About This Literature Summary

This summary of the literature on Access to Foods That Support Healthy Dietary 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. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Food Insecurity literature summary.

Literature Summary

A dietary pattern represents the totality of what individuals habitually eat and drink, and the parts of the pattern act synergistically to affect health. Healthy dietary patterns can help lower the risk of chronic disease.1,2,3,4 According to the Dietary Guidelines for Americans, 2020–2025 (Dietary Guidelines), a healthy dietary pattern consists of nutrient-dense forms of foods and beverages across all food groups, in recommended amounts, and within calorie limits. The core elements of a healthy dietary pattern include consumption of vegetables of all types, fruits, grains (especially whole grains), low-fat or fat-free dairy, protein foods, and oils while also paying attention to portion size.3 The Dietary Guidelines also recommend limiting foods and beverages higher in added sugars, saturated fat, and sodium, and limiting alcohol intake.3 A healthy dietary pattern is not a rigid prescription but rather a customizable framework of core elements tailored to personal, cultural, and traditional preferences.3

Access to foods that support healthy dietary patterns supports health not only at that point in time but also across the lifespan and possibly for future generations.3 Consistent evidence demonstrates that a healthy dietary pattern is associated with beneficial outcomes for all-cause mortality, cardiovascular disease, overweight and obesity, type 2 diabetes, bone health, and certain types of cancer (breast and colorectal).3,5 Having access to healthy, safe, and affordable food is crucial for an individual to achieve a healthy dietary pattern.

There is a relationship between the inability to access foods that support healthy dietary patterns and negative health outcomes. For example, a recent study assessed the link between food-related hardships like food insecurity (defined as the inability to acquire adequate food) on obesity.6 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.6 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.6,7 The food environment surrounding schools can impact children and adolescents as well. A study found that students with fast-food restaurants near (within a half-mile of) their schools consumed fewer servings of fruits and vegetables, consumed more servings of soda, and were more likely to be overweight than youth whose schools were not near fast-food restaurants.8

There are barriers to, and disparities in, the accessibility and availability of foods that support healthy dietary patterns.3 Distance to grocery stores and lack of transportation are barriers that can inhibit access to healthy food options. Data from 2015 show that the average distance from U.S. households to the nearest supermarket was 2.19 miles.9 Another report found that 23.5 million people live in low-income areas that are further than 1 mile from a large grocery store or supermarket. Individuals without a vehicle or access to convenient public transportation,10 or who do not have food venues with healthy choices within walking distance, have limited access to foods that support healthy dietary patterns.11 Predominantly Black and Hispanic neighborhoods have fewer large chain supermarkets than predominantly White and non-Hispanic neighborhoods.9,10 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.12 Lack of access to foods that support healthy dietary patterns may have a greater impact on members of racial/ethnic minority communities, residents of low-income communities,11 and those living in rural areas, especially older adults, due to the other social and environmental determinants they tend to face.13,14 In addition, 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.10

Affordability also influences access to foods that support healthy dietary patterns. Low-income groups tend to rely on foods that are cheap and convenient to access but are often low in nutrients.10,13 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.10,11,15 A summary of recent research on this issue indicated that “low-income residents who shop for food in their neighborhoods may pay more, on average, for produce (apples, bananas, oranges, carrots and tomatoes).”16 Price reductions of healthier food choices can contribute to increased purchasing of those choices.16

Improving access to foods that support healthy dietary 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 Examples of programs to address access to and affordability of healthy foods include: The Gus Schumacher Nutrition Incentive Program, Centers for Disease Control and Prevention (CDC) Food Service Guidelines, and various state and local programs. The Gus Schumacher Nutrition Incentive Program incentivizes the purchase of fruits and vegetables, among participating households, in an effort to expand access to low-income communities.17 CDC Food Service Guidelines provide structure for facilities like schools, private work sites, and venues to improve food safety practices and increase access to healthier food by design.18 One example of a local-level program is Racial and Ethnic Approaches to Community Health (REACH), which works with urban, rural, and tribal communities in underserved areas with inadequate food systems to improve their access to healthy foods.19,20 Another 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.19 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

Increased evaluation and funding for existing efforts is needed to continually improve programs and resources for affected communities.8,10 This additional evidence will facilitate public health efforts to address access to healthy food choices as a social determinant of health.

Citations

1.

Zhao, D., Qi, Y., Zheng, Z., Wang, Y., Zhang, X. Y., Li, H. J., ... & Liu, J. (2011). Dietary factors associated with hypertension. Nature Reviews Cardiology, 8(8), 456–465. doi: 10.1038/nrcardio.2011.75

2.

Steinmetz, K. A., & Potter, J. D. (1996). Vegetables, fruit, and cancer prevention: A review. Journal of the American Dietetic Association, 96(10), 1027–1039. doi: 10.1016/S0002-8223(96)00273-8

3.

U.S. Department of Health and Human Services and U.S Department of Agriculture. (2020). 2020-2025 Dietary Guidelines for Americans: 9th Edition. https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf

4.

Joshipura, K. J., Hu, F. B., Manson, J. E., Stampfer, M. J., Rimm, E. B., Speizer, F. E., ... & Willett, W. C. (2001). The effect of fruit and vegetable intake on risk for coronary heart disease. Annals of Internal Medicine, 134(12), 1106–1114. doi: 10.7326/0003-4819-134-12-200106190-00010

5.

Penney, T. L., Brown, H. E., Maguire, E. R., Kuhn, I., & Monsivais, P. (2015). Local food environment interventions to improve healthy food choice in adults: A systematic review and realist synthesis protocol. BMJ Open, 5(4), e007161. doi: 10.1136/bmjopen-2014-007161 

6.

California Center for Public Health Advocacy, PolicyLink, & UCLA Center for Health Policy Research. (2008). Designed for disease: The link between local food environments and obesity and diabetes. https://healthpolicy.ucla.edu/publications/Documents/PDF/Designed%20for%20Disease%20The%20Link%20Between%20Local%20Food%20Environments%20and%20Obesity%20and%20Diabetes.pdf

7.

Ahern, M., Brown, C., & Dukas, S. (2011). A national study of the association between food environments and county‐level health outcomes. Journal of Rural Health, 27(4), 367–379. doi: 10.1111/j.1748-0361.2011.00378.x

8.

Davis, B., & Carpenter, C. (2009). Proximity of fast-food restaurants to schools and adolescent obesity. American Journal of Public Health, 99(3), 505–510.

9.

Ploeg, M. V., Mancino, L., Todd, J. E., Clay, D. M., & Scharadin, B. (2015). 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. Economic Information Bulletin-USDA Economic Research Service, 138. doi: 10.22004/ag.econ.262116

10.

Rose, D. (2010). Access to healthy food: A key focus for research on domestic food insecurity. Journal of Nutrition, 140(6), 1167–1169. doi: 10.3945/jn.109.113183 

11.

Ver Ploeg, M., Breneman, V., Farrigan, T., Hamrick, K., Hopkins, D., Kaufman, P., ... & Tuckermanty, E. (2009). Access to affordable and nutritious food: Measuring and understanding food deserts and their consequences: Report to Congress (No. 2238-2019-2924). doi: 10.22004/ag.econ.292130

12.

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.

13.

Sharkey, J. R., Johnson, C. M., & Dean, W. R. (2010). Food access and perceptions of the community and household food environment as correlates of fruit and vegetable intake among rural seniors. BMC Geriatrics, 10(1), 1–12. doi: 10.1186/1471-2318-10-32 

14.

Powell, L. M., Slater, S., Mirtcheva, D., Bao, Y., & Chaloupka, F. J. (2007). Food store availability and neighborhood characteristics in the United States. Preventive Medicine, 44(3), 189–195. doi: 10.1016/j.ypmed.2006.08.008

15.

Gustafson, A., Hankins, S., & Jilcott, S. (2012). Measures of the consumer food store environment: A systematic review of the evidence 2000-2011. Journal of Community Health, 37(4), 897–911. doi: 10.1007/s10900-011-9524-x

16.

French, S. A. (2003). Pricing effects on food choices. Journal of Nutrition, 133(3), 841S–843S. doi: 10.1093/jn/133.3.841S

17.

National Institute of Food and Agriculture. The Gus Schumacher Nutrition Incentive Program | National Institute of Food and Agriculture. Retrieved from https://nifa.usda.gov/grants/funding-opportunities/gus-schumacher-nutrition-incentive-program

18.

Centers for Disease Control and Prevention. (2021). Food Service Guidelines. https://www.cdc.gov/nutrition/food-service-guidelines/index.html

19.

Society for Public Health Education. (2019). REACH Urban Communities. https://www.sophe.org/focus-areas/health-equity/reach/reach-urban-communities/

20.

Mozaffarian, D., Liu, J., Sy, S., Huang, Y., Rehm, C., Lee, Y., ... & Micha, R. (2018). Cost-effectiveness of financial incentives and disincentives for improving food purchases and health through the U.S. Supplemental Nutrition Assistance Program (SNAP): A microsimulation study. PLoS Medicine, 15(10), e1002661. doi: 10.1371/journal.pmed.1002661

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