The Public Health Effects of Food Deserts: Workshop Summary (2009)

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1 Introduction BACKGROUND The term “food deserts” describes neighborhoods and communities that have limited access to affordable and nutritious foods. The term was first used in Scotland and characterized neighborhoods that can encom- pass many thousands of people and/or an extensive land area as defined by city blocks or square miles. In the United States, food deserts tend to be located in urban and rural low-income neighborhoods, where resi- dents are less likely to have access to supermarkets or grocery stores that provide healthy food choices. For communities with few food retailers or supermarkets that stock little or no fresh produce, low-fat dairy, whole grains, and other healthy foods, those populations may be more likely to suffer from high rates of diabetes, cardiovascular disease, and obesity. Research into the health implications of food deserts began in the United Kingdom in the 1990s, although economists and geographers had been studying spatial determinants of firm location, transaction costs, and differential prices of food for the poor since at least the 1960s. Sponsor representative Laurian Unnevehr, of the U.S. Department of Agriculture’s Economic Research Service, pointed out in the introductory workshop session that community organizers have seen local food and food access as a powerful vehicle for social change for many decades. The study of food deserts, both here and in the United Kingdom, has since evolved to include public health researchers and practitioners, economists, planners, community activists, and others. Researchers are looking at the effect of food deserts on health out-  

 THE PUBLIC HEALTH EFFECTS OF FOOD DESERTS comes, as well as examining which interventions have the greatest poten- tial to improve conditions. CONGRESSIONAL MANDATE The 2008 Farm Bill directed the U.S. Department of Agriculture (USDA) to undertake a study of food deserts in the United States to assess their incidence and prevalence, to identify characteristics and factors causing and influencing food deserts and their effect on local populations, and to provide recommendations for addressing the causes and effects. The Economic Research Service (ERS) is the lead agency on this effort and is collaborating with other agencies within USDA, such as the Food and Nutrition Service and the Cooperative State Research, Education, and Extension Service. Legislation also instructed USDA to work with other organizations, including the Institute of Medicine (IOM) and the National Research Council (NRC). WORKSHOP ORGANIZATION At the request of ERS, the IOM and the NRC convened a workshop to examine the public health implications of food deserts and to examine promising strategies for mitigating their impacts (see Box 1-1 for the State- ment of Task). A six-person planning committee was appointed by the IOM and the NRC, and biographical sketches of the planning committee are found in Appendix A. To address the Statement of Task, the plan- ning committee developed a meeting agenda, found in Appendix B, and identified and invited experts to provide presentations at the workshop. Biographical sketches of the invited speakers and the session modera- tors are found in Appendix C. The workshop agenda was organized as a representative but not exhaustive overview of food deserts: It examined current research findings on the public health impacts of food deserts and explored ways to potentially mitigate those impacts. At the January 26-27, 2009, workshop in Washington, DC, invited speakers gave presentations on how multidisciplinary approaches can be used to measure where and how food deserts occur as well as potential health impacts and strategies to ameliorate them. The invited speakers based their presentations primarily on their research or perceptions of research in the field. Speakers also addressed the common premise that increasing the availability of healthy foods will affect diet and produce health outcomes. The results of some research interventions and promis-   The planning committee’s role was limited to planning the workshop; this summary has been prepared by the workshop rapporteurs as a factual summary of what occurred. 

INTRODUCTION  BOX 1-1 Statement of Task An ad hoc committee will plan and conduct a two-day workshop on the public health implications of food deserts. In this context, “food desert” is defined as a rural or urban low-income neighborhood or community with limited access to affordable and nutritious food. The workshop will include presentations and discussions that will focus on the health effects on local populations (including both adults and children) of limited access to affordable and nutritious food. Invited workshop pre- sentations will discuss the impacts of food deserts on such outcomes as overall dietary intake (including examination of specific foods, such as fruit and vegetable consumption and intake of high-energy, low-nutrient foods); the prevalence of obesity and overweight; the existence of micronutrient deficiencies; food insecu- rity; and the incidence of chronic diseases associated with poor diets. In addition, presentations will cover promising strategies for mitigating the impacts of food deserts that have been suggested or implemented, or are in the planning stages. An individually authored summary of the workshop will be prepared, along with an unedited transcript of the workshop presentations. ing policies and programs were discussed on how to alleviate problems related to the accessibility, availability, affordability, and quality of foods. More than 75 stakeholders from the general public attended the work- shop, and a list of those participants is found in Appendix D. DEFINING FOOD DESERTS Shelly Ver Ploeg, of USDA ERS, noted that the definition of food desert contained in the Farm Bill is helpful (Box 1-2), but also raises ques- tions. “Limited access,” she said, “is not a well-defined measure: It could relate to distance, to price, and/or to time cost.” “Affordable and nutri- tious food” is more of a continuum of foods. For example, fresh fruits and vegetables might be ideal, but frozen and canned fruits and vegetables, as well as prepared meals and food away from home, also provide nutrition and, in many situations, more practically. She also stressed that the focus of the study is on low-income areas, not individuals with low income who may or may not live in a food desert. Planning committee chair Barry Popkin, of the University of North Carolina at Chapel Hill, stressed that the food people purchase in stores is but one aspect of their total food environment, a point reiterated by many presenters throughout the workshop. As noted in Figure 1-1, we eat 

 THE PUBLIC HEALTH EFFECTS OF FOOD DESERTS BOX 1-2 What Is a Food Desert? In the 2008 Farm Bill, Section 7527 defines a food desert as “an area in the United States with limited access to affordable and nutritious food, particularly such an area composed of predominantly lower-income neighborhoods and com- munities.” In developing the framework and selected topics for this workshop, the planning committee believed it was important to specify geography and quality as factors describing a food desert and defined it more accurately as the following: Food desert: a geographic area, particularly lower-income neighborhoods and communities, where access to affordable, quality, and nutritious foods is limited. Community Work/School/ Food Options Homes Individual Food Markets Home Purchasing Small Stores School/Worksite Food Intake Food Supermarkets Vending Public Health Outcomes Vendor Carts Fast-Food/ Sit-Down (e.g., Obesity) Restaurants Large Food/Drink Activity Distributors Energy • Leisure Expenditure • School/Work • Home • Transportation FIGURE 1-1 Causal web: role of the food environment on diet-related problems. SOURCE: B. Popkin, 2009. Figure 1-1.eps 

INTRODUCTION  in restaurants, at school, and at work. We purchase food and beverages at fast-food restaurants and from vending machines, in school cafeterias and in sit-down restaurants. Food retailers are an important piece of the puzzle, but they only contribute to one factor affecting choice in the Amer- ican diet. While it was important to note the multiple aspects of the food environment to explain the how complex the issues are, Popkin reiterated that it was outside the workshop scope to address the increased access to unhealthy food options beyond the community food options setting. There is much potential for improving the situation of food deserts—providing oases of healthy food in areas without it, to extend the analogy—however, Popkin and other presenters warned against oversimplified definitions and solutions from the start of the workshop. ORGANIZATION OF THE WORKSHOP SUMMARY The workshop consisted of sessions discussing how food deserts can be measured (Chapter 2), the challenges and different approaches to iden- tifying effects of the food environment on health (Chapter 3), the potential health consequences of changes in diet (Chapter 4), lessons from current intervention research to mitigate food deserts, and policy and program options that, although promising, have to date been less rigorously evalu- ated (Chapter 5). Many of the researchers’ work cut across several themes, and the chapters are organized around presentations rather than strictly around themes. After each set of presentations within those ­ sessions, speakers participated in moderated panel discussions with questions from the audience. In the final session of the workshop, various discus- sion threads mentioned by speakers and participants about additional research needed on the topic of food deserts were tied together by rap- porteurs who summarized the current research gaps and future research activities necessary to fully characterize and understand the extent of food deserts and methods to address those issues (Chapter 6). This publication summarizes the presentations and discussions of the workshop.