. But
it's okay right now. I'm just super pleased to introduce Dr. Guadalupe Xochitl Ayala,
San Diego State University, who's going to be the moderator for the next panel. I've
made reference to some of her outstanding work in this area as well, and maybe you'll
all hear bits about that when we get to the Q&A. So Xochitl, over to you.
DR. QUADALUPE XOCHITL AYALA: Thank you, Karen. Good day, everybody. So good to be here with
you today. For this session of the Neighborhood Food Environment, Diet and Health Outcomes,
our first panelist is Dr. Alice Ammerman, of the University of North Carolina. She's
going to discuss her work examining retail food environments, diet, and chronic disease.
Our second speaker is Dr. Christina Economos, from Tufts University. She will review restaurants,
food service environment, diet, and chronic disease. I just want to remind everybody that
we will have a conversation at the end of both of these presentations. So I ask that
you put your questions on the chat and, if possible, direct your questions to one of
the two speakers. Let's get started.
DR. ALICE AMMERMAN: Hello, I'm happy to join you today to talk about retail food environments
and their impact on diet and chronic disease. My name is Alice Ammerman, I'm at UNC Chapel
Hill, and I'd like to thank some of my students who helped me with this presentation, and
thanks to the organizers for this really nice workshop, I am learning a lot. So today we
will be talking about a number of different topics. One, why is this important? What is
the retail environment? What is it made up of? Where do people shop and particularly SNAP
lower income consumers? What do we know about the quality of different retail venues
and what has been the diet/disease impact? And then what is some promising research
opportunity for the future? So why is this important? One is to inform policy, as a lot
of the work we're doing in this workshop is pointing towards and which will in turn guide
research and funding, and then this will help with guiding planning and goal setting. And
as an example, this is our 2030 state health plan in North Carolina, and we pick indicators
that are reasonable to measure to try to guide certain priorities.
And I was talking to a friend with DHHS, who mentioned that they're doing a lot of work
on spending resources and time to improve healthy retail access. And given the data
that and what we're seeing is this is the place where they should be putting their energy,
so that's a good reason to do this workshop. So back to this plan, so one of our health
indicators is limited access to healthy food, and we're trying to move to a smaller percent
of the population who has limited access. Now how do we define that? We define that
as the percent of people who are low income that are not in close proximity to a grocery
store, and this is how we define proximity; less than a mile in more urban and more than
10 miles in rural. And this comes from the data…the county health rankings. I think
all of us are looking at whether there may be ways to improve this measure. Definition
of retail. This is from the corporate world: considered all food, other than restaurant
food, that's purchased by consumers and consumed off premise.
And the industry estimates $6 trillion in sales in 2019, so it's a big part of our economy.
Types of retail food environments. We'll mostly be focusing on these kinds of larger stores,
more traditional grocery stores, but then, of course, the big box and the club stores.
And then there's a lot of interest in corner convenience stores, you'll hear more about
that from other speakers, vending machines, specialty shops, you can get food almost anywhere
these days. And some of the other interesting areas that we won't be able to touch on all
of these but mobile markets, farmer's markets, CSA food box, food trucks, home delivery meal
kits, all the Door Dashes and the many different ways that we can tap into the retail food
environment. Looking at USDA data in terms of share of household calories by food source,
still the large groceries are the bulk of it, and of course, we have to take out restaurants
for this discussion, but that's an increasing part of our food source, maybe adjusted some
during COVID. And then there's the convenience stores, which are the next largest chunk.
Taking a look at kind of nutrition scores for household food acquisition by source,
so these again are the different types of stores or places to get food. Schools being
an exception to stores. And if you look at it by…basically as you come down this list,
you're increasing income. So starting with SNAP and then higher income. So for the most
part, it looks like higher income consumers that the foods they purchase are somewhat
higher nutritional quality, except when you get to the schools, where the food is provided,
and it's more equity in terms of all students getting the same food, so that's a place
where we know it's important to reach children with good nutrition. And then another way
to look at this is in terms of access. This is another kind of distance-oriented definition,
and I think the main point here is that those who are more access burdened are more likely
to use some of the convenience dollar stores where some of the quality of the nutrition
is less good. So early research on the links between diet and health really focused
on distance. So increased nutrition with access to supermarkets,
number of supermarkets in the community, and then there's how they rated their nutritional
quality. So a big focus on how close are you to a supermarket? And that seemed to be associated
with improved diet. And this has had a big impact on policy and practice but there are
some concerns now as we do more research in this area. The results did kind of focus our
attention on this concept of food deserts, which we’re beginning to, I think, question
more now. And then it released a lot of funding for supermarket location and construction
like the Healthy Food Financing Initiative. But there were a lot of assumptions with this
data that say shopping at larger stores with a wider selection results in healthier choices
and most of the studies didn't really look at specific data where people shop and what
they purchase. But we do have data now... a number of researchers have been looking
at the Homescan Nielsen data that provides household packaged good data.
It doesn't give us a lot about fruits and vegetables, but there are other ways that
we're getting at that. So here's a look at nutrient content by store type, and these
are focusing on some of the types of parts of our food intake that we are trying to modify,
such as calories, sugar, saturated fat. And you see, in general, it seems like the larger
stores and the…seem to be doing somewhat better. This also looks at changes over time,
but that the convenience stores, some of the warehouse, the large club stores where people
buy a lot of packaged goods that you're getting kind of higher intakes from that, changes
over time are not terribly consistent, although this may reflect some improvements in some
of the formulation of packaged foods. Another way to look at this is urban vs. rural. And
again, we're looking at the nutritional quality of packaged goods. One big distinction here
which is interesting is most of these lines kind of line up between urban and rural, but
not for the kind of Walmart-type stores, where you've got a much higher dependence from rural
areas on that. I think we'll see more going on here over
time in terms of online purchasing. This doesn't capture, I think, the most recent trends in
that direction. Another approach to this again with urban and rural and then calories per
person per day for packaged good purchases. I think things as you might expect in terms
of grocery stores being the main purchasing point, I think there's a lot of interest in
dollar stores and you see breaking it down by income that lower income in both urban
and rural areas are more dependent on the dollar stores. So, what we can learn about
what food is available there will be important. One more way to look at this…kind of complicated,
but I think showing that the grocery stores as opposed to say, full-service and quick-
service restaurants are still providing us with healthier options and schools probably
doing the best in that regard. So how do we summarize all of this? There have been a number
of big review papers to look at this, and this is, I think a particularly good one,
it was done in 2015, so we probably have more current ones as well.
But overall, looking at the local food environment and associations with obesity, the diet, the
study quality was quite low, and the opinion of those who did this study was 60 of 71 studies
were cross-sectional. Of course, this is a hard thing to study, so we have to rely on
that kind of study design often. Most of the findings were null, there were some trends
inverse associations between supermarket availability and obesity and then obesity in children.
But if you look at this, the majority of the studies were null, but there were some that
were positive in there. And the authors do state that because of the study quality, we
have to interpret these carefully but I think the underlying message is that proximity to
particular retail outlets is not the whole story. So and they conclude that despite the
large number of studies, limited evidence for association between local food environments
and obesity. So why isn't there more of an association? Well, there are many factors
other than distance, as we've said, accessibility of a highway, perhaps between you and a store,
even if it's a half mile away, that's going to make it very difficult if you have a limited
transportation. Quality of food in the stores, as we talked
about the cost of healthier food options, is it culturally relevant? Neighborhood ownership
a sense that this is a neighborhood grocery store that people want to frequent, and it
does seem from some of the research that grocery stores may bring benefits other than nutrition,
like more jobs to the community, perception of healthier food access or a better food
environment, although that doesn't always seem to be correlated with improved diet intake.
So I'll point you towards a publication that I think could be very helpful going forward.
The Healthy Eating Research Group kind of spearheaded this national research agenda
to support healthy eating through retail strategies. I'm not going to go through all of these,
you'll have access to the slides, but 10 priority areas were identified in terms of both understanding
the current environment and then assessing the implementation effectiveness of interventions.
And that will be a subject of a whole other section of this workshop is interventions.
And they did an attempt to look at some of the high priority areas in terms of how they
would address health equity as well as feasibility, and some of the biggest ones as you might
guess, were related to SNAP increasing the amounts, the benefits, frequencies. So these
are all areas of active research and I think continue to be. Another interesting way to
look at this is a study by Winkler et al., in terms of kind of accessibility from anyone's
home, how much does it take to actually get to the place of the store? And then also the
preparation that's required. So you can see we're sort of trending towards easy access,
little preparation, food that's delivered to our doorstep that's half prepared already,
or vending machines at work. So interesting to see how things go as we move more and more
in the direction of accessibility and whether or not that involves equity in terms of people
who are able to access those things. Online shopping, a big area of research. Very recent
Gallup poll showed that a quarter of people order groceries online; it's double the share
from the pre-pandemic year of 2019. Traditionally, the demographic has mostly
been younger, with households over 100,000, and it tends to be resulting in decreased
shopping frequency, of course, some of that is COVID related. But the corporate food world
predicts that many of these habits will likely stick in terms of people becoming more comfortable
and at ease with online shopping. For lower income consumers, again, a very active area
of research, especially as options to pay online with SNAP increase, which is an important
part of this equation. Historically, there's been lower participation by the SNAP consumers,
but this varies by retailers, outside pick up, when that becomes more of an option may
benefit families with young children. Delivery costs can still be a barrier, and that varies
by retailer. Some of the COVID and other emergencies have sped this process along a bit. Some of
my colleagues have looked at the notion of pester power, and whether you can order online
means your children are pestering you to buy the latest sugar-sweetened cereal.
And multiple interventions are now testing tailoring…tailored ordering systems and
nudges to see if we can use online to really move nutrition in a positive direction. So
quickly to wrap up, what's the role for more qualitative community engaged work to try
to improve opportunities for SNAP-eligible shoppers? We have a team at our shop looking
at this and supported by some help from Robert Wood Johnson, Cooking Matters Share Our Strength, this
is the team here. Looking at human-centered design to test and implement food retail interventions
that promote healthier choices. So the challenge here is to develop an intervention for SNAP-
eligible caregivers of young children that meets their needs and advances SNAP-Ed's reach
and impact. As you know, SNAP-Ed is one of our primary ways of reaching lower income
consumers to address some nutrition improvements. So we use the human-centered design to approach,
a participatory approach. And it involves a complicated but very interesting synthesized
journey mapping approach, where you look at, you won't be able to see the details here,
but before the store, at the store, and after the store, what are people's feelings?
What are their frustrations? What would make life easier for them? And the basic findings
we had key insights, were that families would appreciate ways to reduce the cognitive burden
of shopping since there's a lot to juggle. So, more understanding of what lower cost
items are, how to find WIC-eligible items, opportunities for kids and shopping. Again,
this might relate to the pester power, you know, having kids be engaged in some way—and
also later in cooking. And then flexible, customizable options to meet their dietary
needs and preferences. Are there ways to build food boxes and bundled goods and things that
can help that. So in summary, looking at retail and the neighborhood food environment, it's
more than distance either to or the number of retail grocery options. More supermarkets
may improve other environmental factors like job, access, perception of health options
and…but they may not always improve the nutrition or health, and that's where we're
trying to expand the work. Online ordering and delivery options hold promise but are
not yet widely studied. In-store and marketing interventions are under
active study with some promising results, and you'll hear more about that. And we may
need broader approaches to understand and address social drivers of health related to
how we can make access to healthy food more equitable. Thank you for listening to this
talk.
DR. CHRISTINA ECONOMOS: Hi, I'm Chris Economas, Professor of Nutrition at the Friedman School
of Nutrition, Science and Policy at Tufts University. And the title of my talk today
is, Restaurant/Food Service Environments, Diet, and Chronic Disease. So why study restaurants?
Currently, there are over 1 million restaurant locations in the U.S., and of these, about
70 percent are single-unit operations, so they're managed and they're run independently,
whereas there are about 195,000 quick service or fast food restaurant franchises. And despite
the fact that there are more of the single-unit, you'll see in subsequent slides that more
calories are actually coming from quick service. About 20 percent of calories across the population
are consumed from restaurants, and food away from home is associated with higher calorie
and lower nutritional value. There are lots of different intervention strategies to improve
restaurant eating, for example, density of restaurants within a community, proximity
from residents to a restaurant establishment, location, for example, near a park, labeling
policies, supply, looking at the nutritional value of what's being offered, demand, looking
at ordering patterns of customers and then, of course, advertising and marketing.
So we know that eating out is the norm, and any of these intervention strategies alone
or in combination with other environmental food strategies have the potential for massive
impact. So beginning with food expenditures over time, you can see that in about 2010,
these lines cross, and this represents the point in time where we started to spend more
food away from home than on food at home, coming from retail or grocery. So although
more calories are coming from retail and grocery, it's more expensive to eat out, and we're
spending more food away from home. And so in 2017, we were spending approximately $400
billion on food away from home. So looking at proximity and density, there was a recent
systematic review of longitudinal studies looking at proximity and density of restaurants
in relationship to health. And we know that overall, the proximity of residents to restaurants
on things like pediatric weight and pediatric weight change are predominantly null, but
there are stronger associations in girls than in boys when they're seen.
There's limited or mixed evidence looking at the proximity to fast food restaurants
and the effect on increased weight change over time and the density of fast food showing
some effect on weight trajectories and BMI Z-score with stronger relationships in girls
in rural areas, children in high income households and white children. With respect to disparities,
there are some associations with individual outcomes among some groups…subgroups, including
sugar sweetened beverage consumption. And we know that unhealthy food is ubiquitous,
coming from lots of different food environments. And again, 20 percent of calories is coming
from restaurants, so just working on restaurants alone is unlikely to make a difference in
health outcomes but if we work on restaurants in combination with other things in the food
environment, we can have impact on health outcomes. So looking first at the supply side,
these data are from MenuStat looking in that percent of meals at 73 U.S. restaurants that
are compliant with the American Heart Association criteria.
So looking at these 73 U.S. restaurants that are the largest in sales that also have nutritional
information and stratifying by all restaurants seen in the darkest bar, followed by fast
food restaurants, which is in the next darkest bar, followed by full-service restaurants
and then finally, by fast casual. So looking across the different nutrition criteria, you
can see that restaurant meals are doing well with respect to offering protein and meeting
criteria. They're doing next in line pretty well providing fiber, followed by trans-fat,
followed by cholesterol and then for things like calories less than 700, for total fat,
for saturated fat and for sodium less than 50 percent of meals. And this includes an
entree and a side, that are being offered in the largest restaurants with the most sales
are not meeting these criteria. So there's a lot of room for improvement in terms of
what's being offered. And if we look at these same data clustered together by the number
of criteria that the meals are meeting from zero to one, two to four, five to six, or all
seven, which is the highest score that you can get when you combine these criteria, you
can see that most meals are falling into the two to five criteria met, and less than 10
percent are falling into all seven criteria being met.
So again, lots of room for improvement. And if we look at who's actually doing the best,
it's the fast casual restaurants, followed by the fast food restaurants, followed by
full service. So looking more deeply at children's meals, we conducted a study looking at meal
bundles with fruit or non-fried vegetable sides, as well as non-sugary beverages. And
we wanted to see over time if restaurants were offering more of these and if they were
offering them by default. So using another data set called Technomics and looking at
the top 20 restaurants for sales from 2005 to 2015, you can see on the left panel that
the meal bundles with fruit and vegetable sides and non-sugary beverages that were offered
actually increased, as well as the sugary sweetened beverage substitutes or non-sugary
drinks increasing over time. So, in terms of offering in supply, this is good news.
But when you look more specifically at the average percentage of meal bundles with healthy
sides and beverages by default, which is a recommendation you can see it's very low.
So as of 2015, less than 20 percent of these bundles were offering a fruit and vegetable
side and a non-sugary beverage by default. And we know the default strategy is very effective,
so getting more restaurants to implement default is likely to increase what happens with dietary
intake. So on the top fruit and vegetable, and on the bottom sugar sweetened beverage.
So now turning to what we actually consume and using NHANES data, this is showing trend
data from 2003 to the most recent NHANES data 2017/2018. And first looking at estimated percentage
of energy intake among U.S. adults 20 or older, you can see the majority of the calories of
70 percent are coming from grocery or retail, followed by calories coming from restaurants,
hovering at about 20 percent, not changing much over time, followed by the "other" category
and then lastly by the work environment. For children, it's very similar. Again, fairly
stable over time, and you can see that it's about 20 percent of calories consumed from
restaurants by children with again the highest category being grocery or retail, in this
case, followed by school and other, which are tied at about 15 percent.
So now, if we dive into the most recent enhanced data 2017/2018 and look more deeply at the
restaurant category, these data are actually showing the types of restaurants divided into
full serve and quick serve, and you can see that the youngest children are consuming actually
not quite as much from quick-serve or full- serve restaurants as other children, hovering
here at about 13 percent, and the category shown with the dots is quick serve or fast
food and the category shown with the gray shading is full-service restaurants. So together,
this is restaurant eating. This increases as children age. So you can see in school–aged
children, it gets higher, again, higher in quick serve than full serve. And then when
you get to teenagers or 12 to 19 year olds, it's about 28 percent of calories coming from
restaurants with the majority coming from the quick serve segment. This is stable in
about 20 to 40 year olds, and then it starts to decline again as people go through the
aging process and it's much lower in those over 71 years of age.
So the 20 percent is the average across the population, but it does vary by age group.
So now looking at whether or not those foods consumed and the calories consumed are high
quality or not, these data are also using NHANES and looking over time from 2003 to
the most recent 2017/2018, and actually categorizing the foods consumed from restaurants as poor,
intermediate, or ideal diet quality. And so the panel on the left are showing children;
the panel on the right are showing adults. And this is using the American Heart Association
criteria. So you can see that the majority of foods from restaurants for children and
adults falls into the poor diet quality category, followed by the blue showing the intermediate
diet quality. And last down at the bottom, very little is ideal diet quality coming from
restaurants. You can see that the blue line for children is going up a bit over time, showing
that there's been some improvement and the red line is going down a bit. So more intermediate
diet quality foods being consumed by children when they dine out in restaurants.
But there's still a very big room for improvement here in both children and adults. Looking
here at these radar plots, these are also from NHANES using the healthy eating index
2015. And looking at food component scores over time between full-serve and quick-serve
restaurants using, again, the NHANES data. And on these radar plots, the center point
of the graph represents a score of zero, and the outer point of each axis represents the
maximum score for each component. So plots with the most points closer to the outer edge
represent a food pattern that's closer to meeting the recommendations of the 2015/2020
Dietary Guidelines for Americans. They had a plot with many points closer to the center
of the graph. So looking specifically at restaurants, we can see that in full-service restaurants
doing better in total vegetables, greens and beans, meeting saturated fat requirements,
fatty acid, seafood, plant proteins and total protein foods where in quick-serve restaurants
for total protein, dairy, and a little bit for vegetables and saturated fats.
But overall, there's a lot of room for improvement, particularly for quick service with respect
to food components and meeting the AGI guidance that is put out for high diet quality. So
when you get to an actual restaurant, there's an opportunity to make changes as well. And
these data are from a study we conducted with the Silver Diner, a full-service regional
restaurant chain which made changes to its kids menu in 2012. And what they did is they
offered more healthy kids meals, they changed the side dishes to be healthier–fruits and
vegetables. And they removed french fries and soda from the kids menu. And giving you
a sense of what these things actually looked like, these were some meals that were offered.
And in total, what they did is they changed things to be healthier in a way that was more
prominent, more prevalent, and by default. Three things we think are really important
within a restaurant establishment. And so what actually happened? These data are showing
the changes that were from pre-menu changes to shortly after the menu changes. Also 2
years later. And you can see that for healthy children’s
entrees ordered, it went from 3 percent to almost half, and that was sustained
over time. For healthy children's side dishes ordered. it went to about three quarters of orders.
For french fries, it decreased from 50 percent to 22 percent and soda went down from 35 percent
to about 30 percent immediately and further to 24 percent. So looking over time was important.
So we assured that it wasn't just a new or novel change, but something that could be
maintained over time. And also these are pretty dramatic changes over a chain that has about
12 establishments and suggest that this could be done in other restaurants as well. We
also looked at the restaurant's annual revenue, and it continued to grow during this period
by 5.3 percent, exceeding that of similar family dining chains during the same time
period, which is really important because industry can't afford to lose money, and they're shy
to make changes to the menu that might do that. So this demonstrates that even with
healthy changes, you can see an increase in revenue growth.
We also looked at the healthy adult menu orders before and after when these new healthier
children's menu changes were made to see if there was spillover ,and other people ordering
at the table that were on the same check actually had changes as well. So looking at these millions
of orders, we saw for others who were on the same check at the table, there was an increase
in healthier entrees, healthier sides, healthier appetizers, and a decrease in soda and dessert.
Again, suggesting they're made in spillover as a result of the healthier children's menu.
So taking a look at marketing to children inside quick-service restaurants and differences
by community demographics, we've recently examined marketing techniques in 165 quick-service
restaurants from five national chains in socially, economically, and racially ethnic diverse communities
throughout New England. And approximately 95 percent of quick serve restaurants were
marketing less healthy foods, while only 6.5 percent were marketing healthy options.
Some important differences is that more press promotion advertisements inside and on the
exterior of the quick-serve restaurants, or in lower income communities. And more child
directed advertisements with cartoon or TV movie characters, as well as fewer healthy
entree options and more sugar sweetened beverage and dessert options were on the children's
menu inside quick-serve restaurants in communities with higher minority populations. Again, underscoring
some of these differences which is really important when thinking about interventions
and policy changes. Since federal calorie labeling has become mandatory, there's been
quite good compliance across U.S. restaurant chains shown here. And a recent study actually
looked at mean purchase calories per transaction after franchise labeling was started in April
2017 and nationwide implementation in April 2018. Data were collected in three states
and then modeled to represent what might happen nationally. And you can see that there was
a slight decrease in calories per transaction, which is quite promising and suggests that
calorie labeling may have an impact on consumer behavior.
One of the findings in this study was that it wasn't even across communities and by census
track, those that were lower income actually showed less of a decrease in calories ordered
compared to the higher income communities. So, thank you. I look forward to the question
and answer period.
DR. GUADALUPE AYALA: Thank you. Those were fantastic presentations. Thank you, Alice,
and thank you, Chris for leading us in this effort. Really appreciated it. We received
a lot of great questions. So we'll go ahead and get started. Let's see. The first question,
I will direct this to Alice, although I know with most of these questions, both Alice and
Chris could probably answer them. For the first question: Is there a supportive…is
there supportive evidence that demonstrations of healthy food preparation, meals, providing
in-store education about how to read labels and interpret nutrition quality and calories
per serving within supermarkets in rural and urban settings helpful, specifically with
respect to improving self motivation and health outcomes such as obesity?
DR. ALICE AMMERMAN: Great. Well, I will take a stab at that and others chime in —and
Suchi, you too—because you've done a lot of work in this area. So I would say a number
of those things have been tested but not necessarily in the grocery store or retail setting. Like,
and then sometimes like with many things, we see change in knowledge, like reading labels,
and we see people's ability to improve their knowledge, although we're constantly also
trying to improve the label to make it more readable. But whether or not that translates
into longer term behavior change I think is a question. I think taste-testing, we all
know is important from a number of interventions, especially with children, but then maybe referring
question or maybe referring to like sampling in a grocery store whether or not something
like that actually leads to improved intake. I don't think that's been studied.
DR. GUADALUPE AYALA: Awesome. Thank you. We'll move on to the next question just because
we have a few and we have about 10 minutes. OK, here's a general question that either of you
could answer; Has work life balance, folks relying on multiple streams of income and
spending less time at home impacted their increased dependence on restaurant eating?
DR. ALICE AMMERMAN: Chris, I'll take the restaurant, why don't you start?
CHRISTINA ECONOMOS: Yeah sure, I can take that. You know, we have demonstrated that in one of our studies where we were looking
at mother/child diets who were new immigrants to the U.S., we saw that time stress measured
in a validated way really did translate to more processed and take-out restaurant food.
And looked at the fact that working multiple jobs cuts into food preparation time, and
even procurement. And it's much easier to get something that's prepared. We know that,
in general, prepared takeout restaurant food contributes less nutritional value to the
diet. But I really want to underscore the hope and promise that I alluded to and some
of the studies that I showed. Reformulation is often driven by the science and by policies
that are put into place. So supply and demand are both important. And if we can work to
make sure the quality of prepared food, particularly for individuals with low income, even on SNAP
where that is possible, I think in California, maybe it is but not across the country or
it's going to go a long way, as people are forced to work multiple jobs and have other
responsibilities like child care and elder care, etc.
So high quality prepared food shouldn't just be something that is available to people with
advantage.
DR. GUADALUPE AYALA: Thank you, Chris. OK, next question. Alice, I'll direct this one
to you: Can you talk more about online ordering for SNAP participants and what needs to be
done to decrease barriers among participants. For example, knowing about online options,
navigating online, perceived charges, and so on.
DR. ALICE AMMERMAN: Yes, of course, to start with, it's kind of the logistics of how it
works, then, you know, it started with a small pilot, where just a few of the bigger grocery
chains were able to do the online ordering, particularly for SNAP. Online ordering has
existed for a while, but often you would have to pay with a credit card if you wanted to
pick up outside the store. So as online ordering with SNAP becomes more of a possibility that
removes some of that barrier. I think a lot of people are interested in whether some of
the ordering could be tweaked in some way through interventions to direct people towards
healthier options. I'm not sure that results are out of from
those studies yet. And then I think I mentioned the delivery…home delivery that could be
a cost related barrier to people as that’s a part of the online ordering for SNAP participants.
Either of you guys want to add to that?
DR. CHRISTINA ECONOMOS: I guess I just want to add what I've seen in other studies with
SNAP and farmers markets, for example. And something that we did here at Tufts showed
social media can be beneficial. So if we can advance our marketing and advertising of some
of the things that are going on within SNAP and WIC, by using social media and meeting
people where they are, I think it will go a long way in awareness and then hopefully
utilization.
DR. GUADALUPE AYALA: Excellent, thank you. OK, another question. Again, this could be
directed to either of you. This is related to combining intervention approaches. So can
you talk about the studies, or maybe elaborate on what you talked about, that offer healthier
meal options at lower costs and combining that with nutrition education?
So sort of the combination of those two strategies and the impact that has on changing
behavior in either the restaurant or grocery environment.
DR. ALICE AMMERMAN: I'll say a little bit and then Chris can probably say more. I think
it does kind of point to the importance of combined interventions that offering lower
cost things without it, whether it be in store purchasing, or meals, without some education
or maybe exposure to being able to taste it is probably not going to be successful without
kind of coordinating those efforts. So just because it's low cost doesn't mean people are
going to buy it but if they obviously taste is really important. If it tastes good, and
people understand that it may be beneficial for their health, then putting those two together.
Clearly, the cost of food is really important for low income folks to be able to eat a healthy
diet. So looking for options like that is really important.
DR. CHRISTINA ECONOMOS: Yeah, and I guess I would just underscore that combining things
it’s really important. And in some of the work we did looking at reviews of calorie
labeling, it's clear that action-oriented messaging in the form of education is really
important to pair with just the numeric strategy of labeling with calories.
So it's not just the knowledge part, but it's also making it actionable, and often making
it positive as well is really important. And the other thing that I would say is when I
mentioned the work on the Silver Diner, I talked about prevalence, prominence, and by
default. There's a combination of things that were done there, increasing the number, increasing
where it's shown, and then that default strategy is really important. So that's what we felt
in that particular study was really important. And then the last thing that's harder to do,
but it has been beneficial in a number of studies, are incentives, and kind of, rewards
to get people to start making a behavior change that hopefully they will maintain.
DR. GUADALUPE AYALA: Excellent, thank you both. Building on that last comment, Chris,
and this is a question for both of you as well. So thinking of influential people in
our lives, including primary care physicians, can you talk a little bit about the state
of the science related to food prescription programs and their influence on changing
behavior, whether it's grocery shopping or restaurant consumption?
Yeah, there's quite a bit of work going on in that area. And some of it is coming out
of Tufts. I would say that the evidence is emerging in this area. And there's definitely
some promise for specific populations particularly those that have a diagnosis. But I think in
terms of going to the entire population, there still needs to be a lot more research to see
if that can be helpful. I would say again, that has to be paired with affordability.
So prescribing high quality foods without making them affordable is going to be very,
very difficult. So in combination with our federal food assistance programs, I think
has a lot of promise.
DR. CHRISTINA ECONOMOS: Just to add a little bit, we often think of physicians and other
providers as being cheerleaders. They don't have a lot of time to spend going and sometimes
don't have the background to give a lot of detailed information. But they can certainly
say this is really important for you. Make a referral. We've done a small food prescription
program where we use kind of CSA type boxes. And, of course, you have to do a lot going
along with that with how you use what's in the box. And we found that getting just the pickup
of the box could be challenging. Sometimes the prescription programs give you a coupon
to take to a farmer's market. But that may not be something where people are most comfortable
being people have tried for years to make farmer's markets more comfortable for a broader
socioeconomic range, and I think we still have work to do there.
DR. GUADALUPE AYALA: Great, thank you.
DR. ALICE AMMERMAN: Chris, you should add something there. You've done work in that
area.
DR. GUADALUPE AYALA: That's okay. There’s a lot of questions there. I could answer many
of them. Here's another question though. And it was posed actually during session four,
but we never got to it. And I'm curious to know if anybody has an answer to this one:
Is there any measurement for food preparation skills, healthy eating knowledge and consumer
purchasing knowledge at the community level, like county level or census track level?
DR. ALICE AMMERMAN: So food preparation skills? Food preparation skills, healthy knowledge,
healthy eating knowledge, consumer purchasing knowledge?
DR. CHRISTINA ECONOMOS: Yeah, I mean, there's some nutritional literacy scales that have
come out which I think are more comprehensive than just nutrition education and kind of
bring, I know this one for children that we worked on here at Tufts. Sarah Amin, URI, was
leading that work. But I think it's really important. So I would say, looking more into
the food literacy area.
DR. ALICE AMMERMAN: I will say that some of the students who helped me put together this
presentation are particularly interested in culinary skills and food prep and how that
can affect diet. So hopefully, we'll have a future generation of researchers looking
at that.
DR. GUADALUPE AYALA: That's great, always promoting the next generation, Alice. Thank
you for that. Chris, here's a question for you: Were you able to control for how marketing
outside of a restroom affected restaurant food choices by children and families?
DR. CHRISTINA ECONOMOS: In the particular studies I showed, no. But we actually did
another study where we marketed healthy alternatives, meaning size and beverages, community wide.
And we did that using traditional things like billboards, and radio, and lots of other community
advertising. And in that case, we were able to substitute
some of the traditional advertising that was going on by buying billboard space and buying
radio time, and within the buses, signs like that. So you're actually displacing so to
speak, which I think is really important, instead of just adding something healthy to
the mix without displacing something unhealthy. And those results are forthcoming. And we've
taken that work and turned it into a social media campaign for scale because those are
really expensive studies to do with placement in a community. But using social media, I
think it's a way that we can, again, really meet people with what they're utilizing on
a daily basis.
DR. GUADALUPE AYALA: Great, thank you. This is our last question. And it's very much along
the themes of Dr. Chilton’s talk yesterday, and feel free either of you to answer: So
in terms of policy, is there a push within nutrition sciences to improve living wages,
as it relates to cost of living across neighborhoods? Also, what are some, if any, policies being
promoted to address structural racism and injustice, and marketing low value, nutritious
food, depending on community demographics?
DR. ALICE AMMERMAN: There's a lot packed into that question.
DR. CHRISTINA ECONOMOS: Yes.
DR. GUADALUPE AYALA: A lot, yes. Maybe it’s a reflection question too.
DR. ALICE AMMERMAN: I'll mention one thing that actually just came up with one of my classes and students, I'm teaching a nutrition
policy class now where students were asking about living wage, and in North Carolina,
we've been looking at school lunch staff and the fact that they are not necessarily
paid at a rate of other state employees, and trying to actually working on legislation
to try to change that. And then also, some of you may know that school food services
often charge an indirect rate by the school so they actually have to pay for the use of
it which cuts down on the amount of money they have to pay their staff and to produce
healthy meals. So those are a couple of kind of small but important policies that could be addressed.
DR. CHRISTINA ECONOMOS: Yeah, I think it's a really important question. Certainly the restaurant
industry has been working on minimum wage and living wage. With the question about are
nutrition scientists working on that, I think it's a really important leverage point.
If we want the entire food system to change, then making sure that people are making enough
money is really important for a variety of reasons. The second question around health
equity, and I think there's a lot of work going on there. There needs to be more. But I think
both of us presented data stratified as best as possible from national surveillance data
so we can start to look deeper into what's actually going on. And I would say the more
we can do that, the better because if you look at the average in any particular area,
or for a variable, it does not tell the story at all. So I guess just encouraging people
to pull the data apart as much as possible and really look more deeply at who's impacted
and then trying to go deeper to understand what the drivers are, and why that impacts
the current.
DR. GUADALUPE AYALA: Right, that's great food for thought to leave us with. Thank you both
for sharing your time. Today was a really interesting discussion, great presentations.
So thank you for your leadership in the field overall. To all of the participants, thank
you for your very provocative questions, and really helping us think about this field and how to
move forward. So, we are now at a break time, we have about 15 minutes. Starting the networking
chat which you can engage with fellow attendees on the topics just discussed or any other
topics. We invite you to visit the networking lounge and enjoy the conversation until about
2:25 Eastern Time. Until then…and then after that you can join us for the third panel, which
is on measurement of food access and neighborhood food environment. So thank you everyone. Thank
you panelists, thank you audience and we will see you all shortly.
DR. ALICE AMMERMAN: Thank you.
DR. KAREN GLANZ: Good afternoon, everyone, I hope you all had a good short break and
are ready for the next session. In this panel, we're going to review measures of community
and consumer neighborhood and food environments, including geographic information systems,
technologies, and technology-aided measurements. Speakers will address what's known about the
validity and reliability of these measures. Provide examples, and I think will provide
some provocative thoughts about where we're going in the future. We are expecting Leslie
Lytle to join us to moderate the panel, but as at the moment, she's having some technical
challenges. So I'm going to go right ahead and introduce our panelists. We're covering
really three different areas. The first being what I described earlier as community food
environment measurement. Next, measuring the consumer food environment and then technology-aided
measurement of the food environment. Our first panelist is Dr. Alana Rhone of the USDA's
Economic Research Service. She'll discuss measuring the community food environment.
Next, Dr. Alison Gustafson of the University of Kentucky will discuss measuring the consumer
food environment, and our third speaker will be Dr. Marta Jankowska of the Beckman Research
Institute at the City of Hope, who will focus on some innovative technology approaches to
measuring the food environment. And before we get started, I want to encourage people,
as in the previous sessions, to ask questions in the chat box, and we will get to as many
of those as we can during the Q&A. Alright, let's jump right in, Alana.
DR. ALANA RHONE: ...I have the great pleasure
in presenting the Food Environment, Food Store Access, and How to Measure the Food Environment
Using Geographical Information Systems. I must note before I begin, the findings and
conclusions in this presentation are those of myself and should not be construed to represent
any official USDA or U.S. government determination or policy. The food environments and food
access is important because easier access to retailers that sell healthy and affordable
food may allow consumers to be less reliant on easily accessible sources of less healthy
food and improve their diet quality. Also, access to a supermarket or large grocery store
is a problem for a small percentage of households. Some consumers are constrained in their ability
to access healthy and affordable foods. About 14 percent of households live in low-income
neighborhoods, with a significant number of households that do not have access to a vehicle
and also live far from the nearest source of healthy food.
Easier access to retailers that sell healthy and affordable food may also make it easier
for some Americans with access barriers to achieve food security. In 2019, 10.5 percent
of American households were food insecure or lacked enough food for an active, healthy
life for all household members at some time in the year, and about 4.1 percent had very
low food security. Where at times food intake of at least one household member was reduced
or eating patterns were disrupted. The economic research service has many data products. There
are two mapping tools that are among those products, and they look at the food environment
and food access specifically. Both mapping tools utilize GIS technology to assess the
food environment. The first mapping tool is the Food Environment Atlas. The Food Environment
Atlas assembles statistics on food environment indicators and also provides a spatial overview
of a community's ability to access healthy food. The Atlas assembles statistics on three
broad categories of food environment factors. The first is food choices. Indicators of a
community's access to and acquisition of healthy, affordable foods such as the number of food
stores and restaurants in a county; food and nutrition assistance program participation,
like the National School Lunch Program; and local foods, such as information on food hubs,
the farm-to-school program, and the number of farms in a county. The second category
is health and wellbeing. Indicators of a community's success in maintaining healthy diets such
as food insecurity and diabetes and obesity rates. The third category is community characteristics,
indicators of a community's characteristics that might influence the food environment,
such as demographic composition and income and poverty, among other things. This map
is from the Food Environment Atlas and shows the number of farmers markets in a county
in 2018. The dark maroon-colored areas are counties that have more than three farmers'
markets, and the yellow areas are counties that have zero farmers' markets.
Using GIS software, we can map all our indicators to give a better picture of the food environment
in a county and also see if there is any kind of correlation between any of the indicators.
The next mapping tool is the Food Access Research Atlas. The Food Access Research Atlas offers
census tract-level data on food access that can be viewed, downloaded, or printed for government
community planning, or research purposes. The Food Access Resources Atlas provides a spatial
overview of food access indicators for low-income and other census tracts using different measures
of supermarket accessibility. It also estimates food access data for the overall population
and subgroups within census tracts, such as households without vehicles and SNAP participants.
The Atlas includes four measures of low income and low access census tracts. The first
three measures are defined by low income status of a census tract and proximity to the nearest
grocery store for a significant number or share of people using different demarcations.
These measures are low income and low access at 1 and 10 miles. Low income and low access
at half and 10 miles, and low income and low access at 1 and 20 miles. The half-mile
and 1-mile demarcations are for urban areas, and the 10 and 20 miles are for rural areas.
For example, the low income and low access measure at 1 and 10 miles are low-income
census tracts, where a significant number or share of the population is greater than
1 mile from the nearest supermarket, supercenter, or large grocery store for an urban
area, or greater than 10 miles for a rural area. The fourth measure, which is the low
income and low access using vehicle access and 20 miles are low-income census tracts,
where a significant number of households did not have access to a vehicle and are more
than half a mile from the nearest supermarket. Or a significant number or share of residents
are more than 20 miles from the nearest supermarket. As mentioned, there are four measures of low
income and low access in the Food Access Research Atlas.
However, in this slide, I will only be going over two; the low income and low access at
one and 10 miles measure and the low income and low access using vehicle access and 20
miles measure. These estimates show the change in low-income and low supermarket access census
tracts from 2015 to 2019. The number of census tracts classified as low income decreased
slightly from 2015 to 2019. This reflects improvements in household income, whereas
from 2010 to 2015, the number of low-income census tracts increased. The number of low
access, one and 10 miles census tracks increased slightly from 27,527 census tracts in 2015
to 27,548 in 2019. When vehicle availability and proximity to a supermarket are considered
together, such as in the low income and low access using vehicle access and 20 miles,
estimates show a slight decrease of a little over 1 percent point in this share of tracts
in 2019. When low income and low access are compiled together, the number of low income
and low access tracts at the 1 and 10 miles measure increased slightly.
And the low income and low access using vehicle access and 20 miles measure decreased slightly.
A neat feature of the Atlas is by utilizing GIS software, we can create maps showing food
access indicators by census tract using different measures and indicators of supermarket accessibility.
Here is an example of how the Food Access Research Atlas can be used. This map shows
low income and low access areas in the DMV, DC, Maryland, and Virginia areas in 2019.
The yellow areas are census tracts that meet the low income and low access using vehicle
access and 20 miles definition. The kelly transparent green areas are areas that meet
the low income and low access definition at the one and 10 miles measure. And the bright
lime green color tracts are tracts that meet both definitions. These tracts may be the
worst off because they have many people without vehicles and many who are quite far from the
nearest supermarket. Now I have overlaid our map with a map of the wards in D.C. to get a
richer picture of where exactly these areas are in the D.C.
As you can see, most of these areas are in wards 7 and 8. These are Northeast
and Southeast DC. Now, let's take a look at other ways using GIS technology can be used
to assess the Food Environment. As mentioned before, for both mapping tools, the Food Environment
Atlas and the Food Access Research Atlas we use ESRI GIS mapping software. In the Food
Access Research Atlas GIS tools are used to assess distance to the nearest food store
for populations. Downscaling methods are used to disaggregate to half kilometer square grids.
So why is downscaling using GIS tools important? We downscale because we want to measure populations
at various distances to stores. For example. And the first picture, which shows an image
of low-income census tracts in Little Rock, Arkansas in 2019. Let's focus only on the
census tract boundaries, which are outlined in gray. People live in these census tracts.
However, just by looking at the map, we don't know if the census tract has areas that are
densely populated and are sparsely populated. Also, food stores are sometimes distributed
unevenly around an area. Downscaling, which is used in the second image, which is a pixilated
version of population distribution in Little Rock, Arkansas in 2019, gives us a more granular
measure of population distribution within the tract. The yellow areas have less than
10,000 people. The navy blue areas have less than 100 people, and the gray areas have less
than 50 people on the map. The red lines are interstate freeways. So downscaling is like
a distribution and density measure, all in one. If we can downscale populations using
GIS technology, to those smaller areas, such as half kilometer square grids just like
used in the second image, we can describe access in populations a lot better. The data
products, and estimates, and this presentation can be found on the ERS webpages. And this
concludes my presentation. Thank you.
DR. ALISON GUSTAFSON: Hello. I'm Dr. Alison Gustafson, an associate professor here at the University
of Kentucky. And I'll be presenting today on the consumer food environment measurement
approaches, challenges, and opportunities. The goal of our talk today is first to understand
what the consumer food environment is in the United States. Second, examine current measures
available to quantify the helpfulness of the consumer food environment. Third, I'll then
discuss the gaps in measures related to reliability and validity of the tools we currently have.
And lastly, I discuss emerging consumer food environment changes and the need for enhanced
measures. First, I'd like to define the consumer food environment. The definition today is
availability, price, quality, and variety of foods for consumers coupled with advertising,
promotional messages witnessed by consumers. Why is the consumer food environment so critical?
Not all stores are created equal. There is a great variety of pricing, promotion, availability
of food items within and between different neighborhoods.
We also know that in order to provide a sustainable, healthy, and equitable food system, what is
inside the store where consumers shop needs to be measured and addressed, as well as neighborhood
level factors. Where do we measure the consumer food environment? We measure food venues where
consumers, customers, individuals can purchase food. This includes, but is definitely not
only limited to these venues, grocery stores, supercenters, gas stations, convenience stores,
corner stores, dollar stores, restaurants, including fast food and fast-casual, vending
machines, farmers' markets, national parks and rec locations. And now, most recently,
online grocery shopping. Dr. Ammerman will go over this section in far more detail than
I will, but briefly, I'd like to just note that in the consumer food environment today,
65 percent of food is purchased at traditional stores, such as grocery stores and supercenters.
So that's majority of my talk today will be centered around tools or measures that measure
the helpfulness of grocery stores, given that most people spend a majority of their food
dollars at this type of location. However, we also know that at convenience
stores such as corners stores and gas stations, 15 to 20 percent of people's food dollars
used these types of venues. Third, we have non-traditional or mixed-use, such as dollar
stores or cooperatives. Ten percent of food dollars are spent in dollar stores and thus
this emerging venue is critical to be measured within the consumer food environment to understand
the helpfulness of the food that is available where people shop. Lastly is small-scale locations
such as farmer's markets or community-supported agriculture, such as a CSA. People spend less
than 1 percent of their food dollars are spent here. That's for today. I will not delve
deep into the different audit tools that are available for measuring the helpfulness of
a farmer's market. However, there are studies that have utilized different tools to address
farmer's market helpfulness, and I can point you in that direction. And now want to move
on to measuring the consumer food environment, the tools that we currently have to date.
The Nutrition Environment Measurement Survey, developed and tested by Dr. Karen Glanz and
her study team. NEMS is an observational tool within the retail space to assess the availability
of healthy options, price, and quality. This tool has inter-rater reliability and test-retest
reliability of approximately 0.73 to 1.0. This tool is used in stores, convenience stores,
restaurants, including fast, casual, and fast food; college campuses, vending, and has been
adapted in several locations in Texas, Brazil, and with the Rudd Center. As we mentioned
in this slide, two sides previously, the consumer food environment comprises significantly of
different venues, with a majority of people spending their dollars at grocery stores and
convenient type locations. This tool has been adapted to be used at these different locations,
which makes it a widely reputable and robust tool. Next, there's the Thrifty Food Plan
tool that people use. The USDA provides a representative helpful and minimal cost meal
plan. People then have use, study authors have
then used this tool in 11 studies to date to identify food and beverages that could
be purchased to meet the minimum requirement for a healthful diet. Thus, as you know, in
the recent press and also through our recent administration, there's been an expansion
of the SNAP benefits based on the Thrifty Food Plan. What's the minimum requirement
to meet a healthful diet? So this tool will then be used in stores to say what is the
minimum amount of food that's available for customers and their stores to meet the TFP?
These are not obviously the only tools available for measuring the consumer food environment.
There are a variety of tools that I am categorizing as healthy baskets. One is the Healthy Eating
Indicator, or HEI, Shopping Basket. Many of you might be familiar with that we use HEI
in dietary surveys. This tool or basket is used to measure commonly consumed food and
culturally acceptable food are identified. Practical considerations included meals, convenience,
and price. This tool used 35 items from 17 different
categories. Another basket is the Healthy Food Access Basket. This considered demographic
and food purchasing data were used to define food in the healthy basket. This basket utilized,
this tool, excuse me, utilized an approach of saying "we want to look at the foods most
commonly consumed." So it's one thing for a store to have healthy food but if those foods
are not as commonly purchased, then it might be irrelevant. And that...thus this group
utilized purchasing data to define their healthy basket. They used 44 items were used in their
basket to meet the nutritional needs of most families. So this may not look at families
who have disabled children. This may not include families who are larger than most. However,
their approach was to look at purchasing data, to define the measures. The last one I'll
talk about is the Market Basket Assessment Tool. This looked at availability of fruits,
vegetables, low-fat dairy, eggs, lean meats, and whole grain among our SNAP retailers.
They are still waiting on reliability and validity reporting on the inter-rater reliability
measures. However, this tool focused more on SNAP retailers rather than all types of
consumer food environment. And so again, there's different tools for different purposes. So,
what are the most common items measured? The two most common tools, as we've mentioned,
are NEMS and TFP. They measure a wide variety of foods and beverages, including fruits,
vegetables, dairy, meat, frozen items, canned items, milk, eggs, whole grain, beverages,
and a variety of snacks. Other less commonly cited measures focus on simply fruits and
vegetables. So many times in market baskets, these baskets are just focused on fruits and
vegetables. And I'll get into the good reasons why they may only want to focus on one type
of food item. They also may only look at prices of fruits and vegetables across different
venues. Different tools have different purposes, and there is no one perfect measure. However,
we know that to measure the consumer food environment, we need to think of the consumer,
and I think there needs to be more addressing of the individual within the development of
these tools. What is commonly measured among studies? Availability
is the most common factor that we measure. Most studies utilizing an audit tool as the
ones I've previously talked about report on availability of healthy relative to unhealthy
food within food venues. So, for example, people will measure "is there availability
of fruits and vegetables." They will also then measure availability of low-fat dairy relative
to higher fat dairy items as one example. Price. About half of the studies will report
on price differences of healthy food relative to the less healthy foods such as whole milk
price relative to low fat or skim milk. NEMS will report on the price of higher fat meat
relative to lower fat meat, such as ground beef, at 80 percent versus 90 percent. Quality
is the third factor. Only a third of the studies report on quality of food within the stores,
such as bruises, bumps, or dents in cans. Quality is a very important factor because
although the food may be available across different venues such as apples, if those
apples are bruised in one venue versus another venue, the consumer is less likely to buy
bruised apples, and thus quality is an important factor that needs to be considered when measuring
the consumer food environment. I'd now like to go over four different review
studies or systematic reviews of tools and their recommendations. Our first author was
in 2008 and reported that 40 percent used reliability or validity testing. Therefore,
less than half of the studies to date are using our conducting reliability and validity
testing. And thus we're not sure if the measures we're using to conduct our audits is actually
reliable or valid. Most are observational, and many were cross-sectional in nature, meaning
at one-time point. And lastly, this author addresses how these tools are best suited
for proposed outcomes needs to be addressed. And I will get into that in a little bit.
The next systematic review was done by Dr. Lytle, who is in this session, and she said
we need to pay attention to psychometric properties, including reliability and validity, and address
utility of the measures across populations. Thus, Native American populations are highly
different than white suburban location, and that we need to address how these measures
vary across the population. Tools need to describe their data reduction
methods and how they can relate to obesogenic indices. And we need to improve the rigor
of the study design. I had conducted with my co-author systematic review in 2011 and
indicated that neighborhood or place matters. Store availability is different in geographic
areas, and we need to provide a multi-level perspective when measuring the consumer food
environment. Not one single measure, such as availability or price, or quality at one
time point is sufficient to adequately describe the consumer food environment. Studies need
to measure availability, price, and quality over time, and we need to move away from a
cross-sectional observational manner. Dr. Karen Glanz recently conducted a systematic
review and found that the two most common tools are NEMS and TFP. Again, most studies
were cross-sectional. Again, standardization of measures is needed, as well as measurement
of quality, reliability, and validity. Thus, all four study authors across all systematic
reviews across time points in the past 11, over 11 years, we've all indicated there needs
to be validity and reliability measures. There needs to be longitudinal measurement
of these, and we've all also indicated that there needs to be a measurement of the geographic
location around these stores. And lastly, there needs to be more focus on the development
of tools related to the outcome of interest. Are gaps in measurement? I cannot stress enough
we need to have the validity and reliability between and within measures. There needs to
be more sensitivity to detect change over time regarding price, promotion, and availability.
For example, there's a new emerging non-meat products and plant-based meat substitutes,
as noted by Dr. Karpyn, such as the Impossible Burger. These tools need to be sensitive to
detect the change in the helpfulness or the unhelpfulness for that matter of different
food items available for our consumers, such as vegan items. Also changes in beverages
such as seltzer alcohols. Previous tools may not be interested in measuring the availability
of alcohol, however, other tools may want to make note of the changing landscape of
alcohol beverages available for consumption, and those tools need to be sensitive to detect
these changes. I will also note that many authors have noted
that we need to think about additions of culturally relevant and appropriate foods. Not all cultures
look at food, fruits, vegetables the same way. Or would they consume them in the same
way. We need to get out of a monolithic white perspective and think of different cultures
and how they shop for their food. Adaptable tools are needed, which are dynamic for individual
and neighborhood changes. Food venues selling food continue to change, and audits need to
be readily adaptable. No one audit can be static over time. We need to have sensitive,
adaptable tools. And this is holding true regardless of the venue, whether it's grocery
stores, fast food or corner stores. Audits need to be developed and tested from a diverse
perspective to reflect the cultures and neighborhoods of our collective consumers. Our consumer
is not a white middle-aged woman. Our consumer is anyone from a Latinx Hispanic household
to an LGBTQ. And there needs to be a wider lens with how consumers shop within their
neighborhood and within their food venues. Tools also need to be relevant for disease
prevention and obesity prevention, as Dr. Lytle mentioned, tools need to be used with
the health outcome in mind. Perhaps we want to look at a tool used for prevention of cardiovascular
disease and how does the consumer food environment meet the prevention of those risk factors?
How does the tool meet the risk factors for obesity? These tools need to think of the
health outcome in mind when being used within intervention studies. I'd now like to briefly
move on to the new consumer food environment.
To make my point about how food venues are constantly changing and we need tools
that are adaptable and sensitive to these changes. We now know that there is a
gross growth with online shopping. Growth of online shopping, especially with COVID-
19 and the emerging rising COVID Delta variant. Once COVID-19 was confirmed in the United
States, there was a surge in online shopping for various food and beverages, coinciding
with an increase of 48 percent in online sales. Some business forecast models predict that
30 percent of all food and beverages will be purchased online by 2025. There is a large
variance in availability of online shopping, whether delivery or pickup between rural and
urban locations and across different types of stores. Think Amazon to Walmart to Kroger.
There are no measures currently which address price, availability and promotion of online
shopping. We need tools to be dynamic to be adapted for new venues, selling new foods
for all cultures. In summary, all studies need to engage and report on quality measures
of reliability and validity. Longitudinal studies are needed to assess
changes over time within an intervention. We need to provide a multi-level perspective
neighborhood, house, school, individual within the consumer food environment. This can help
shed light on where resources are best utilized to improve health outcomes among those most
vulnerable. I'd now like to stop and thank you all for your time and attention and open
it for questions and comments.
DR. MARTA JANKOSWKA: Hi, my name is Marta Jankowska I'm an Associate Professor at the Beckman Research
Center at the City of Hope Cancer Center in Duarte, California. Please do feel free to
follow our lab on Twitter. We're @HDSCALECOLLAB. Today, I'm going to be talking about two projects
that are utilizing different types of technologies to enhance our measurement of the food environment.
The first uses crowdsourced health data to come up with some unique food environment
measures. The second is focused more on measuring exposure and interaction with the food environment
using Global Positioning System or G.P.S. and geographic information systems, or GIS
data sources. So, measuring the food environment is notoriously difficult. Government and industry
data sources are most commonly used, but they have a lot of well documented issues. So,
to ensure that these data sets are showing useful data, often ground truth validation
needs to be performed, which can be incredibly costly and time consuming. So, several researchers
have been looking into crowdsourced data as an alternative, which can possibly help fill
some of the content gaps in government and industry data.
It can track these data sources for existing or newly opened closed outlets, and possibly
reduce the burden of ground truth validation. We're going to talk about a study we've been
working on in San Diego and some of the interesting measures we've been able to come up with using
this data. Yelp data comes with several attributes like the dollar sign price or average star
rating, but it also comes with the set of reviews that people have written. We can mine
those reviews for several attributes about the food outlets. So, we screened the business
reviews for Yelp from the years 2004 to 2016, getting a total just over one million reviews
from almost 300,000 users for about 8,000 food establishments. And then we apply topic
modeling and sentiment analysis to the reviewed text. So, topic modeling is a type of natural
language processing method for discovering the abstract or hidden topics that might appear
in a collection of documents. LDA is one type of topic modeling, and it classifies text
to that particular topic using probability distributions.
The model describes the patterns of words that are repeating together and occurring
frequently. So, what you get are several topics, and under each topic, a set of corresponding
words that occur together frequently within that topic. So, in this image, for example,
the yellow topic sees gene, DNA, and genetic occurring together. So, we ran Yelp data through
LDA. We settled on 20 topics, and those are shown in this table on the left, and named
those topics based on the types of dominant words included in each topic. We then assigned
the most closely aligned topics to each review. So, every review got coded as a topic. We
looked at the average type of distribution by neighborhood throughout San Diego, and
you can quickly see some patterns emerged of the types of restaurants that dominate
certain neighborhoods of the city. So, first of all, everybody's unhappy on Yelp. So, several
neighborhoods see a dominance of the displeasure category or displeasure topic shown here in
green, especially Carlsbad. For some reason, they're very unhappy there.
But other topics definitely emerged. So, for example, in central San Diego, there is a
huge popularity of breakfast and happy hour spots in Coronado, which is a bit of a higher
end neighborhood. We see the topic of atmosphere high end being dominant. For Alpine, which
is a bit more of a rural area in the eastern part of the county, people are talking the
most about pizza. We mapped some of the topics to see the distribution throughout the county.
So, for example, we see the neighborhoods with higher dominance of Mexican restaurants
as classified by LDA analysis, and they are concentrated in the south of the city, as
well as a short sort of corridor up through the mid to Eastern areas. Here, we're looking
at aggregates, that these aggregations are coming out of classification of each individual
food outlet. So, this can be particularly useful in filling in some of the gaps that
we don't get from government or commercial data where we don't know much about the types
of foods that are being sold. We are now actually working on figuring out
how we might be able to classify words into healthy versus unhealthy topics, to get a
ranking of the healthiest restaurant or market. With the Yelp data, we can also look at pricing
and that sentiment or customer satisfaction. And this is an...actually could be a really
important factor to consider in terms of assessing not only the presence or absence of specific
food types, but their quality and their ability to satisfy basic customer needs. So, in the
data analysis, the algorithm is looking for specific sets of words that would imply positive
or negative sentiments or opinions. These are then aggregated into a scale from positive
to negative sentiments. In this figure, sentiments are aggregated by neighborhood. But again,
we can also examine specific food outlets to see the sentiment of that particular location.
As seen here, we can also see sentiment changed over time. So, in some neighborhoods like
central San Diego, we don't really see much change in sentiment at all.
In Chula Vista, we see a decrease in overall sentiment outcomes, so, people are getting
less and less happy with their reviews. But in Harbison Crest, we see a lot of variation
throughout the years, although this may be due to a small amount of restaurants in this
area. So, the opening or closing of even one restaurant will likely have an impact on average,
as seen for the neighborhood. Another area we're looking into with the Yelp data is ethnic
preferences. So, again, while a grocery store or a restaurant may be present in a neighborhood,
does it actually have the types of foods that the dominant racial or ethnic groups in the
area prefer? So, you can use natural language processing to pick out other languages, for
example, Spanish, and then match restaurants with the predominance of Spanish words. We
can compare them to neighborhoods with high prevalence of Hispanic ethnic density. So,
on the left here, we're seeing what the Yelp reviews with more of the Spanish language
are. Whereas on the right, we're looking at where Hispanic ethnic density is from the
budget census related variables. And we can overlap these and see if the restaurants
are actually meeting the needs of the population that they are attempting to serve. We are
similarly looking at restaurants and food stores classified under Asian type categories
in Yelp to find census tracts that can be considered Asian food deserts. And we're comparing
them with Asian food insecurity as measured with SNAP data from the American Community Survey.
I'm not going to go into depth into this analysis because we actually have a poster being presented
during the conference from our undergraduate interns. So, please do go check that out.
So, some conclusions from this work so far. There definitely are issues with crowdsourced
data, such as representation, or who is contributing to the data, the coverage of the data. Although
over time, this is getting better and better, and there can be marketing bias. So, for example,
Yelp has been known to try to convince businesses to spend ad dollars to get better reviews.
But Yelp and other customers data can work in tandem with more traditional data sources
to fill in missing gaps. It can aid in ground truth efforts by reducing
the number of outlets that need to be ground truth, and it can add variables of interest.
It can fill content gaps, and it can be used to classify food stores by ethnic types. So,
I'm going to pivot now and talk about some of the ways that GPS and GIS can be used to
obtain better measures of exposure to the food environment. We've definitely seen a
huge increase in interest of not just the food environments where people live, but being
able to assess the types of environments people encounter during their daily travel patterns,
or even more specifically, the types of food environments that somebody actually enters
and interacts with. In this image, which is courtesy of Lukar Thornton, we see that people
purchase foods in a variety of locations beyond their neighborhood. So, we want to be able
to accurately measure this type of behavior, ideally passively without passing on a lot
of burden to participants. We have a few studies where we have put outward facing cameras on
participants to be able to objectively classify when they enter a food establishment.
And we paired that with a GPS tracker and then underlined GIS measures of food environments.
And what we get as a result is this picture on the right, where we see somebody passing
through a bunch of food environments and ultimately an environment they stop and engage with.
So, here they're passing through several fast food or taqueria outlet possibilities, but
they actually end up stopping at lunch just south of the U.S.-Mexican border, and we can
actually validate that with the imagery that we've collected here as well. This type of
data is important to gather because as ground truth data to then test developed algorithms
that don't have image data that are only relying on the GPS and GIS data. We wanted to know how
accurate this type of measurement can be so we can use this type of ground truth data
to create rules for when we classify somebody as in or out of a restaurant. An example is
in the images above, where we've set a five minute rule of being within the buffer of
a food outlet location as the rule for actually interacting with that food outlet rather than
just passing through or passing next to it. In the lower images, we can see how this plays
out in real life with the GPS data passing through the drive thru of the food outlet,
and then we can actually validate that food purchase with the imagery. So, in combining
GPS and GIS data, eventually, ideally, through the smartphone, we can be incredibly, it can
be incredibly useful in terms of moving towards passive measures of the food environment exposure
and engagement, rather than burdening users with surveys or constant reporting. And I
think eventually these types of methods are going to be key in implementing just in time
adaptive intervention strategies related to food environment engagement. Right now, we
are relying heavily on distance based notifications. In these types of applications, we're just
using a geofence. But as we collect more data about behaviors, such as time spent in a location,
trip mode, such as car or walking, which we can actually get from the accelerometer
data on the phone and other contextual factors like stoplights, we can really hone in on
the likelihood that someone is actually interacting with a food outlet rather than just passing
through. As we're increasingly getting more interested
in mobility and the food environment, we're going to want to reduce participant burden
in these types of studies and move towards passive measurement methods. We need more
ground truth studies to understand the types of errors that passive sensing methods can
produce and hopefully, with enough research, we can start applying these methods in actual
interventions. Just want to say thank you to the people in our labs that helped with
all of these studies, and also thank you to the NIH and NSF for funding this research.
Please feel free to reach out to me to keep the conversation going, and I'm happy to take
any questions.
DR. KAREN GLANZ: Alright, thank you. Thank you, Alana, Alison, and Marta, for those interesting and
provocative talks and expanding our scope in our ways of thinking of measurement, especially
Marta's talk, which kind of introduces us to some new and emerging technologies. We're
going to go to a question and answer session. And for that, I'd like to introduce our moderator,
Leslie Lytle. Leslie will not be seen live on camera, but you have a thumbnail picture
of her, so, she can be seen that way. Dr. Lytle is a professor from The University of
North Carolina at Chapel Hill, has done a tremendous amount of work in this area, and
so, I'll turn it over to you, Leslie.
DR. LESLIE LYTLE: Yeah, thank you so much again. I'm really sorry. I had trouble with the audio
and visual earlier, but I was really interested in the presentations. Thank you panelists
for your great presentations, and we have quite a few good questions, so, I'm going
to jump right in. There are a couple of questions for Alana that I think are related. They are
specifically about the Environmental Atlas and Food Access Research. One question is
about any plans that you have for updating that atlas with more current data. And then
there was also a question regarding the accuracy of the databases used for the food atlas identification
of food locations. Those of us who work in this area know there's quite a few studies
about ground truthing, with various findings about accuracy of the list services and databases
that are available commercially. So, if you could, just mention briefly plans for updating
the databases, as well as what you know about ground truthing and accuracy.
ALANA RHONE: So, we do have plans to update both atlases. The Food Environment Atlas and the
Food Access Research Atlas with more current data. We are currently in the process of updating
the Food Environment Atlas and our information on the location of our store directories.
We use two different datasets: one being stores that are authorized to accept SNAP, and another
is...that's called STARS and then another data set, which is called TDLinx, which is a Nielsen directory,
and it gives a store list, an annual snapshot of stores. And we merge both of these directories
together so that we may accurately capture stores and the right location and that they
are really open. So, that's how we kind of, you know, make sure that we have accurate
information using our stored data set.
DR. LESLIE LYTLE: OK, thanks. Also, a follow up, Alana, someone asked about how rural...how
you defined rural for the distance to a supermarket.
ALANA RHONE: Yes. I would love to go over that. So, rural status and urban status comes from...directly
from the Bureau of Defense's urbanized area definitions, where rural areas are sparsely
populated areas with fewer than 2,500 people and urban areas are areas with more than 2,500
people.
DR. LESLIE LYTLE: OK, thank you very much. I actually have a question for Alison. Alison,
I thought that your data on the proportion of online shoppers was just really fascinating
and to think that 30 percent of all food will be purchased online by 2025 kind of blows
my mind. I'm hearing there's this discussion out in the field about the potential for marketing
through online shoppers or providing incentives when someone is shopping online. It seems
like that could open up a whole new can of worms.
DR. ALISON GUSTAFSON: Yes. So, Leslie, we have a study right now funded through Share Our Strength...No Kid Hungry,
people might be familiar with that, looking at how to navigate healthy marketing within
the online platform. And we also have a couple of grants going in around that online healthy
marketing, especially for SNAP now that SNAP online has been expanded to so many different
storefronts. So, that's something that we need to help the public-private partnership,
that we need to be helping those retailers with their healthy marketing. And I don't
know if you saw last week maybe, Instacart will be taking quite a bit of money from advertisers
to be doing marketing in their online space. So, that's something we're trying to work
on as far as intervention work and also policy change with Share Our Strength and with USDA,
especially since so many SNAP dollars are about to be redeemed online. So, that's something
that we all need to kind of put our ear to the ground for and start to have conversations
around that.
DR. MARTA JANKOWSKA: (CROSSTALK) that there's a lot of mobile based apps like Waze, for example,
is already taking marketing dollars from fast food outlets. So, as you're on your route
and Waze is telling you where to go, you'll get a pop up that says, "Hey, you're half
a mile from this McDonald's, and you can get a dollar off your burger. Check it out." So,
there's a lot of innovation going on in the marketing space for online and mobility based
data that, as researchers, we are incredibly behind on.
DR. LESLIE LYTLE: Yeah. Yeah, I think that's going to be a fascinating area to keep our eyes
on. Marta, a related tech question for you: How has GPS and GIS research design controlled
for neighborhood demographic and resource access, such as internet and smartphones?
And also, is there more? Are there more data collected and available in areas with higher
income?
DR. MARTA JANKOWSKA: So, a lot of the research that comes out of that Pew Research Center is showing
that the disparities in access to at least smartphones are really decreasing over time.
So, at this point, we're seeing penetration of smartphone access quite extensively throughout
different types of populations in the United States. Internet access is a little different,
and there, especially, just like with our industry provided data sets, rural data is a little
less accessible and less prevalent than urban data. That being said, in the GPS related
studies, a lot of those are being collected with sampling frameworks in mind to try to
get a wider range of access. So, it really depends. Is it researcher enabled, in which
case, usually, hopefully, the researcher has thought about getting a wide range of people
involved? Or is it collected from commercial datasets where commercial sources are providing
smartphone data? And in that case, again, there's less concern, I think, on their end
about who they're representing. But smartphone penetration has really gone
far in the past 10 years.
DR. LESLIE LYTLE: Yeah, I think this is a question probably for Marta or Alison. There's a question
that says,: what are your thoughts about shopping behavior in the research narrative? This appears
to be an oversight in the literature. I think that shopping behavior can be tracked via
technology, but also I think from Allison's talk on consumer behavior, you might have
some insights.
DR. ALISON GUSTAFSON: I can go first, Marta. Yeah, so, one thing. Yeah. And so, and it's a little bit
about what Marta was saying of in the moment decision making. And so, we, myself and Jared McGuirt,
who's at UNC Greensboro, are working with some different state providers. So WIC
and SNAP at the state level and using technology that we put inside the store called Beacon
to then give alerts on their phone while they're shopping to help the consumer make different
choices while they're in the moment of their shopping behavior. And then we're also looking
at that in the online space. So, while you're shopping online, is there a way to help push
or behaviorally nudge to make healthier purchases while you're actually putting items
in your cart in the online space?
DR. LESLIE LYTLE: Thanks. Marta, anything else to add?
DR. MARTA JANKOWSKA: Yeah, and I would add to that that all of these new resources that we're seeing
like Instacart and other online based options, I mean, they're collecting all that data.
So, whether or not as researchers can get access to it, I haven't seen much being done
in that space yet. I haven't heard of people trying to get that data, but I think there's
a lot of potential. Yeah. Alison, go ahead.
DR. ALISON GUSTAFSON: Yeah. So, we actually are in the works with Instacart, seeing if they are open to
share their SNAP purchasing data with us. So, we are hoping that we can keep that bridge
and be able to have access to all of their SNAP purchasing data. But I want to note that
in rural communities, it's obviously not as robust as it is in urban sites.
DR. LESLIE LYTLE: Yeah, that makes sense. A related question, is sort of about using that technology
for intervention use. So, it's talking about how might one use ecological momentary assessment
with smartphones or mobile devices in order to characterize individual environment interactions
and something like a just in time adaptable intervention? Are we seeing any work in that
space where we're trying to use something like an ecological momentary assessment with
a smartphone to intervene and prompt behavior?
DR. MARTA JANKOWSKA: Yeah, I think there's actually quite a bit of research on that, especially because
the reliability of just using the GIS data with the GPS data is quite low still. So,
we're trying to get better at coming up with these rule sets of when someone's actually
in a restaurant, or going to the restaurant trying to predict that, but that is still
pretty recent. And so, a lot of people, a lot of researchers that are using just in time
interventions with food related outcomes, they have to use EMA because there's really
no other way of knowing did someone eat? Is someone about to eat? What kind of choices
they're about to make. So there is quite a bit of research using EMA, and I think that
right now we're just going to have to keep doing that. Eventually, I mean, this is a bit
high in the sky, but I think eventually we can get to a place where passive sensors on
the smartphone might be able to do pretty good at predicting when someone's about to
purchase food. Interesting. I want to bring the conversation back to Alana.
We have a question here about: Has GPS/GIS food data been integrated with other social
determinants of health data, such as transportation access, education, housing status, and employment
status? You talked a little bit about transportation. Can you say anything more about the other
social determinants of health and those other characteristics?
ALANA RHONE: Yes, I sure can. In the Food Environment Research Atlas, we do include social determinants
of health. We do have things such as people's access to recreational centers, poverty and
income information also in the Food Environment Atlas. But in the Food Access Research Atlas,
we really basically only look at income and vehicle access. We also have information in
there about SNAP participants, and we also look at race as well. So, you can find the
number of people, for example, who have a certain race or ethnicity that live far from
a grocery store.
DR. LESLIE LYTLE: Alright, great. Thank you for clarifying that. Another question for Marta: Can you
talk about any available, actually tried and tested smartphone apps that could help us
measure the food environment and track our spending habits?
DR. MARTA JANKOWSKA: Yeah, that's a good question. I don't know any off the top of my head. I haven't
done a lot of research into what's out there. I know there's a lot out there, and a lot of
it is not tested, so, people are just trying to make quick money off of these types of
apps. Yeah, that's the most I can say about it.
DR. LESLIE LYTLE: Yeah, I'm sure apps are coming. We probably just don't have them tried and
true yet. I think we have time for one more question. And I think that this probably could
go to any of our three panelists. In your opinion, will we someday be able to better
predict individual consumption using food environment and sales data? And what would
that look like? You know, I think this question is getting to the point of we all believe
that the food environment affects people's eating behavior, their nutritional status,
and their health outcomes. But we still have some real challenge in actually seeing those
connections in the data that we produce. Do you believe that we're going to be getting
better at that, on using food environment and sales data in the future?
DR. ALISON GUSTAFSON: I'll go first, just because I do a lot of work with receipt data, and I think
we have a ways to go. So, I've done some work with Simon French and their expertise with
receipt data. And I think, right, they're just capturing what's being purchased and
then who's actually consuming it from that. We are still not even sure yet.
So, I personally would love to see if someone knows a developer that...where, as a researcher,
someone could hand the receipt and they could, in a sense, annotate but digitally what they
were thinking, who they were with, what their geographic food environment was around them
and then what they intend to do with that food that they just purchased.
DR. LESLIE LYTLE: Yeah, but then we run into unconventional food sources I think farmers' markets, where
we would really like to see people moving to farmers' markets, but there's no receipts
given at farmers' markets.
DR. ALISON RHONE: And even that. And one of your question, which is always a good point, and I do work
with food pantries, so, there's no receipt for food pantries. There's no...you know, so that kind
of what they're using, what they get from the WIC office. So, there's always those
all those other sources of food. But for the places where you could get a receipt or a
digital sale, I think, but I still think there's a lot of gap even in that. So, Leslie, you
know, so, I'd like to see us maybe just even work on that. But...
DR. MARTA JANKOWSKA: Yeah, I agree, just because food inherently is such a social phenomenon. And so, you know,
whether you're going to a party or potluck and you're ingesting a bunch of food that
other people brought, whether you're buying snacks for your kid's soccer team, I mean,
in order to get that narrow of a pipeline, you know, you have to essentially be a singular
person, only purchasing food for yourself and without any other interaction. But I don't
think is possible. I mean, there's a very small section of the population that that
could be possible. But I think in my mind, it's less of like the overarching goal,
and it's more of a where can, we without too much user burden, collect information that
might help us provide better choices to a person. So, it's less about knowing every
little thing that they put into their body and more about what are the general habits
that we can help shape while they are in the middle of food purchasing, which I think is
a really exciting area.
DR. LESLIE LYTLE: Yeah, yeah, I I agree. We are out of time. I want to thank the panelists for
their great responses to these very interesting questions. Before we move on to the next break
again, I want to thank you for your questions and the panelists for sharing their presentations.
We are going to take a quick five minute break from about 3:30 to 3:35. Session six, which
is Innovative Interventions to Address Neighborhood Food Environment will begin at 3:35 in the
auditorium. So, thanks again for this wonderful conference and we'll look forward to learning
a lot more interesting stuff in the next day and a half ahead.
DR. KAREN GLANZ: Welcome back from your break, everyone. We're
ready to move into session 6. We have a pretty packed afternoon here. As we move into
the session, I want to remind everyone to add your questions to the chatbox during the
presentation so we can address them in the Q and A session that follows. We've had robust
input of questions, we haven't been able to get to all of them, but many of them have
been very insightful and added to the presentations. We're going to start the next panel that highlights
interventions and evaluation strategies intended to make neighborhood food environments more
health enhancing. Speakers will describe various intervention studies and their findings and
identify and discuss some research gaps and ways to move this science forward. I'm especially
pleased to introduce Dr. Mary Story from Duke University and the Healthy Eating Research
national program. She is going to lead the moderator panel. So, Mary, over to you.
DR. MARY STORY: Thank you, Karen, and welcome everyone to session 6. This has been a terrific
panel today. And Karen, you gave a wonderful overview of the state of the science. And
we've had panels on health impacts and measurements, and now we turn to food retail interventions,
and we'll be dealing with three specific areas and communities grocery stores and supermarkets,
small food stores and sources, and food pantries. So, we're fortunate to have presentations
from three leading scholars who have conducted extensive innovative research in this area.
First, let me introduce Dr.Tamara Dubowitz, who's a senior policy researcher at the RAND
Corporation. She's a social epidemiologist and has done some of the most innovative and
rigorous work on neighborhood food environments, including SES and health disparities, and
the introduction of supermarkets in communities where they lack large food stores. And she'll
be taking on this latter topic today. Our second speaker will be Dr. Joel Gittelsohn,
a professor in international health at the Bloomberg School of Public Health at Johns
Hopkins University. Joel's training is in medical anthropology
and public health nutrition. He's led multiple nutrition and food-based intervention trials
in Native American communities and has done landmark work on interventions in small food
stores in Baltimore, which is his topic today, and the end of session we'll have Dr. Christina
Roberto, Associate Professor of Health Policy in the School of Medicine at the University
of Pennsylvania. She's a clinical psychologist and epidemiologist, and her research is expansive
and innovative in the areas of policies and interventions to promote healthy eating. And
today she'll speak on community interventions and food pantries and within food retail environments.
Unfortunately, Christina cannot join us live for the Q&A after the presentation, so
she will not be able to answer any questions. Now during any of...during the presentations.
Please enter your questions into the question and answer box during the talks. And also
if you could, just indicate if it's for Tamara or Joel or both.
So, with that, I'm really pleased to have the presentations on now.
DR. TAMARA DUBOWITZ: Good afternoon, and thank you so much for coming to hear about what
we've learned about placing supermarkets in food deserts. First, I think it's really important
to understand what we are talking about when we refer to food deserts. Technically, food
deserts have been defined as geographic areas or places with limited access to healthful,
varied foods. Now, the United States Department of Agriculture, or the USDA, definition has
looked at low-income and low access areas. A low-income area has been defined by a poverty
rate of 20 percent or greater. A low access urban area is where 33 percent of the population
lives ten or more miles from the nearest large grocery store. A low access rural area is
where 33 percent of the population lives ten or more miles from the nearest grocery store.
Yet low access to a supermarket is more nuanced than it may seem. Well, 23.5 million people
live in low-income areas that are more than a mile from a supermarket. About 11.5 million
are low-income and live in such areas. There are different numbers of folks who fit into
these categories who have access to vehicles or not.
So, I want to stop here for just a second because this is really important when we're
trying to gauge whether these policies that intend to incentivize supermarkets to locate
in food or supermarket deserts will ultimately change food shopping behaviors or diet. We
know that places with limited food access are characterized by higher levels of racial
segregation and income inequality. But it is unclear whether food access or income
constraints our greater barriers. Supermarkets and large grocery stores have lower prices
than smaller stores, and we know that when they can, low-income households shop where
food prices are lower. We also know that easy access to all food, and not just lack of access
to specific healthy foods may be an important factor in explaining increases in obesity.
And we know that understanding market conditions that contribute to differences in food access
is critical to policy intervention and design. The Healthy Food Financing Initiative or HFFI
is the largest national policy that has sought to address food deserts.
This is a public-private partnership that provides grants and loans to finance the construction
and development of grocery stores and other healthy food retailers in underserved areas.
It's jointly administered at the federal level by USDA, HHS, and the Treasury Department.
And since 2011, this model has leveraged $220 million in federal funding into an estimated
$1 billion in additional private investments, resources, loans, and tax incentives. The
ultimate goal is to attract fresh food retailers to invest in underserved communities. So,
the big question is, has it worked? For now, I'm focusing on studies that have been able
to design and implement natural experiments. There are really only a small handful of studies
that have examined supermarkets before and after. In Leeds and Glasgow in the U.K., there's
a set of studies. One in Leeds that had a pre-post-intervention design. The one in Glasgow used a pre-post
design with a comparison area. Now, both showed that the new stores created switchers or individuals
who switched to now shop at the new store. And while these studies did not report changes
in diet, they did report that the switchers had better psychological health or had changes
in their psychological health. Another study in Philadelphia, Pennsylvania, and in Trenton,
as the comparison, has two sets of pre-store opening data, and so far they found correlates
of diet to be perceived nutrition, environment, perceived food availability, and income. The
study that I am most equipped to talk about is PHRESH or the Pittsburgh Hill Homewood Research
on Neighborhood Change and Health, which at its inception was called the Pittsburgh Hill
Home Research on eating, shopping, and health. The original study started to examine a new
supermarket in the Hill District neighborhood in Pittsburgh, Pennsylvania. Homewood was
the control neighborhood. Now, we collected baseline data in 2011, a full-service supermarket
opened in 2013, and we had follow-up dietary and food purchasing data collected in 2014,
2018, and currently. Some of our main results are published in a 2015 Health Affairs Paper
titled, "Diet and Perceptions Change With Supermarket Introduction in a Food Desert, But Not Because
of Supermarket Use." So, we found that this new full-service supermarket led to some improvements
in local resident's diet, as well as to increase satisfaction with their neighborhood as a
place to live. However, the study found no significant improvements
in resident's fruit and vegetable intake, whole grain intake, weight, or rates of obesity.
And importantly, the improvements in diet and neighborhood satisfaction were not significantly
linked with frequency of shopping at the new supermarket. Both frequent and infrequent
shoppers experienced the same improvements. And just some quick illustrations to show
that there were indeed differences. Here we see that our Hill District neighborhood residents
or the intervention residents did find a net decrease in caloric intake compared with our
control group or our Homewood neighborhood residents. And here you can see a decrease
among our Hill District residents in sugar consumption, compared with a small increase
among our Homewood residents in sugar consumption during the same period. Next, similarly, we
found a net decrease in empty calories among our Hill District or intervention neighborhood
residents compared with our Homewood or comparison neighborhood residents.
While this illustrates that both our intervention and comparison, neighborhood residents decreased
their fruit and vegetable intake between the baseline or prior to the grocery store opening
and after the grocery store opened. Before the supermarket opening, residents in both
neighborhoods thought that healthy foods were not easily accessible, with just 16 percent
of respondents perceiving fruits and vegetables as easily accessible in the Hill District
and just 22 percent reporting the same thing in Homewood in 2011. And here you can see
quite obvious changes that after the supermarket opened, and we asked the exact same question
to the exact same people in 2014. Seventy two percent of Hill District residents reported that
they perceived fruits and vegetables to be easily accessible, while just 27 percent of
our Homewood participants reported the same thing. Importantly, we found pretty large
changes in satisfaction with one's neighborhood as a place to live, with Hill District residents
reporting a pretty large increase between 2011 and 2014 and Homewood residents staying
the same. Now, when we looked at all of these outcomes
and whether they were related to regular supermarket use, the only outcome that was related to
regular use of the supermarket was better-perceived access to healthy foods. It is important to
note that when we looked specifically at SNAP participants, we did see benefits in both
food security and diet after the opening of the full-service supermarket. And these results
are published in a separate analysis in a more recent paper in Health Affairs from August
of 2020. Now, because so many of the changes were not associated with use of the supermarket,
we went back to our data to try and understand whether it could have been improvements in
neighborhood socioeconomic conditions, perhaps related to the new supermarket that may in
fact be responsible for these improvements in resident diet. What we found was that,
in fact, neighborhood socioeconomic conditions may have contributed to these dietary shifts.
However, it was not a simple story. We saw through our pathway analyses that these shifts
seemed to operate differently for renters versus homeowners.
I also want to note here that we collected data again in 2018, which was four years after
our initial follow-up data collection to understand whether these shifts held. Now our preliminary
and unpublished results suggest that, in fact, the dietary shifts did not hold. However,
the neighborhood satisfaction and the perceived access to healthy foods did seem to hold.
Please stay tuned for more results as we are getting ready to submit them for publication.
I do want to note here that there's been a lot of other work, not necessarily based on
natural experiments. But based on secondary data analyses that have shown that household
resources are, in fact, a stronger predictor of dietary quality than geographic access
to healthy food options. Some of this work has been done by Markovsky and Snyder, who
used a national sample of proprietary data on food shopping behavior, and they found
that households in low income and low supermarket access census tracts may travel farther to
shop for food, but don't necessarily change their purchasing habits because of distance.
Similarly, Ver Ploeg, Wilde, and colleagues have analyzed food apps data and have found
similar results. So, while there's been a good amount of research centered around food
deserts, supermarkets, and diet, only a few studies have been able to capitalize on rigorous,
scientific design to examine the impact of eliminating a food desert to investigate
whether the opening of a supermarket changes food purchasing behaviors or diet of residents,
and there have been mixed results on whether diet changes. We have also found
that people don't necessarily go to the nearest supermarket. That is, factors other than proximity
matter. We've also found that other neighborhood characteristics matter. We've found that the
pathways are potentially very complex. So given all of this, what are our conclusions
and next steps? Well, first I ask whether we're too focused on diet as an outcome, that
is perhaps there are other outcomes that are just as and if not more important. Secondly,
supermarkets do not open in isolation. There are other neighborhood conditions that are
likely changing, including housing, transportation, general neighborhood aesthetics, and socioeconomic
conditions. There are likely other neighborhood factors and characteristics that are tied
with supermarkets' openings. There are a spectrum of possibilities regarding supermarket quality,
and this is actually very important and also very hard to measure and to quantify. What
I've learned from all of this might be something we already know, and that is really there
don't seem to be magic bullet solutions and relationships, and pathways are part of the
processes. I think it's really important to try and consider
all of this and look at it within all of these different domains of complexity. Thank you so much.
DR. JOEL GITTELSOHN: I'm really pleased to be here today to speak on this topic, Improving the Small
Food Source Environment, Overview and Future Directions. In this talk, I'm going to provide
a little bit of background, talk a bit about what we've learned in terms of interventions
and small food sources, address some of the key challenges and gaps and talk a bit about
future directions. First of all, some introductions. When I refer to small food sources, I'm talking
about small retail food sources, such as corner stores, bodegas, convenience stores, and the
like. I'm also speaking about prepared food sources, such as carryout restaurants and other
kinds of independently owned restaurants. What I'm not talking about are chain fast
food restaurants. I'm not speaking about supermarkets or other large grocery stores. So let's start
off by taking a picture of a particular context. This is a map of the city of Baltimore, and
you can see the city is highlighted in several different ways. One of the ways that we focused
on is in terms of identification of healthy food priority areas, formerly known as food
deserts. About 25 percent of the residents of Baltimore City live in healthy food priority
areas where there is low healthy food availability, a low median household income, limited personal
vehicle access, and a greater distance to a supermarket. And in this particular setting
of Baltimore City, despite the fact of low access to larger food sources such as supermarkets,
there is a heavy access and use of small corner stores, small grocery stores and carryout
restaurants. As depicted in this picture, you can see all the different colored dots
represent all the small, different types of small food sources. And in this particular
setting, and in many other settings, there appear to be associations between the presence
of these types of food sources, and food insecurity and obesity.
And you can see this map shows essentially an overlap between areas of high food insecurity
in obesity and the areas that you saw before that were healthy food priority areas. So
then why do we think working in small food source interventions is a good idea? For several
different reasons. First of all, they're ubiquitous. These small food sources are already in low income
disadvantaged communities, and so therefore there's no need to build entirely new stores
and supermarkets. They're already there. They're also very regularly used. They tend to be
open five to seven days a week, 12 or more hours a day, and many residents report using
these small food sources on a daily basis. Some two or three times a day. Also, much
of the high fat, high sugar, high sodium foods that people consume come from these sources.
So this represents an opportunity to address the the root of some of the dietary issues
that we are considering for these settings. Prepared food sources also account as for
more than 50 percent of calories in some of these settings.
And so therefore, that's part of the reason we selected prepared food sources, as well
as retail food sources as part of the topic of this particular presentation. Another reason
to work with small food sources may not be so apparent immediately, but the owners of
these food sources need to have good relationships with community members. They need to try to
respond to the needs of community members in order to stay in business. Well, what have
some of the interventions looked like to improve small food sources? There's essentially been
four different approaches that have been used, demand type interventions, supply type interventions,
infrastructure, and training. Demand interventions are ones that focus on communication with
the consumers or the customers of these small food sources. So point of purchase promotions
such as shelf labeling, posters, flyers, menu labeling, and prepared food sources and so
forth, as well as interactive activities, including taste tests. Then, we have supply
types of interventions which act to increase or decrease the availability of healthy or
less healthy foods, and perhaps making them a little bit easier to locate within the store.
We can talk about infrastructural changes, such as the provision of produce refrigerators,
and we can talk about training of small store owners and managers introducing methods of
how to make healthier food selections, how to source those foods, how to store them safely,
how to promote these foods to their customers. And most of the work that has taken place
in the past in these small food sources has focused on combining two or more of these
approaches. About a decade ago, we did a couple of systematic reviews. The first you can see
is listed is for small food stores, so for retail food stores. And the second is for
prepared food sources. And I'm going to be providing a little bit of summary of some
of the main findings of those studies. I've also have updated the information a bit by
some of the more recent reviews, such as the one by Pinard listed at the bottom. And if
you look at the more recent intervention approaches in small food stores, in addition to what
I've described before, you can see that a number of the interventions more recently
have focused on strategies such as incorporating social marketing approaches.
So audience segmentation and targeting approaches, behavioral, economic or nudging strategies.
There's been increased interest and use of different types of pricing strategies to
encourage the selection of healthier foods, increased interest in emphasis on store conversions
or larger types of infrastructure changes beyond just introducing a refrigerator, and
an emphasis on community partnerships on strengthening the relationships between store owners and
community members. What have these different studies found over the years? Well, I think
there's been a lot of promising findings. First of all, in general, almost all of these
interventions of any type have shown increases in the stocking of the promoted foods or beverages.
When it's been measured, there's been a impact on sales of these foods typically found, and
there's been an impact seen in customer purchasing of these items. When it's been measured, we
see some dietary changes, and in the very few times it's been assessed, we do see some
positive health outcomes occasionally with these interventions.
But I have to emphasize that measurement of health outcomes in small food source interventions
is actually quite rare. So quite a few challenges remain for small food source interventions,
and I'd like to list them out and talk a little bit about how we and others have addressed
them. So I think one of the major challenges I hear about is how to scale up and sustain
small food source interventions. Related to this is a lack of attention to suppliers of
these small food sources. A challenge that remains is that level of community engagement.
Although there are reasons for this engagement to take place, it can vary dramatically. There
can be a lack of technology in stores, for example, for inventory management to track
sales and so forth and lack of rigorous evaluations, taking it all the way to health outcomes or
even sometimes to dietary outcomes. It's just not there in a lot of the studies, even nowadays,
that are being conducted. So these are some of the challenges. I wanted to address a few
of these a little more closely and talk about, first of all, this challenge of scaling up.
In order to scale up the the sort of numerous small food source interventions that have
been conducted, we need to address what I call the supplier or the distribution problem
that exists for small, independent food sources. And in Baltimore City, what we found is that
it's a very different picture in terms of the distribution modality if you are a bag
of potato chips than if you are a bag of groceries. If you are a bag of potato chips, there's
a very strong supply demand loop between wholesalers or distributors and the corner stores. Those
foods are delivered to the corner stores. This creates a strong sales of those foods.
There's a perceived strong demand, a very, very robust feedback loop. This is strengthened
by formal and informal agreements between wholesalers and distributors, and the corner
stores, such as free delivery, incentives, reduced cost for items, provision of freezers
or refrigerators or display racks, that sort of thing. The situation is almost entirely
the reverse. If you are a bag of groceries or produce in a corner store setting, the
supply demand feedback loop is very weak, and in fact, for the most part, corner store
owners have to go get it themselves. They have to drive to the wholesaler or distributor
and pick up these foods. There is costly or no delivery available, and where there is
delivery, it often requires a high level of minimum purchase to make it worthwhile. So
very much disadvantaged in terms of access to healthier foods for small retail food sources,
at least in terms of corner stores. We've actually been trying to address this challenge
in Baltimore City through the development of a mobile app we call BUD, which stands
for Baltimore Urban Food Distribution app. And the goal of BUD is to develop an affordable
solution for corner stores to access and have delivered healthier foods and beverages, ultimately
leading to improved access to locally sourced healthier foods and a more resilient food
system. And essentially, what the app does is it connects corner stores with local producers
and wholesalers. Wholesalers and producers can set up reduced cost product, healthier
products that are reduced costs through collective purchasing.
Corner owners can sign up for and collectively purchase a BuddyUp! deal so they can get
even a small amount of produce or other healthier foods for a relatively inexpensive price and
have it delivered to their store. So this is in process, and this is a type of intervention
strategy to address the supply, the distribution and supplier challenge. Some follow up questions
that we are faced with are things like how to handle distribution costs effectively and
essentially in terms of keeping the costs down low. The fact that in fact most corner
stores are not interested in just stocking healthy foods, that in order to make the use
of the app available and desirable to them, we probably have to make the app stock other
foods, possibly unhealthy foods. Another challenge or follow up that we need to consider is the
fact that we're talking about prepared food sources as well as retail food sources. So
we need to see if these supplier related challenges are similar for prepared food sources. So
there's some further work that needs to be done in this area.
A second gap relates to this whole issue of sustainability, which in some ways is overlapping
with the concept of profitability from the store perspective, as well as public health
benefits. And any solution or program or policy for sustainable change in small food sources
has to be tied to profitability in my view. Much intervention work overlooks this issue
of sustainability, and an approach that we've used or one strategy is to take a system science
view of things. An example of this is at one time Baltimore was considering implementation
of the Staple Foods Ordinance. And so, we worked with them to develop a systems dynamic model
to simulate the inclusion of different foods and beverages in different amounts in a proposed
ordinance, and use the systems dynamic model to recommend modifications to the ordinance.
This is a visual that was created through a group model building process of the flow
of different things. You can see that there's a ordinance characteristics, there's supply
characteristics, there's consumer characteristics. This is a interface that shows some of the
slider bars that have been done to modify some of the different parameters. And we tested
four different simulation: a basic SNAP simulation, a SNAP depth of stock simulation, the Minneapolis
Staple Foods Ordinance requirements, and WIC requirements. And these are some of the details
of the simulation in terms of required minimum stock. Comparatively, the level of enforcement
that we perceive to be present or required. And what we're able to output in this case,
in this particular image is what would be the profits associated with each of these
different simulations of a different type of a staple foods ordinance. And you can see
that certain of these simulations or revealed more profitable types of outcomes in terms
of the store perspective than others. So, the snap depth of stock simulation showed that,
in fact, it was very unprofitable to implement that particular policy versus the Minneapolis
Staple Foods Ordinance would actually provide a small profit.
There are a lot of different outputs that are possible with this type of simulation,
and we're currently writing and publishing on this work.
DR. JOEL GITTTELSOHN: Some follow up questions, do system science methods like group model
building replace more traditional formative research and community engagement approaches?
And, of course, how best to combine system science approaches with other types of strategies
for planning. Finally, I want to just bring up this issue that of multilevel, multicomponent
interventions as a particular gap or area of work. When I speak of multilevel, multicomponent
interventions, I talk about combining different intervention strategies in a thoughtful way.
And so we need to think about complementarity of the different interventions, the interventions
being referential to each other. So, for example, a school intervention refers to or builds
on a retail food store intervention. They need to be mutually supportive with one building
on another and supporting another. So, if you're going to work with small food sources,
you should need to work with suppliers. You need to work with and effect demand by customers
as an example, and this is just a visual image of the B’More Healthy Communities for Kids
intervention conceptual framework showing the different components of this multilevel
intervention, which was implemented successfully in Baltimore City.
And giving some idea about how the different levels or components of the intervention were
reinforced and complemented each other through the use of agent based modeling through social
media, through the stocking of healthier foods, and so forth. So, some of the follow up questions
and there are many beyond these, what are the community level effects of multilevel
interventions, not just the effects that would be measured at an individual level? How best
to measure these effects? How to sustain these kinds of complex programs and initiatives?
These are all things that we need to address in future work. So, in summary, small food
sources, both retail and prepared, are ubiquitous in low income communities. They tend to be
regularly used and are partially responsible, at least for the unhealthy food access, diet
patterns, and diet related chronic disease. Interventions in these settings typically
target supply, demand, infrastructure, training of staff or some combination of these strategies,
and they've had positive impacts in the literature on stocking, sales, revenues, purchasing, and
consumption of healthier foods. Small food sources are, of course, are part
of larger food systems which will influence supply and distribution issues, and figuring
out interventions which can address these multiple levels are are important. System
science offers one set of tools that can help us to better understand and plan for cost
effective, sustainable interventions. And related to all of this, multilevel interventions,
which incorporate small food sources, show great promise in achieving some of these objectives.
I want to thank you for your attention today, and please feel free to contact me for future
questions or requests for information. Thank you.
DR. CHRISTINA ROBERTO: Hi, everyone. My name is Christina Roberto, and I'm delighted to be
able to participate in this workshop today. The title of my talk is promoting healthy
choices in food pantries. And in the short time we have together, what I'm going to try
to do is cover what we know about interventions and food pantries to promote healthy eating.
I'll then share some insights from psychology and behavioral economics that can be used
to inform the design of food pantry interventions. And then I'll tell you a little bit about
some work we're doing in my lab, the PEACH lab, on a behavioral economics informed randomized
controlled trial to promote healthy choices in food pantries. To address what is known
on food pantry based interventions to promote healthy choices, there's a recent literature
review by on colleagues and Public Health Nutrition from 2019. And I went through that
review carefully to try to identify studies to present today. They had identified seven
randomized controlled trials in seven pre-post studies, and I thought in our short time together,
we would focus on the randomized controlled trials because those tell us the most in terms
of causal impacts of these interventions. Fortunately, in this workshop, we have folks
like Hilary Seligman and Caitlin Caspi, who are really expert in this area and doing very
innovative work, and I'm sure they'll share some of their research as well. So, if we
drill down into the RCTs, you actually find that some of them are multiple papers about
one intervention. One of them, it wasn't clear to me that the outcomes related to a different
health or behavioral outcomes that weren't meaningful for our conversation around food insecurity
and healthy choices. So, I won't be discussing that one. So, I'm just going to talk about
the first three on your screen there. And I do want to put an asterisk on the Wilson
one. Brian one is the last author on that, and a lot of his work has been discredited
in the last several years, but he is not the first author, so I thought I would share it
with the asterisk that it's a study that would need to be replicated. So, this first study
that I'll share is a test of the Food Stamp Nutrition Education Program that was offered
at community sites, including food pantries, was also available to clients in their home.
And this was a basic education program that covered five different topics. They included,
MyPyramid discussion around food groups, food safety, shopping behaviors, and research
management involvement. So, talking about things like shopping on a budget. And in the
program, 30 to 60 minute lessons were provided and the lessons were tailored. So, in this
study, they randomized women to either that food study nutrition education program or
to a control group. And I just want to highlight a couple of the methods, concerns, and the
randomization. So, clients that were arriving together were randomized to the same group,
but that wasn't stratified, and so it likely led to these group sizing balances. And as
far as I can tell, I don't think they were clustering standard errors to account for
people in the same group. So, these are just some limitations to this RCT. In terms of
the actual study design, one lesson was provided to both the Food Stamp Nutrition Education
group and the control group. And then that Food Stamp Nutrition Education group received
four additional lessons, and the control group received lessons after the study was over.
What they found is that the intervention significantly increased food security by point 0.37 points
on a 6.0 scale compared to the control group. I'll mention this suggests some promising
data on the basic nutrition education to improve food security and a food pantry and other
settings. So, although nutrition education can be very useful and is, you know, an important
component of many interventions, I think the field is recognized over many decades that
education is not going to be sufficient. And so I'll talk about this intervention, the
Freshplace food pantry intervention, which really tries to go beyond education. And this
intervention is designed to address the root causes of poverty, and it was developed by
three community agencies and in collaboration with the university to do the evaluation.
Now, a choice pantry is one where you can go and select the food that you want, as opposed
to a lot of other pantries where food might be prepackaged in bags, and you don't have
much choice. The goal of this intervention was to work
with clients to help them set small, achievable behavior change goals, and I'll describe a
little bit more about what it involved. So, it included monthly meetings with a project
manager to receive motivational interviewing using goal setting and provide social support,
and then it had targeted referrals to community services like SNAP and Energy Assistance.
And finally, there were tailored offerings. So, a six week cooking classes, nutrition
education, but also access to computers for job searches, depending on different needs
of different clients. In this randomized trial, they randomized adults to either the Freshplace
intervention I just described or a control which were food pantries where bags of food
were received. And you can see the ns' on your screen. And then they did quarterly follow
ups for 12 months. At baseline, about half the sample reported very low food security.
The results from this study found that the Freshplace group was half as likely as the
control group to experience very low food security.
In addition, those in the Freshplace group gained 4.1 points in self-sufficiency across
all the different time points when compared to control, and the households with the lower
monthly incomes benefited more from it. And finally, the Freshplace group significantly
increased their fruit and vegetable intake compared to the control, and that amounted
to two additional points on the measure they were using, or one additional serving per
day. So, they are really some promising results from this intervention. This next study took
place at a food pantry in New York. And when the researchers were visiting the pantry,
they noticed there was a dessert table that had desserts like frosted sheet cakes, brownies,
cookies, pies, assorted pastries. But they also noticed that one of the dessert items
was a protein bar, and relative to the other items that seemed healthier. And so they wanted
to encourage people to select the protein bar. So, the intervention manipulated two
things, they manipulated whether the protein bar was displayed at the front of the table
or at the back of the table, and then they also manipulated the packaging it was in.
It was either in its original packaging in a box or in a clear bag without the original
packaging. OK. So, this study took place over five successive Tuesdays between October and
November, and they alternated treatment by days. There were 443 people who participated
because that was the number of the clients attending the food pantry on those days and
they would stop data collection if any of the dessert products ran out. So, let's take
a look at the first set of results from this study. On the y axis are the proportion of
people that actually chose the protein bar, and you can see there's an advantage for putting
it in the front, though it is not statistically significant, and you can see there's an advantage
for keeping it in its original boxed packaging, though again, it's not statistically significant.
When they break down by the four different cells, the only one that emerges as statistically
significant with a higher proportion of people taking the bar is when it's placed in the
front and in the original boxed packaging. OK, so, I started off with this nice systematic
review that looked like it had a ton of studies in it. But once you really dug into the ones
where we have, you know, good randomized, at least the ones where we have randomized
controlled data at this point where we can feel more certain about what we know, you
realize that it's really limited and a lot more research needs to be done. There are
tons of gaps, and I feel that, you know, the field is really wide open. The pre-post studies
that I didn't get into, I think, have some really innovative ideas, and I think the next
phase for those are going to be moving into randomized controlled trials. And my last
part of the talk I'm going to share a food pantry experiment that we're doing in my lab
that's funded by NIH NCI and I don't have results for you, but I will share sort of
how we design the intervention and what the research design looks like. So, I just want
to acknowledge my wonderful research team and community partners. These are the collaborators
on the study, and we're working with a community based organization called the Jewish Federation
of Greater Philadelphia, and Brian Gralnick and Deidre Mulligan are two points of contact
there, and they've just been absolutely amazing partners and we call this study the Mitzvah Market study.
We designed the study really thinking about
principles from psychology and behavioral economics. So, there's a fundamental insight
in psychology that's now, you know, really well known where we think that there are kind
of two systems of thought in how people make judgments and decisions. So, a good way to
think about this is there's a kind of system one that's fast and automatic, effortless
we make a lot of judgments based on associations and emotions when we're in a system one kind
of mindset. Sometimes though, we're engaging system two, and that's when we're doing the
kind of thinking that's slow, controlled and effectual. And so most of our food decisions
and choices that we're making, we're often in system one at the grocery store, you know,
at a restaurant just kind of making these decisions quickly as opposed to, you know,
picking up a cereal box, turning around and carefully studying the nutrition facts label
that'd be engaging kind of system through reasoning. So, a lot of what I'll present
has been, of course, widely popularized by the book Nudge, which makes the case that
choice context really matters, and there's, you know, been decades of psychological research
on this, and the idea of "Nudge" is that they don't abridge freedom.
So, they're not, you know, they're not bands, they're not taxes, they don't change price
incentives, they're trying to redesign the choice experience to encourage healthier choices
and choices that are in people's self-interest and without incurring that sort of additional
penalties. So, for the study that I'm going to describe to you, we had a really unique
opportunity here to change Mitzvah Market's online ordering system. So, this is a choice
pantry that has an online ordering system where people place orders about once a month,
and you can see a picture of it on your screen there. So, for this study, we took this opportunity
to redesign the online interface using insights from psychology and behavioral economics.
So, for example, one foundational insight is we're influenced by the placement of things
and cues that we see. So, based on some work of that Anne Thorndyke has done demonstrating
that traffic light food labeling increased the purchase of healthy green items in a hospital
cafeteria and decreased the purchase of less healthy red items.
We've also adopted a traffic light labeling system. In that same study, that Anna and colleagues
did show that making water more available in the cafeteria also boosted sales. So, we're
also using a choice architecture intervention where we display the healthiest option at
the top of a web page within a certain food isle, and I'll show you what some of this looks
like in a moment. The next insight we applied was the idea that people are highly prone
to stick with default options. There's a very famous organ donation study that I think most
people are familiar with at this point that shows that when you have to opt out, so you're
defaulted to be an organ donor in those countries where you're defaulted to be an
organ donor, they have much higher rates of organ donation. And so we've applied this
to our online store by pre-populating shopping baskets with healthy, preferred items. So,
for example, when you log in, brown rice might already be defaulted into your shopping cart,
and you can kick it out if you don't want it.
But it's a nudge to try to encourage you to order the brown rice. And Jamie Coutinho has
some really nice work using this kind of pre-populated shopping basket, which is what we drew from
to create that intervention. The other insight is the notion that other people signal what
to do and what is appropriate. So, we tend to be very influenced by other people's actions
and social norms. And so what we ended up doing in our store is displaying messages
highlighting commonly selected healthy items. So, for example, you know, we might say that
in any given month, bananas are the most popular fruit being selected in the pantry, and that's
data driven, that's based on the actual data from the pantry. And finally, our last intervention
is called healthy swaps, where if you click on an item, let's say white rice, for example,
a pop up like this would come up, nudging you to switch to brown rice. And the pantry
before we even start working with them has a point system where they were discounting
some of the healthier items. So, this is also highlighting the fact that
it's fewer points, it's more economical to pick the brown rice relative to the white
rice. So, here's a picture from our online store when you first log into the store, you
can see that social norms messaging at the top. This example says "Flavorful, diced canned
tomatoes are very popular with Mitzvah Market clients in July. Try some today," to try to
really highlight and normalize what most people are doing in terms of their fruit vegetable
purchases. And then there's a little description for people for how they're going to interpret
those different traffic light symbols that we're using, right. So, you can see that green,
yellow, red there. You'll note that we have the whole store done in both Russian and English
because there's a very large Russian immigrant population that goes to this pantry.
Then you can see on this next screen, here's an example of what it looks like as people
are shopping. You can see the picture of one of the aisles. This is a green aisle with
the brown rice labeled green at the top. And then towards the bottom, you get items
like white rice, which are labeled yellow towards the bottom and working in conjunction
with the traffic lights. And I just want to highlight the SWAP system, Supporting Wellness
at Pantries, developed by Katie Martin and others, which is again, using this kind of
traffic light technique, but what's really great about it is it's actually a way that
food pantries can get a sense of the stock that they're, what they're offering in their
pantries and how they're stocking their pantries. So, regular green traffic lights are used
as they're ordering food from food banks to help make sure they have a good balance
of different options for clients. So I want to end just by sharing a little bit about
the research design we're using for our NIH R01 funded by NCI.
We're recruiting 500 participants at the pantry who are able to use the touchscreen ordering
system, which is the majority of people that go there. And we're examining how our intervention
in the suite of behavioral economic tools is going to influence what people select using
that data that comes from the online ordering system. We're looking at how it impacts their
fruit and vegetable intake, both by self-report and something called the Veggie meter, which
is able to detect levels of beta carotene, for example, in the skin. And we're measuring
weight and blood pressure. Our initial study design was to collect this information at
baseline three months after the intervention and then 12 months after the intervention
had started. Now we like everyone who've been really impacted by COVID-19, and so in the
new version of the study, we're only going to be able to look at three month outcomes.
But I think we're still really excited to see how this impacts shorter term behavior
and health. And the hope of all this work is that we can inform low cost food pantry
interventions. But I also think there are some interesting
applications for online ordering platforms in general, which are becoming more and more
popular, particularly in light of the COVID-19 pandemic. So I want to thank you all very
much for your time. Please come visit us online at the Peach Lab and my contact information
is on the screen. And thanks for the opportunity to be able to share this work at this exciting
workshop.
DR. MARY STORY: So, welcome back. Thank you both Tamara and Joel for such engaging
presentations. And we have several questions. And Joel was having some computer connection
problems, so Tamara you get to answer all the questions.
DR. TAMARA DUBOWITZ: Great I'll answer all the questions.
DR. MARY STORY: So Joel will come back on, but in the meantime, we have several questions
and we have about 10 minutes left for questions. And the first question for you Tamara was:
can you summarize your understanding from your work and others of the differences in
effects of opening new supermarkets and food deserts on different subgroups? You mentioned
SNAP participants, but also socioeconomic groups.
DR. TAMARA DUBOWITZ: Got it, so that's a pretty large question in terms of just summarizing the effect of
new supermarkets on all different subgroups. I think I could probably speak best to most
of the research that's been done has looked at opening supermarkets in food deserts that
are normally or by definition, lower income neighborhoods with lower income residents.
So it in terms of subgroups, we can look at different racial/ethnic groups. I don't think
that very much work has looked at all of the different subgroups and how this might impact
groups differentially. Our own work has been able to look at, in particular at SNAP participants.
Because in the residents we've been following, and I'll say that the way that we were, recruited
our cohort was done by recruiting a geographically random sample from our intervention neighborhood
and from a controlled neighborhood. Both of these neighborhoods are low income and predominantly
Black. So, our study has really focused on Black neighborhoods and the subgroup that
we're most familiar with are SNAP participants. It does seem that snap participants in particular
did see more positive results than in our intervention neighborhoods than snap participants
in our comparison neighborhood. So that's probably the subgroup that I can speak to
most easily. I'll stop there so we can answer some other questions.
DR. MARY STORY: OK, so on your last slide, Tamara, you asked, is research too focused on diet
as an outcome. What, could you expand on that, like, what other outcomes do you think should
be answered?
DR. TAMARA DUBOWITZ: Sure, and you know, I kind of wish that Joel was here also, but Mary, I think that
you're so well equipped to talk to this as well. So even though I think that one of the
huge questions here is how do we create shifts in diet? And I think that diet has been one
of the main outcomes that my own research has focused on. One of the things that I think
we've learned is that diet is part of a much more complicated picture, and I think most
people probably know this of many other (a), health outcomes. But (b), when we're talking
about things like supermarkets, that is one really important neighborhood change in a
food, it's really changing that quote unquote, "food environment" is really important in
these neighborhoods. But concurrently, there are other developments that are happening.
Housing improvement, transportation improvements, green space improvements, all kinds of other
sort of aesthetic things that might be happening that yes, they might be impacting diet, but
they might be impacting other psychological distress, perceived stress, hope, satisfaction
with one's neighborhood as a place to live. And I think it's very difficult, but also
really important to try and isolate these different pathways and to try and understand
how and that they all actually do relate to one another. So when I, although a lot of
our research has focused on diet as a main outcome, it's not, it's become much less obvious
to us that diet is the most important outcome that we should be looking at when all of these
other health outcomes are related to diet and all of these other neighborhood changes
are related to the food environment.
DR. MARY STORY: Yeah, I was wondering, you know, Healthy Food Finance Initiative is wonderful,
and it's brought so many grocery stores into communities that really need them. But a supermarket
and grocery store, they have well, they have healthy food, they also bring in, they also
have a lot of unhealthy foods as well. And so, I know the Healthy Food Financing Initiative
doesn't put any parameters on, you know, they just want to bring the grocery store or supermarket
in. They're not required to have pricing strategies or other in-store strategies. So I was wondering
like, you didn't find any significant differences in fruits and vegetables or whole grains.
And I'm wondering if you think like there's other, the factors that you mentioned, I think
are really important. But what about requiring or having more pricing strategies, which we
know I think would really work if you could incentivize and have healthier or having incentivizing
the healthy foods or else the promotional practices and marketing practices and then
even looking at like what Joel was talking about with the distribution issues that changing
the trade promotion practices that are used by manufacturers and distributors.
If those other factors, interventions within the grocery store, along with bringing in
a small food store or a supermarket would really be kind of help shift them the diet
quality.
DR. TAMARA DUBOWITZ: Yeah. Welcome back Joel.
DR. JOEL GITTELSOHN: Thank you. I hope I'm really back.
DR. TAMARA DUBOWITZ: Yeah, you're back just in time to answer all the rest of the questions.
DR. JOEL GITTELSOHL: OK, hit me.
DR. TAMARA DUBOWITZ: I'll answer what your question quickly, Mary, before I know that there's probably
a lot of questions for Joel as well. But in terms of parameters for HSFI or the Healthy
Food Financing Initiative and what kinds of grocery stores end up locating in neighborhoods,
it's really difficult. And one of the issues is that this is supposed to be an incentive
to get grocers to locate in places where typically they don't want to locate. They don't want
to locate in these areas in supermarket deserts because they don't think that they can make
money. So if HSFI started saying, "Well, you know, you can only locate if you're willing
to only make sure that your healthy foods are displayed in the most prominent areas
and you limit your junk food, which we know you make more money on." The practicality of
this probably wouldn't work. But then on the other hand, we're seeing supermarkets located
in food deserts that are providing just as many unhealthy foods as they are healthy foods.
I'll say one thing about this, and that is, although I think that this is a question of
opening supermarkets and allowing for the access of healthy foods, it's much more than
that. It's opening up a business that is creating
life in a community and is an economic anchor. And I think if I were to make parameters, which
I don't think that they can do, I would make parameters that said, this needs to be a grocery
store that works with the community and is responsive to community needs and involves
the community in as many ways, shapes, and forms that it possibly can. And I would actually
focus less on food and more on creating a space that residents feel hopeful and happy
about. And that's a little bit radical when we're talking about diet and dietary shifts,
I think. Or maybe not radical, but maybe doesn't make total sense. But that's what I've learned
from the past decade of our research.
DR. MARY STORY: And some of the other stories that I've heard, it's like when there's a
food co-op that's owned by members of that community, it really does become a community
place as well as just a place they can shop. OK, well, I'm going to jump into other
questions because we only have a few minutes left. Joel, a couple of people asked that your
BUD app sounds absolutely amazing. Can you please share more about how you decided to
use this specific app, and where can they find information about BUDDY and the eligibility
requirements?
DR. JOEL GITTELSOHN: So the whole BUD experience and the reason for the BUDexperience and app is that
what we found was that suppliers, well, it was really easy for a bag of potato chips
to make it to a corner store, but it was very difficult for an apple to make it to a corner
store. And this related to all sorts of incentivization and really robust feedback loop for junk
food and deliveries of junk food, free delivery, and so forth, but not anything like that for
healthier foods, such as fresh produce. So we basically, we found that most of the corner
store owners in Baltimore at least have to go out and go get anything healthy they want
to put in their stores as opposed to having it delivered to them. And it's not worth it
for them. And I think this is a really unexplored area. So the Bud app was, the idea of the
BUD app was developed to address this distribution and supply problem for corner stores. It's
sort of a lot of the work that I've done previously has been multilevel, multi-component, but
this is really addressing one particular piece of this issue.
We received an R34 to develop the app, so we're in the process of developing the app.
We're just about to begin piloting it in just a few stores before we do a larger pilot in
about 20 stores. And yeah, I mean, I think it's a really interesting idea. It's my first
time developing software. I'm not directly writing of the software myself obviously,
but it's a huge challenge and involves lots of usability testing and so forth. I'm very
interested in collaborating with other people who are interested in expanding this model
in the future. Right now, our funding is just to do this work in Baltimore as more of a
feasibility trial.
DR. MARY STORY: You know what, I just got a message saying, I need to wrap this up. I'm really
sorry, we had several questions and I'm sorry we couldn't get to them all. But I really
want to thank both of you again for these amazing presentations, and we appreciate the
questions from the audience. Next, we're going to head into our Networking Break for you
to engage with your fellow attendees on the topics just discussed. You can visit the Networking
Lounge and join that conversation. And at 4:55, you'll need to return to the auditorium
for the final presentation of the day which highlights gaps and opportunities to address
the neighborhood food environment. Thank you very much, and it was a pleasure to moderate
this session.
DR. TAMARA DUBOWITZ: Thank you so much.
DR. KAREN GLANZ: Welcome back, everyone. Hopefully, you've had a chance to have some discussions
during the networking break, or at least you had a chance to maybe get up off your seat
and stand up. We like to take activity breaks in some meetings, but everybody's on their
own with this virtual workshop. I'm delighted to introduce to you our final speaker for
the day, Dr. Kristen Cooksey-Stowers from the University of Connecticut. She's going to
speak on gaps and opportunities to address the neighborhood food environment, including
emerging work from the field and some really interesting work that she herself has been
leading. So I'll turn it over to Kristen and again encourage you to put your questions
in the chat box.
DR. KRISTEN COOKSEY: Good afternoon, everyone. I hope you have enjoyed day two of this workshop
on the State of the Science on the Neighborhood Food Environment, Health Impacts, and Interventions.
Thank you to NIH and the organizers for the opportunity to join today's session.
Today, I will be discussing the topic of Gaps and Opportunities in the Neighborhood Food
Environment: Strategies to Advance Health Equity. So, what does health equity actually
mean? Braveman and colleagues define it as the principle underlying a commitment to reduce
and ultimately eliminate disparities in health and its determinants, including social determinants.
And we have this call to action. If an effort does not address poverty, discrimination or
their health-damaging consequences for groups of people who have historically been excluded
or marginalized, it's probably not a health equity effort. We also have the critical first
do no harm principle, which I think this quote nicely captures. That without careful design
and implementation, policy systems and environmental strategies may inadvertently widen health
disparities. This idea was vitally important prior to the
COVID-19 and structural racism pandemics, what experts are referring to as the twin
pandemics, and it is even more critical moving forward. Here is an adaptation of the World
Health Organization's framework for how to alleviate health inequities. As you see, it
highlights policy and governance as key structural determinants to leverage and keep in mind.
It also points out how other determinants of equity in society, like gender, racism,
income and even citizenship status shape intermediary determinants of health like, but not limited
to the focus of today's workshop, neighborhood food environments, and ultimately impact health
inequities downstream. In other words, health and well-being is determined by social equity.
Notably, this is a simplified version of the model and doesn't show all of the potential
interrelationships. Instead, we're focusing on basic pathways and food availability here.
Reflecting on this framework, the design implementation of equity focused neighborhood food environment
interventions should account for upstream structural determinants of health and thus
be more effective in addressing major long term impacts on health inequities downstream.
The first point that I want to leave you with today is that intersecting social determinants
of health matter. There have been cumulative impacts of racism in food and policing amid
COVID-19. Much of my research has focused on how upstream factors like policy, place
and race shape inequitable neighborhood food environments, particularly food swamps, where
unhealthy food retailers inundate healthier alternatives. So this research prior to COVID-19,
I was able to engage in national discourse around evidence based approaches to identifying
food areas. For people of color, including but not limited to Black Americans, structural
racism across systems has posed cumulative barriers to optimal health and well-being
in light of COVID-19. The same communities are faced with too many unhealthy food retailers,
over policing, too few job opportunities and medical resources to cope with the pandemic.
And as we know, individuals with pre-existing conditions like diabetes and hypertension
are among those with heightened COVID-19 risk. People of color were more likely to have conditions
going into the pandemic. We also know that people of color are more likely to be food
insecure and live in inequitable neighborhood food swamp and food desert environments prior
to COVID-19. Living in a food swamp area where fast food and junk food are the most successful
food options is a serious structural challenge, especially in the middle of a global pandemic.
One of our recent studies using a national sample of adults in the US showed that Black
Americans were most likely to report that they reside in a food swamp. Earlier in the
pandemic, grocery stores remain open while smaller food retailers were closed, but we
know there were inequities in access to supermarket and grocery store access prior to the pandemic.
Recent CDC data show that ethnic disparities in COVID-19 hospitalizations, deaths and in
vaccination rates persist. Judging from pre-pandemic data on disparities in traffic stops, arrests
and police use of force, we know there is racism in the U.S. policing system.
The civil unrest across the world in response to the murders of George Floyd and Breonna
Taylor led to devastated food stores in many neighborhoods. Future interventions targeting
food environment should account for how intersecting policies impact the lived experiences of Black
Americans and other marginalized groups. This 2020 article by Leon and colleagues outlines
how healthy food retail has changed during the COVID-19 pandemic. The authors write, "The
pandemic has placed unprecedented strain on the U.S. food system and changed the way food
is distributed, sold, obtained and prepared and consumed." And though not the primary focus
of the publication, they also comment on the relevance of structural racism to neighborhood
food environment research. They write, "Many communities have also been impacted by uprisings
against police brutality and structural racism that may have damaged, disrupted or destroyed
food retail outlets and other infrastructure, creating even more food access issues."
For the next part of my presentation, I will go through the following domains to identify
some research gaps and opportunities for neighborhood food environment research to advance health
equity amid the twin pandemics, including new grocery stores, existing food retailers,
online grocery shopping, food banks and food pantries, and community kitchens. Research
on the grocery stores can generally be characterized by majority pre/post quasi experiments, limited
randomized controlled trials, limited use of community based and qualitative research
methods. Still, grocery stores have been linked with improvements in perceived food access,
neighborhood satisfaction, psychological health outcomes and food security among SNAP participants.
Studies show no impact on overall diet. And studies show mixed findings regarding fruit
and vegetable consumption and in BMI. To advance health equity, there are opportunities for
this area of research to involve more rural settings, qualitative research methods, community
based research methods, integration of health care services and multilevel interventions
integrating within- store components. Regarding scope, future work should consider
providing more information about food insecurity, unhealthy food and beverage intake, social
support for healthy eating, community support and social cohesion, employment outcomes and
the concurrence of COVID related closures among small food stores and restaurants nearby.
And last but not least, future work should further explore the fear of displacement and
gentrification among residents. For the last five years, I've worked very closely with
the Invest Health Hartford team and local residents groups to pursue a new grocery store in the North
Hartford Promise Zone and gentrification. And displacement associated with a new grocery
store is a real concern for the community. Next, I'll talk about research on modifying
environmental changes within existing food retail. I'll focus particularly on corner
stores and grocery stores. In terms of methods, this research area reflects a mix of exploratory
studies, store audits, natural experiments and a strong use of community based research
methods, mixed methods and customer intercept surveys.
Generally, findings from these studies point to place based disparities in the quality
of food environments within these store types where less healthy foods and drinks and more
salient and prominently placed. Results show that corner stores and small grocers are more
prevalent in low income communities, and that food insecure populations shop at them more
frequently. In terms of intervention outcomes, minimum stocking standards have had no impact
on healthy food availability or the availability, of culturally preferred produce and whole
grains. Healthy corner store interventions targeting equipment and technical assistance
show mixed findings regarding improvements in healthy food and beverage availability
and customer food purchases and consumption. For example, a recent publication on a four
year evaluation of the North Carolina Healthy Food Small Retailer Program found that there
were increases in the supply of healthy food and beverages, but no change in Veggie
Meter, or objectively assessed food vegetable intake.
Corner store interventions targeting both food availability and affordability more consistently
show increased produce purchases and sales across healthy food categories. Another recent
systematic review looked at the efficiency of interventions within grocery stores and
assessed 36 qualitative studies and included 30 quantitative studies in a meta analysis.
Their results show that interventions with pricing combined with promotion and prompts
have the largest effects. Regarding sales, results show that interventions within existing
grocery stores have significant effects on the sales of healthy foods and beverages,
including increased sales of fruits and vegetables. Research in this area will be strengthened
by larger sample sizes, more diverse settings, subgroup analysis, standardized reporting
of sample sizes, objective diet and food purchase data, seasonality adjustments. We also need
to learn more about linkages to home food environments, the impacts of store closures
due to COVID-19 and 2020 civil unrest, and a broader use of equity focused post-intervention
outcomes, including disparities in the quality of food purchases and diet, but also issues
around trust, social cohesion, well-being and psychological health outcomes.
Last, research on modifying food environments within existing food stores can further advance
health equity by leveraging community based research approaches to developing interventions
from the design stage, targeting unhealthy foods and beverages, aiming to increase the
availability of culturally preferred nutrient-rich items tailored to rural settings, and aiming
to overcome the many challenges reflected in qualitative research with small food retailers.
And some of these new challenges may be related to COVID-19. These interventions should be
inclusive, sustainable and accessible to diverse populations in terms of cost feasibility and
translated in a variety of languages, and integrate other systems and social determinants
of health like transportation and housing, health care and faith-based groups. Next,
online grocery shopping has become more popular and necessary since the start of the COVID-19
pandemic. Also in 2020, the USDA rapidly expanded its SNAP online purchasing pilot.
In terms of methods, experiments, simulations, qualitative research and mixed methods are particularly
common. To date, studies point to increased accessibility when multiple forms of payment
are accepted. And recent research on points of decision prompts and pre-refilled grocery
shopping carts find increases in healthy food selection in terms of healthy eating Index
2015 scores, high fiber items, fruits and vegetables, and items with lower sodium, fat
and cholesterol. Recent research in this area also suggests there is lower access to online
grocery shopping, particularly with curbside pickup for low income, WIC and SNAP participants,
and overall, lower access to nutrition information across populations. And compared to in-store
shopping, results show lower impulse spending on candy, frozen desserts and grain based
desserts. A 2019 study manipulating product positioning and food swaps showed a reduction
in the saturated fat content of selected food items. And some qualitative research, recent
research found that individuals with overweight or obesity particularly prefer online grocery
shopping options with nutrition rating information, interactive healthy eating aisles and healthy
shopping preference settings. Opportunities for online grocery shopping
research to advance health equity may include learning more about the effects of COVID-19
across diverse settings, relative spending on unhealthy versus healthy options, disparities
in affordability and pricing, disparities in access by geography among non-English speaking
participants, low income, program use across sociodemographic groups and delving more into
who is using delivery versus pickup options, including curbside options. Barriers to use,
including perceived theft and crime, food quality, availability of cultural food, comfortability
with technology, and also to examine linkages to job creation. There are also opportunities
for more formative research for targeted interventions with diverse samples like racial ethnic minorities
and people with lower educational attainment. Some targeted formative work has already been
done with SNAP and WIC participants, mothers and rural families. More work can also be
done exploring the efficacy of bundling online grocery shopping with other social determinants
of health interventions. And there is a need for standardized approaches
to online grocery shopping experiments. As an example of thinking across social determinants,
this study points to online grocery shopping delivery services as a viable option for addressing
food disparities in areas with limited transportation. And Rummo and colleagues published this
standardized guide to developing online grocery stores for testing nutrition related policies
and interventions. The authors point out that standardized approaches will support reproducibility
and meta analysis of intervention effects. We conducted a systematic review involving
community kitchens and found that they are understudied, particularly in the US. Although
studies that have been conducted on this area, there are diverse settings with diverse populations.
For example, the Healthy Kitchen Healthy Children program hires women to deliver subsidized
healthy snacks to schoolchildren in Palestinian refugee camps in Lebanon. The majority of
studies, though, utilize qualitative methods for formative research or process evaluations.
The qualitative research in this area points to strong program reach for populations with
high food insecurity and high health inequities. The results show that people participate in
community kitchen programs for a variety of reasons, including overall positive perceptions,
increased dignity, social cohesion, social skills, community participation and cooking
skills. Research on factors impacting sustainability increased financial and entrepreneurial skills.
As supported by about county health rankings, community kitchens have great potential for
advancing health equity by promoting food security, nutrition education and as a community
asset more broadly. Future work on community kitchens should move beyond process, evaluations,
to explore impact on health inequities, expand formative research to design interventions,
and have greater geographic representation, including but not limited to the United States.
Regarding scope, research on community kitchens can explore whether they have had any physical
changes in access due to COVID-19 and prioritize equity oriented outcomes related to employment,
financial and entrepreneurial skills, mental health and social cohesion.
The last domain I'll discuss today is food pantries. You've heard a lot about some
innovative research in this area already and you'll hear more tomorrow, so I'll just briefly
highlight a few additional equity considerations. We published this study on structural characteristics
of the food banking system and obesity inequities among food insecure pantry clients. Our results
from key stakeholder interviews highlight opportunities to better leverage federal policies
like TEFAP or The Emergency Food Assistance Program to address disparities in access to
quality information, to dismantle structural racism, stereotypes and other biases and mistrust in communities
of color, to enhance food pantries as inclusive safe spaces for immigrants and other historically
marginalized groups to equitably access food. Future work in this area should focus on understudied
health disparities in the food pantry context including heart disease, mental health and
wellbeing. Understudied populations and food pantry research include ethnic minorities,
immigrant populations, rural communities and LGBTQ youth, for example.
We need to learn more about the effects of COVID-19 on food distribution models in the
food banking system. For example, pre-pandemic, there was a shift to more dignified client
choice food pantry models, but the urgent nature of the pandemic caused pantries to
resort back to pre-packed boxes. It'll be helpful to explore whether these changes will
have long term impact on the system. We also need to learn more about the availability
of culturally preferred produce, grains, etc. So, learn more about social connectedness
in pantries, disparities in access to health promoting resources, structural racism and
any linkages between discrimination, stress and food choices and consumption in pantry
setting. Regarding interventions targeting the food banking system, future work should
integrate other systems linked to social determinants of health like housing and education, expand
the use of community based research approaches to developing and evaluating PSE strategies
targeting inequities. More formative research to enhance the cultural
relevance of nutrition related interventions. The expanded use of technology and digital
interventions to disseminate information across the food banking system more equitably. Leveraging
natural experiments linked to COVID related changes in the TEFAP program, including community
eligibility changes and national experiments linked to changes in written nutrition policies.
The twin pandemics have affected many aspects of the neighborhood food environment, people's
lives including pre-existing social inequities, and people's food behaviors, and their connection
to the neighborhood food environment. Social context matters for advancing health equity
via neighborhood food environment research. The twin pandemics will likely impact the
scope of and approach to this research for the foreseeable future. Strategies for advancing
equity oriented neighborhood food environment research include understanding recent environmental
changes and potential disparities in access; community based and citizen science research
approaches to intervention, design, implementation, and evaluation; pursuing interventions that
work across systems and integrate other social determinants of health like health care, education,
civil rights, and policing; and expanding our use of equity oriented measures and outcomes
like dietary disparities, but also mental health outcomes, well-being, employment, perceptions,
attitudes as well as experiences. We should apply theoretical approaches that consider
community assets, strengths and resilience, as well as consider the life course and intergenerational
perspectives. Thank you. Any questions?
DR. KAREN GLANZ: Thank you Kristen for that fantastic talk and lots of food for thought. And that
fits into our issues of food environment, health disparities and so on. We have a couple
of questions from people in the audience for you. So, one of the first questions is simple
relating to some things you're talking about near the end of your talk. Can you recommend
any measures to assess citizen science (INAUDIBLE)?
DR. KRISTEN COOKSEY-STOWERS: Yes. Yes. So, one of the things that we've really been focusing on
in Hartford in terms of community based research approaches are the perceptions. Perceived
food access, particularly perceived food swamp exposure, which is an area that I'm most equipped
to speak with in terms of equity in the food environment, because it turns out that
food swamp measures are strong predictor of diet related health inequities. And there's
a lot more work to be done in this area. But so far we see correlations between obesity
disparities at the national level, we see correlations with food swamp measures in terms
of what their reporting and dietary habits. Other work by Colin Rommel and others shows
relationships between adolescent health disparities and Joel Gittelsohn's team has found some
work looking at food swamps and housing vacancy. So it's a strong predictor in terms of some
of the many social inequities that we've heard about today, and we're doing some citizen
science work in Hartford and (INAUDIBLE) in particular.
And it's really turning out to be a strong framework to use.
DR. KAREN GLANZ: Right. OK. Another question we have. Given the changing food prices and increasing
promotions seem to be among the promising strategies to increase healthy purchases in
food retail settings, what would you recommend as the top priorities for researchers and
funders to inform changes in those areas of price and increased promotions?
DR. KRISTEN COOKSEY-STOWERS: Thank you for that question, it's a really good question. I mean, I think
the first thing that's really important to keep in mind is that we should be letting
the community answer that for us before we start and to not go in with a preconceived
notion on which particular items we should be promoting, both in terms of price and promotion.
We know that those strategies work overall, but we still need to learn a lot more about,
you know, for whom and which items in particular. And so I'm a strong proponent of community
based work because the answer to a lot of our questions is that it depends. So, Dr. Schwartz
and I have done some work in food pantries in Hartford, and we started out finding out
from the pantry directors what are the items that they're looking to '"move", right? Because
there's a conception and concern that if they invest in and work toward stocking healthier
produce options is that it wouldn't move, right? So, we started out with asking what
are the items that you're concerned about moving?
And marrying that with some client level data in terms of what items they would prefer to
see their pantry stock more. And let some of that formative of research guide the intervention
and which items we chose to promote in a ingredient bundle, which did sort of, as we know, as
other speakers spoke about today, convenience. And the bundling approach is a strategy that
helps us, but rather than go in and decide what items we wanted to manipulate and promote,
we let the clients as well as the pantry directors inform that discussion.
DR. KAREN GLANZ: So I'm going to throw you a question of my own in relation to that.
DR. KRISTEN COOKSEY-STOWERS: Go ahead.
DR. KAREN GLANZ: Just to get your response. So let's suppose you asked the food pantry customers
users what it is they would like to see more of. And they say, we want more Ho Hos
and we want more cheaper hotdogs. What would you, what would you do with that information?
DR. KRISTEN COOKSEY: I honestly think that's a great question, Karen. And I think I wear
sort of two hats here in Hartford. I'm an academic, but I'm also a board member of the
Connecticut Food Bank in our Food Share. And that is a huge concern among donors and among
key stakeholders that does not pan out in the data. The clients are like, it reminds me of
this sort of data on what participants showing that they're very much in the know. They're
very kind, or they're not trying to game the system. Very similar sort of consistent findings
in our work but also on Dr Katz's work showing that clients want to see more nutrient-dense
foods. They are very sophisticated in how they're navigating their food donors and their
environment throughout the month. I did some cognitive interviews preparing for pantry
intervention in Hartford. And you can just see the wheels turning, you know. On Wednesday.,
I can go to the pantry for my protein, and then by the end of the month I can go to SNAP
and stock up, right? And so that is not what we see in the data in terms of them wanting
to see more unhealthy food. That is, you know, that those items are cheaper.
Those items are, particularly in an equitable food around areas like food swamps, that it's
more than they can, then they want to see. So I definitely hear the concern, including
among donors and stakeholders in this space. But clients are very vocal about wanting to
see more healthy food that they can always afford in grocery stores.
DR. KAREN GLANZ: OK. But I'm being, I'm getting a signal that we have only time for one more
question. So, this is a question about the community and health care settings and kind
of resource management and access interaction with the food environment. Do you have any
good examples of either demonstration projects or a resource where social workers have been
involved in nutrition counseling and financial management of food access and so forth?
DR. KRISTEN COOKSEY-STOWERS: I have to be honest, I'm not familiar with any particular sort of large
scale studies in this space, but we have been doing some work looking at how the health
care system can better integrate with the food banking system. We conducted a national
study with CEOs of food banks. And this idea of better inclusion of social workers indeed
on staff is really percolating the system that we need to be working across...across like sort of our
disciplines or sectors. And so I'm not aware of any large scale studies but social workers
are definitely coming up a lot in terms of how can we work in a more intersectoral way
in pantry setting?
DR. KAREN GLANZ: Alright, Thank you. Thank you so much for a wonderful talk and for taking
time to answer these questions from the audience.
DR. KRISTEN COOKSEY-STOWERS: Thank you all. Thank you for the opportunity. Have a nice night.
DR. KAREN GLANZ: Sure. We're almost to the end of the second day of our workshop. And I see
over 300 of you are still with us. So that's terrific. We've covered a ton today, and tomorrow
morning we're going to do a little bit of reflection on much of what was covered today
as we go on and hear even more examples of innovative research, reviews of research that's
being conducted, and also about policies and programs that federal government is undertaking
to address both food insecurity and the neighborhood food environment. I want to pick on three
things to just end the day that I think have been somewhat crosscutting, but that particularly
stuck out to me in a super full day. The one has to do with social determinants, and Kristen
has highlighted this quite a bit in her talk as well. The idea that poor conditions coexist
with poor neighborhood food environments, they often coexist with minority racial makeup
in neighborhoods, poverty, discrimination, poor housing. But they also, as I showed in
some map, they also coexist with higher rates of smoking, low access to health care and
a number of other things. So, the issues are far beyond food. And they're
not just in terms of food and healthy eating and determinants of healthy eating that we
need to consider in the big picture if we really want to improve health and quality
of life overall. And another point along the same lines is that we need to both look for
and encourage programs that cut across different aspects of social determinants of health,
of quality, of life, of physical health risk factors and diet. Again, Kristen mentioned
the Promise Zone model as one of the areas that she's working in. I've also worked in
the Promise Zone. This was a model that President Obama started to actually get large departments
in the federal government working together that had not. Housing and urban development
working with Health and Human Services, working with the U.S. Department of Agriculture. It
really is a tremendous idea that probably needs to be revived and expanded, not just
on the federal level, but also on local levels. And the last point that I just want to point
to as food for thought is that we're only limited by our creativity, our innovation
and the novelty of ideas. And I've heard about public private partnerships
for decades. And yet some of the most interesting and promising interventions that we've heard
about today fall in that space. For example, the Silver Diner restaurant intervention that
Chris Economos talked about where the restaurant chain actually changed their menu and changed
their default working with health experts. And the results were really impressive. Another
one that we've heard of late this afternoon from Joel Gittelsohn is working with the owners
and managers of small stores using the BUD app to help to try to correct errors and gaps
in the food supply chain as a way to get the healthier foods into these stores, something
that was a real obstacle for the retail industry in that space. So I think those are just a
couple of examples, there are many more. But just to plant those ideas in everyone's head.
Thanks to everyone for being with us for a great day of this workshop. And we will return
again tomorrow at 12:30 Eastern Time for the third day of our workshop.
I hope as many of you as can will join us. We have, again, a wonderful line up of speakers and some time for discussion and synthesis of what we've talked about.
In regards to food insecurity and neighborhood food environments in this workshop. So, thanks everyone and have a good evening.