THE PUBLIC HEALTH EFFECTS OF FOOD DESERTS

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THE Public HEalTH EffEcTs of food dEsErTs Workshop summary Paula Tarnapol Whitacre, Peggy Tsai, and Janet Mulligan, Rapporteurs Food and Nutrition Board Board on Agriculture and Natural Resources Board on Population Health and Public Health Practice

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. This workshop was supported by Contract No. AG-3K06-C-08-0034 between the National Academy of Sciences and the U.S. Department of Agriculture. Any opin - ions, findings, and conclusions or recommendations in this document are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. I nternational Standard Book Number-13: 978-0-309-13728-7 International Standard Book Number-10: 0-309-13728-4 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM homepage at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover credit: Top left: Urban corner store in Baltimore, MD, courtesy of Joel Gittelsohn. Top right: Fast food stock photo, with permission from iStock.com. Bottom left: Dollar store, courtesy of Joseph Sharkey. Bottom right: Enclosed urban grocery in Baltimore, MD, courtesy of Joel Gittelsohn. Center: Farmers market in Washington, DC, courtesy of Kamweti Mutu. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine) and National Research Council (NRC). 2009. The public health effects of food deserts: Workshop summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern - ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem - bers, sharing with the National Academy of Sciences the responsibility for advis - ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro - viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE ON THE PUBLIC HEALTH EFFECTS OF FOOD DESERTS* BARRY M. POPKIN (Chair), Director, UNC Interdisciplinary Obesity Program, The Carla Smith Chamblee Distinguished Professor of Global Nutrition, School of Public Health Professor, Department of Nutrition, University of North Carolina, Chapel Hill ANA V. DIEZ ROUX, Professor, Epidemiology Director, Center for Integrative Approaches to Health Disparities, Associate Director, Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor JOEL GITTELSOHN, Associate Professor, Center for Human Nutrition, Department of International Health, Johns Hopkins University, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland BARBARA A. LARAIA, Assistant Professor, Division of Prevention Sciences, Department of Medicine, University of California, San Francisco ROBIN A. McKINNON, Health Policy Specialist, Risk Factor Monitoring and Methods Branch Applied Research Program, National Cancer Institute, Rockville, Maryland JOSEPH R. SHARKEY, Associate Professor, Social and Behavioral Health, Director, Texas Healthy Aging Research Network, Director, Program for Research in Nutrition and Health Disparities, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas Study Staff PEGGY TSAI, Study Director JANET MULLIGAN, Research Associate HEATHER BREINER, Program Associate PAULA TARNAPOL WHITACRE, Consultant Science Writer LINDA D. MEYERS, Food and Nutrition Board Director ROBIN A. SCHOEN, Director, Board on Agriculture and Natural Resources ∗ Institute of Medicine and National Research Council planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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FOOD AND NUTRITION BOARD*∗ DENNIS M. BIER (Chair), Children’s Nutrition Research Center, Houston, Texas MICHAEL P. DOYLE (Vice Chair), Center for Food Safety, University of Georgia, Griffin DIANE BIRT, Department of Food Science and Human Nutrition, Iowa State University, Ames YVONNE BRONNER, School of Public Health and Policy, Morgan State University, Baltimore, Maryland FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst RICHARD J. DECKELBAUM, Institute of Human Nutrition, Columbia University, New York GORDON L. JENSEN, Department of Nutritional Sciences, Pennsylvania State University, University Park REYNALDO MARTORELL, Department of Global Health, Emory University, Atlanta, Georgia SUSAN T. MAYNE, Division of Chronic Disease Epidemiology, Yale University School of Medicine, New Haven, Connecticut SANFORD A. MILLER, Center for Food, Nutrition, and Agriculture Policy, University of Maryland, College Park J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, University of Maryland School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts MARTIN A. PHILBERT, School of Public Health, University of Michigan, Ann Arbor JIM E. RIVIERE, Center for Chemical Toxicology Research and Pharmacokinetics, North Carolina State University, Raleigh PATRICK J. STOVER, Division of Nutritional Sciences, Cornell University, Ithaca, New York WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts ∗ Institute of Medicine boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the report rests with the rapporteurs and the institution. vi

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Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON L. BANDY, Financial Associate vii

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BOARD ON AGRICULTURE AND NATURAL RESOURCES W. REG GOMES (Chair), University of California (emeritus), Oakland PEGGY F. BARLETT, Emory University, Atlanta, Georgia ROGER N. BEACHY, Donald Danforth Plant Science Center, St. Louis, Missouri HAROLD L. BERGMAN, University of Wyoming, Laramie H.H. CHENG, University of Minnesota (emeritus), St. Paul RICHARD A. DIXON, Samuel Roberts Noble Foundation, Ardmore, Oklahoma DANIEL M. DOOLEY, University of California, Oakland JOAN H. EISEMANN, North Carolina State University, Raleigh GARY F. HARTNELL, Monsanto Company, St. Louis, Missouri GENE HUGOSON, Minnesota Department of Agriculture, St. Paul KIRK C. KLASING, University of California, Davis VICTOR L. LECHTENBERG, Purdue University, West Lafayette, Indiana PHILLIP E. NELSON, Purdue University, West Lafayette, Indiana ROBERT PAARLBERG, Wellesley College, Watertown, Massachusetts KEITH PITTS, Marrone Organic Innovations, Davis, California CHARLES W. RICE, Kansas State University, Manhattan HAL SALWASSER, Oregon State University, Corvallis PEDRO A. SANCHEZ, The Earth Institute, Columbia University, Palisades, New York NORMAN R. SCOTT, Cornell University, Ithaca, New York ROGER A. SEDJO, Resources for the Future, Washington, DC KATHLEEN SEGERSON, University of Connecticut, Storrs MERCEDES VAZQUEZ-AÑON, Novus International, Inc., St. Charles, Missouri Staff ROBIN A. SCHOEN, Director KAREN L. IMHOF, Administrative Assistant AUSTIN J. LEWIS, Senior Program Officer EVONNE P.Y. TANG, Senior Program Officer PEGGY TSAI, Program Officer CAMILLA YANDOC ABLES, Associate Program Officer KARA N. LANEY, Associate Program Officer RUTH S. ARIETI, Research Associate JANET M. MULLIGAN, Research Associate KAMWETI MUTU, Research Associate ERIN P. MULCAHY, Senior Program Assistant viii

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BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE JAMES W. CURRAN (Chair), Emory University, Atlanta, Georgia MARGARITA ALEGRÍA, Cambridge Health Alliance, Somerville, Massachusetts SUSAN M. ALLAN, University of Washington, Seattle GEORGES C. BENJAMIN, American Public Health Association, Washington, DC BOBBIE A. BERKOWITZ, University of Washington, Seattle DAN G. BLAZER, Duke University Medical Center, Durham, North Carolina DAVID R. CHALLONER, University of Florida, Gainesville R. ALTA CHARO, University of Wisconsin, Madison JOSE JULIO ESCARCE, UCLA Med-GIM & HSR, Los Angeles, California HOWARD HU, University of Michigan Schools of Public Health and Medicine, Ann Arbor MATTHEW W. KREUTER, Washington University in Saint Louis, St. Louis, Missouri MARGARET E. O’KANE, National Committee for Quality Assurance, Washington, DC GEORGE W. RUTHERFORD, University of California, San Francisco, School of Medicine, San Francisco SUSAN L. SANTOS, University of Medicine and Dentistry, New Jersey, Medford, Massachusetts MARTIN JOSE SEPULVEDA, International Business Machines Corporation, Somers, New York SAMUEL SO, Stanford University, Stanford, California ANTONIA M. VILLARRUEL, University of Michigan School of Nursing, Ann Arbor PAUL J. WALLACE, The Permanente Federation, Kaiser Permanente, Oakland, California GINA M. WINGOOD, Rollins School of Public Health, Emory University, Atlanta, Georgia ix

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Acknowledgments This report is a product of the cooperation and contributions of the speakers and participants who attended the workshop on January 26-27, 2009. Their presentations helped to set the stage for the fruitful discus- sions in the sessions that followed. This workshop summary report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Coun - cil’s Report Review Committee. The purpose of the independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and respon - siveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: Alice Ammerman, Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill Angela D. Liese, Center for Research in Nutrition and Health Disparities and Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia Diego Rose, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana xi

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xii ACKNOWLEDGMENTS Mary Story, Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis Elizabeth Tuckermanty, Cooperative State Research, Education, and Extension Service, United States Department of Agriculture, Washington, DC Although the reviewers listed above have provided constructive com- ments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Dr. Eileen Kennedy, Friedman School of Nutrition Science and Policy, Tufts University, Boston, Massachusetts. Appointed by the National Research Council and Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institu - tional procedures and that all review comments were carefully consid- ered. Responsibility for the final content of this report rests entirely with the authors and the institutions.

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Contents SUMMARY 1 1 INTRODUCTION 5 Background, 5 Congressional Mandate, 6 Workshop Organization, 6 Defining Food Deserts, 7 Organization of the Workshop Summary, 9 2 DETERMINING THE EXTENT OF FOOD DESERTS 11 National Overview of Food Deserts by Demographics and Socioeconomic Status, 11 Measuring Food Deserts: Focusing on Urban Areas, 14 Measuring Food Deserts: Focusing on Rural Areas, 17 Dynamics of the Food Shopping Environment, 21 Discussion: Measuring Food Deserts, 23 3 STUDYING FOOD DESERTS THROUGH DIFFERENT LENSES 27 Epidemiological Approach, 27 Geospatial Approach, 30 Economic Approach, 32 Discussion: Different Approaches, 33 xiii

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xiv CONTENTS 4 DIET AND HEALTH EVIDENCE TO SUPPORT IMPROVED FOOD ACCESS 37 Effects of Selected Dietary Factors on Obesity, 37 Effects of Selected Dietary Factors on Cardiovascular Disease and Cancer, 40 Discussion: Health Consequences, 42 5 AMELIORATING FOOD DESERT CONDITIONS 45 Research Interventions, 45 Policy Interventions, 56 Small Stores, 59 Farmers Markets and Other Alternatives in Low-Income Communities, 61 Discussion: Policy Interventions, 65 6 RESEARCH GAPS AND NEEDS 67 Development of Methodology and Tools, 68 Approaches to Measuring Food Deserts and Outcomes, 69 Next Steps and Closing Thoughts, 73 REFERENCES 75 APPENDIXES A PLANNING COMMITTEE BIOGRAPHIES 79 B WORKSHOP AGENDA 83 C SPEAKER AND MODERATOR BIOGRAPHIES 89 D WORKSHOP PARTICIPANTS 97