Access to Foods that Support Healthy Eating Patterns
The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Access to Foods that Support Healthy Eating Patterns is a key issue in the Neighborhood and Built Environment domain. For the purpose of this summary, the phrase “access to foods that support healthy eating patterns” is interchangeable with “access to healthy foods.”
Access to foods that support healthy eating patterns contributes to an individual’s health throughout his or her life.1 Healthy eating habits include controlling calories; eating a variety of foods and beverages from all of the food groups; and limiting intake of saturated and trans fats, added sugars, and sodium.1 Healthy eating can help lower the risk for chronic disease.1–4 Evidence also shows that poor nutrition and an unhealthy diet are risk factors for high blood pressure,2, diabetes,5–7 and cancer.8,9 According to the 2015—2020 Dietary Guidelines for Americans, healthy eating patterns include: a variety of vegetables; fruits, especially whole fruits; grains, at least half of which are whole grains; fat-free or low-fat dairy; protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), unsalted nuts and seeds, and soy products; and oils.1 Some research has shown that increased access to healthy foods corresponds with healthier dietary practices.10
There are barriers to, and disparities in, the accessibility and availability of foods that support healthy eating patterns. Data from 2012—2013 show that the average distance from U.S. households to the nearest supermarket was 2.19 miles.11 Individuals without a vehicle or access to convenient public transportation,12 or who do not have food venues with healthy choices within walking distance, have limited access to foods that support healthy eating patterns.13 A study in Detroit found that people living in predominantly black low–income neighborhoods travel an average of 1.1 miles farther to the closest supermarket than people living in predominantly white low-income neighborhoods.14 Transportation and distance to sources of healthy foods impact low–income and rural communities, especially older adults living in rural communities.13,15,16 Overall, for those who do not have access to a car or public transportation, the cost of travel time to find healthier options in addition to out–of–pocket expenses may be too high.12
Another barrier to accessibility of healthy food choices is living in a “food desert.” In food deserts, food sources are lacking or limited, particularly in low income areas that are more also likely to have a higher share of convenience stores and small food markets.17–19 These options tend to carry foods of lower nutritional quality compared to large chain supermarkets, which may have a wider variety of healthy options.20 Furthermore, this lack of access to foods that support healthy eating patterns may have a greater impact on members of racial and ethnic minority communities, residents of low–income communities17 and those living in rural areas18. Several studies have shown that residents of these communities are more likely to be affected by poor access to supermarkets, chain grocery stores, and healthy food products.10 For example, predominantly black and Hispanic neighborhoods have fewer large chain supermarkets than predominantly white and non–Hispanic neighborhoods.10,16 These disparities may decrease access to healthy food options for minority populations.
Affordability also influences access to foods that support healthy eating patterns. Research shows that low–income groups tend to rely on foods that are cheap and convenient to access, but are low in nutrient density.21 Fresh fruits and vegetables and other healthier items are often more expensive at convenience stores and small food markets than in larger chain supermarkets and grocery stores.13,22 A summary of recent research on this issue indicated that “in neighborhoods without supermarkets, residents likely face higher prices for many healthy foods, because small stores typically charge more for items such as fresh produce.”12 Research also shows that price reductions of healthier food choices can contribute to increased purchasing of those choices.23
Studies show a relationship between the inability to access foods that support healthy eating patterns and negative health outcomes. For example, a study of 40,000 California residents examined how access to healthy food choices impacts rates of obesity and diabetes.24 Residents of neighborhoods with fewer fresh produce sources and plentiful fast food restaurants and convenience stores were at a higher risk of obesity and diabetes.24 Lower rates of obesity and diabetes were found in areas with increased access to healthy foods and a higher density of full–service restaurants and grocery stores.24,25 Additionally, the food environment surrounding schools can impact children and adolescents. One study found that students whose schools were within a half mile of a fast food restaurant were more likely to be overweight or obese than students whose schools were farther away from fast food restaurants.26
Improving access to foods that support healthy eating patterns is one method for addressing health disparities and population health. Several strategies that aim to “improve diet by altering food environments” are being considered and implemented.8,10 For example, a study has shown that a small financial incentive increased the use of Supplemental Nutrition Assistance Program (SNAP) benefits in participating farmers markets – resulting in increased access to healthy foods.27 Several strategies have also been proposed to encourage more equitable access to healthy food choices, such as, “attracting and opening supermarkets in underserved neighborhoods, selling healthy foods at reduced prices, and limiting the total number of per capita fast food restaurants in a community.”10
Additional research is needed to increase the evidence base for what can successfully impact the effects of access to foods that support healthy eating patterns and health outcomes.8,10 This additional evidence will facilitate public health efforts to address access to healthy food choices as a social determinant of health.
Disclaimer: This summary of the literature on access to foods that support healthy eating patterns as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue.1,2 Please keep in mind that the summary is likely to evolve as new evidence emerges.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 dietary guidelines for Americans: 8th edition. Washington: HHS and USDA; 2015 Dec.
2 Zhao D, Qi Y, Zheng Z, Wang Y, Zhang XY, Li HJ, et al. Dietary factors associated with hypertension. Nat Rev Cardiol. 2011 Jul 5;8(8):456–65.
3 Steinmetz KA, Potter JD. Vegetables, fruit, and cancer prevention: a review. J Am Diet Assoc. 1996 Oct;96(10):1027–39.
4 Joshipura KJ, Hu FB, Manson JE, Stampfer MJ, Rimm EB, Speizer FE, et al. The effect of fruit and vegetable intake on risk for coronary heart disease. Ann Intern Med. 2001 Jun 19;134(12):1106–14.
5 Swinburn BA, Metcalf PA, Ley SJ. Long-term (5-year) effects of a reduced-fat diet intervention in individuals with glucose intolerance. Diabetes Care. 2001;24(4):619–24.
6 Feskens EJ, Virtanen SM, Rasanen L, Tuomilehto J, Stengard J, Pekkanen J, et al. Dietary factors determining diabetes and impaired glucose tolerance: a 20-year follow-up of the Finnish and Dutch cohorts of the Seven Countries Study. Diabetes Care. 1995 Aug;18(8):1104–12.
7 Marshall JA, Hoag S, Shetterly S, Hamman RF. Dietary fat predicts conversion from impaired glucose tolerance to NIDDM: the San Luis Valley Diabetes Study. Diabetes Care. 1994 Jan;17(1):50–56.
8 Penney TL, Brown HE, Maguire ER, Kuhn I, Monsivais P. Local food environment interventions to improve healthy food choice in adults: a systematic review and realist synthesis protocol. BMJ Open. 2015;5(4):e007161.
9 World Health Organization. Fruit, vegetables and NCD disease prevention [Internet]. Geneva: WHO; 2003 Sep [cited 2018 Feb 16]. 2 p. Available from: http://www.who.int/dietphysicalactivity/media/en/gsfs_fv.pdf
10 Larson NI, Story MT, Nelson MC. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74–81. doi: 10.1016/j.amepre.2008.09.025
11 Ver Ploeg M, Mancino L, Todd JE, Clay DM, Scharadin B. Where do Americans usually shop for food and how do they travel to get there? initial findings from the national household food acquisition and purchase survey. Washington: USDA Economic Research Service; 2015 Mar. 27 p. EIB-138.
12 Rose D. Access to healthy food: a key focus for research on domestic food insecurity. J Nutr. 2010 Jun;140(6):1167–69.
13 Ploeg MV, Breneman V, Farrigan T, Hamrick K, Hopkins D, Kaufman P, et al. Access to affordable and nutritious food: measuring and understanding food deserts and their consequences: report to Congress. Washington: USDA Economic Research Service; 2009 Jun. 160 p.
14 Zenk, S. N., Schulz, A. J., Israel, B. A., James, S. A., Bao, S., & Wilson, M. L. (2005). Neighborhood racial composition, neighborhood poverty, and the spatial accessibility of supermarkets in metropolitan Detroit. American journal of public health, 95(4), 660-667.
15 Sharkey JR, Johnson CM, Dean WR. Food access and perceptions of the community and household food environment as correlates of fruit and vegetable intake among rural seniors. BMC Geriatr. 2010 Jun;10(1):32.
16 Powell LM, Slater S, Mirtcheva D, Bao Y, Chaloupka FJ. Food store availability and neighborhood characteristics in the United States. Prev Med. 2007 Mar;44(3):189–95.
17 Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Prev Chronic Dis. 2009 July;6(3):A105.
18 Smith C, Morton LW. Rural food deserts: low-income perspectives on food access in Minnesota and Iowa. J Nutr Educ Behav. 2009 May–Jun;41(3):176–87.
19 Morland K, Wing S, Roux AD, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. Am J Prev Med. 2002 Jan;22(1):23–29.
20 Brown AF, Vargas RB, Ang A, Pebley AR. The neighborhood food resource environment and the health of residents with chronic conditions. J Gen Intern Med. 2008 Aug;23(8):1137–44. doi: 10.1007/s11606-008-0601-5
21 Drewnowski A, Eichelsdoerfer P. Can low-income Americans afford a healthy diet? Nutr Today. 2010 Nov;44(6):246–49.
22 Gustafson A, Hankins S, Jilcott S. Measures of the consumer food store environment: a systematic review of the evidence 2000–2011. J Commun Health. 2012 Aug;37(4):897–911.
23 French SA. Pricing effects on food choices. J Nutr. 2003 Mar;133(3):841S-843S.
24 Babey SH, Diamant AL, Hastert TA, Harvey S. Designed for disease: the link between local food environments and obesity and diabetes. Los Angeles: UCLA Center for Health Policy Research; 2008 Apr 1.
25 Ahern M, Brown C, Dukas S. A national study of the association between food environments and county-level health outcomes. J Rural Health. 2011 Winter;27(4):367–79. doi: 10.1111/j.1748-0361.2011.00378.x
26 Davis B, Carpenter C. Proximity of fast-food restaurants to schools and adolescent obesity. Am J Public Health. 2009 Mar;99(3):505–10.
27 Baronberg, S., Dunn, L., Nonas, C., Dannefer, R., & Sacks, R. (2013). The impact of New York City's Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009. Prev Chronic Dis, 10, E163. doi: 10.5888/pcd10.130113