Healthy Food Access in Urban Areas: Barriers and Solutions Part 1

Healthy Food Access in Urban Areas: Barriers and Solutions Part 1


MOLLY MITCHELL: Good afternoon,
everyone, and welcome. My name’s Molly
Mitchell, and I’m the manager of the Mid-Atlantic
Public Health Training Center. And on behalf of
the training center and the Maryland Department
of Health and Mental Hygiene, I’d like to welcome everyone
to today’s presentation, our May public health practice
grand rounds on “Healthy Food Access in Urban Areas– Barriers and Solutions.” And before I introduce our
speakers today and get started, I’ve just got a few
announcements to make. For those of you who
are watching online, I’d like to invite you
to please check out some of our archived
grand rounds that are on our
website, as well as some of our other online
trainings as well. And I’d like to
draw your attention to some of our live face-to-face
trainings that are coming up, including grant writing
and logic modeling. And just alert that next
month’s grand rounds is going to be on reducing
asthma disparities in children. Also, for those
watching online, please know that any time during
the presentation you can email a question to
either of our presenters by simply clicking on the link. And we also do ask that you fill
out the sign-in form so that we can give our federal funders a
better idea of who’s watching and how many people are
watching today’s webcast. And so with that, I’m going
to go ahead and introduce our speakers today, Anne
Palmer and Holly Freishtat. Since 2006, Anne has been the
Eating for the Future Program director at the Johns Hopkins
Center for a Livable Future. She’s responsible for directing
the food and nutrition work at the center. This includes
identifying opportunities to build awareness
about the current food system and its impact on public
health and the environment, collaborating at a regional
level with other institutions to determine the potential
of regional food systems reaching underserved areas,
working with Baltimore City’s food policy director on
improving food access in Baltimore, and facilitating
community food assessments with community organizations. Prior to this position,
Anne worked for 13 years developing and managing
strategic communications and large-scale health
communication campaigns and programs in Asia. She holds a masters of
international affairs degree in communication and
development studies. And our second speaker
today is Holly Freishtat. Holly Freishtat is Baltimore
City’s first food policy director. In this role, she created
the Baltimore Food Policy Initiative and
intergovernmental collaboration that aims to increase access
to healthy, affordable food in food deserts
in Baltimore City. Ms. Freishtat has spent over a
decade working on food issues in a variety of
contexts, including work on food and health policy
as a Food and Society Policy Fellow and at the Washington
State University King County extension, where she founded
a farm-to-school program and developed the
program’s gardening and cooking
nutrition curriculum. Ms. Freishtat also
worked for Skagitonians to Preserve Farmland,
where she developed a farm-to-health
health care pilot project that provides healthy
seasonal foods to hospitals and retirement
communities while creating new markets for farmers. Ms. Freishtat has a
masters of science from Tufts University
in food policy and applied nutrition, and was
a Food and Society Policy Fellow in 2007. So with that, I’m going to turn
the floor over to Anne Palmer. Thank you. ANNE PALMER: Good
afternoon, everybody. I’m thrilled to be here today. I just want to thank Molly for
inviting us both to come down. As she said, I work at the
Center for a Livable Future. We are an
interdisciplinary center in the School of Public Health. And we really look
at the intersections of public health, the
environment, agriculture, and food. And so a lot of our work
is looking at the systems, even though today we’re
going to be talking primarily about healthy food and
healthy food access. So why do we even
talk about food? And I think one of
the things that I’ve noticed since I’ve been
working on this topic area is that we have treated a lot
of different services in city government, such as
water, air, food, shelter et cetera– except for
food, we have treated those with– that they need
to be attended to and regulated in some way. And so I think one
of the things that we see with the increase
of diet-related disease is that food has primarily
been in the private sector. And we’ve sort of left it there
until certain trends started happening and we realized
that maybe this needed to be considered more as
a service or as a good that the public has
to have access to. And so I think what you’re
seeing there has just been a boon in
literature and research and activities going on
around the country around food and what’s going on
with our food system, in large part driven by
the obesity epidemic, but by other reasons– you know, for other
reasons as well, is that there is an attempt
now to try to structure food and to attend to it in a
way that we need to do it from a policy perspective and
an environmental perspective as well. So I want to talk a
little bit about some of the current trends and
what has changed in our food system over the past probably
about, I’d say, 30 to 40 years. And then I’m going
to talk specifically about how some of these
play out in urban areas. Think about going into a store– any store. And it is unlikely
that you’re not going to find food of some sort. I have noticed food in auto
parts stores, libraries. Any possible store you could
go into has a food display. So we have tons and
tons of opportunities to be eating all the
time, continuously. We have more food available now
than we’ve ever had available. So really, you don’t
ever have to be hungry. I think the other thing you’ll
notice in our food system is that we have an abundance
of the types of food products that we are developing. I don’t mean different
varieties of carrots. This is really more
processed food. So if you were in a
grocery store in the 1970s, you’d find about
8,000 food products, and now you find about
48,000 food products. And so those are really
much more processed foods than we ever had
access to before. The other thing that’s happened
is you see a big increase in serving sizes. And because people
are eating out more, that that actually has
a bigger impact in terms of the number of calories
they’re taking in. Throughout the
presentation, I’m going to talk about what
some of the barriers are to people accessing
food in urban areas. And I’m going to look
at it from a perspective of physical barriers,
economic, social, and educational barriers. And where it’s
feasible to do that, I’m also going to
talk about some of the Baltimore-based
research that has been generated on these topics. Before I do that, I do want to
introduce you to some concepts and to some
definitions that we’re going to be using
throughout the presentation. Food security is really just
do people have sufficient food to live, do they
have enough food, are they experiencing
hunger on a regular basis. If you are a food
secure individual, there is some point in the
course of a month or a year where you don’t have
adequate access to food and you’re experiencing
hunger of some sort. So food security and insecurity
are concepts that are generally well known in our field. The other definition
is something we call community food security. And this is a much more
holistic definition about what’s happening at that
community level with regards to food. And so you look at not only
is there just food there, but what’s the
quality of the food, is it nutritionally
high quality, is it culturally acceptable. Where is the food being grown? Where is it coming from? How is it being transported? How much participation
do the people who live in that area have in
getting their food, or are they just
going to this one store that happens to be located
2 miles from their house? So it really is
an attempt to look at what’s happening at
that community level. And recognizing the
household level’s important as well, but trying
to back up a little bit and seeing what’s happening
in a community with this. And then when we use the
term food environment, we’re really just talking
about any source of food that exist in a given
area– a community, we can say, any geographic area. So it’s restaurants, gas
stations, food stores, supermarkets, corner stores– anything like that is part
of that food environment. So what’s the food
situation in Baltimore? So I think we have a pretty
interesting situation. I’m sure a lot of you
you’ve heard the term food deserts before. And I’m going to talk a
little bit about that. Holly will talk about
that more in detail. But I think what you’ll
see happening in Baltimore is if you live in a
lower-income community, that the food that you
have available to you isn’t necessarily
always the best quality. There’s a lot more processed
food, a lot more fast food. And in some cases, the food
is also not very affordable. Our food insecurity rate
in the state of Maryland has increased
pretty dramatically. I just updated these statistics. It used to be about 9%,
and we are now up to 12.5%. And that’s a steady
increase since 2008. And we have households, up 5.1%,
that have experienced hunger on a regular basis. And that was about 3%
just a few years ago. So we really are
seeing the effects of the recession and the
economics impacting people in their ability to get
food and to be food secure. And you’ll see that
we are still lower than the national average, but
we’re climbing, unfortunately. In addition, you will find that
even poverty isn’t necessarily a predictor. You find a lot of
people living in poverty that are not food insecure. But that definitely is
there is this pretty strong relationship. So I’m going to talk
about physical barriers now, and think a little bit
about the built environment and how that impacts people’s
ability to get healthy food. For each of these bullet
points, this is typically one study that’s been done. As you know, from being
researchers yourself or people who have studied,
that for every study you can find that
says one thing, you can find a study
that says something else. So you’re going to hear some
contradictions in what I’m saying. But just bear in mind
that this is just to give you some sense of
the complexity of looking at these systems. So if you see a headline
in The New York Times that says this is not
a problem, this study shows that, that it’s
always important to dig deeper and figure out what
are they really trying to measure there,
because I think you’ll find that there’s
evidence depending on how you measure it. So this particular study looked
at if you added a supermarket, did it have a change in
the consumption levels and fruits and
vegetables– of produce. And in one study, they
found that it is up to 30% more that consumption increased. And this was among a
group of African Americans in the low-income neighborhood. You also find that if
you have a low income– you’re designated low income
in particular zip codes, that you’re going to have fewer
supermarkets in your zip code. Again, by design–
and this is more looking at what’s the
relationship, what’s the density of the
food stores there. A newer study that has come out
breaks this down in a little more granular way that I think
is really important to look at. So if you don’t
have a supermarket, and then you do
have a supermarket– so you’re changing
that food environment– that supermarket is a
source for healthier food. However, if you’re
somebody who has access to a lot of different
supermarkets, having more access
doesn’t necessarily make it a healthier food choice. It makes it somewhat
unhealthier. Then it ends up being a
dose response, almost. You’re getting so
much food around you that you’re not making
different choices. And what they found in
this particular study, that if you were now shopping
at a supermarket versus perhaps a smaller corner
store or a grocery, that you were increasing
the number of purchases you made for produce. We also have a
situation in Baltimore– I think we have 44
supermarkets in Baltimore. Is that right, Holly? So 44 supermarkets. And what we know about
those supermarkets is they’re very different. If you go to a
supermarket in Roland Park and you go to a supermarket
in southwest Baltimore or in east Baltimore, what’s
inside that supermarket and the quality of that
market varies dramatically. This research that I’m
for referencing right now is actually funded by a Center
for a Livable Future Innovation Grant. Dr. Franco had published this. And so a lot of the data is
going to be coming from that. But what he found is when
you looked at the food that was actually in the store– and he gave this score using
a particular measurement tool called the nutrition
environment measurement survey– came up with an index score. And those scores
for supermarkets in low-income neighborhoods
were about half fewer compared to a
predominantly middle to high-income
white neighborhood. So it really does
make a difference in terms of where
you’re living, in terms of what you have access to. This I found rather
fascinating– even if you were looking
at a chain market. So if you had a Safeway store
in Baltimore City and a Safeway that was out in
the county, there would still be a fairly dramatic
difference in the healthy food availability score. So it is not consistent
across chains. And they actually do really
market to those neighborhoods what they think is
going to sell and what they think people want. If you look at diet– this was, again, from
the same dataset. I’ve now since read data
that has said this maybe isn’t as strong a predictor. This was using the
MESA dataset, which is a cardiovascular
disease dataset of 900 patients in Baltimore. And when Dr. Franco
looked at this, he found that those patients
had a lower-quality diet than people– if you lived in a
low-income neighborhood and had low healthy
food availability than people who were
living in middle to upper-income neighborhoods. So again, it’s not only
affecting purchasing patterns, but it’s affecting
consumption patterns as well. Now I’m going to talk a little
bit about economic barriers and what happens. And as you can imagine,
if you’re a supermarket, you aggregate a lot
of your purchases. And so you have volume buying
and you can offer people much better prices. If you’re a small corner
store, you typically are buying from a wholesaler,
sometimes even going to maybe a big box store
and buying those items. And so you’re going
to charge more, because you aren’t buying
the volume that you need to have lower prices. So that’s one way of explaining
the difference in what happens with prices. But I think even with that,
knowing that, there is still is probably some price inflation
going on that we can see. Brookings Institute
had done a study that looked at 132 food
products over 3,000 and found that 2/3 of them
were more expensive if you are in a store that
was under 10,000 feet. A small supermarket would
be about 25,000 square feet. Some of the supermarkets now,
they’re closer to 50,000, 60,000, even 70,000 square feet. So just to give you
some sense of size. These are really
more small grocers. And we used some of the
data that Dr. Franco collected to look at what
the cost differences were in Baltimore. And we found that up to $1.30
more for a box of cereal, and then a half gallon milk
was actually about $0.81 more. If you’re living
on a tight budget, that is a pretty dramatic
amount to be paying more for. The other study that I’m
a co-author on that’s going to be published in
the next couple of months is a supermarket study looking
at how people make decisions. And when people are factoring in
how to shop and where to shop, the other things they
are going to cost out aren’t just going to be
the cost of the food, but they’re also going to
look at how long does it take for them to get
to the store, what’s the cost of that transportation. And spoilage and
waste is a big factor. If they’re going to a store
that maybe the quality of the produce isn’t so
great, and it might only last a few days, that can
be a bit of a problem. Are you going to buy
your produce there? Or, are you going
to just not buy produce because
the chances are it might go bad before
you need to eat it. So that becomes part of
those economic barriers that people calculate in when
they’re making food decisions. We did a community
food assessment in southwest Baltimore
back in 2008, just to give you an idea of
how the money gets divided. This was about 147 people
I think that we talked to in the southwest neighborhood. There were two markets
there at the time. On average in a month,
they spent about $280 at the supermarket, but
they also spent about $140 at the corner store, which
was pretty significant. So if you think about
walking into a corner store and spending that type
of money, and what food is available to you,
it’s pretty poor quality, for the most part. And there are a
lot less options. What we tend to find in
terms of patterns of shopping is that people will go once
a month, maybe twice a month, to a larger supermarket and
do the bulk of their buying. And then they use those corner
stores and smaller markets to fill in what they need. And so it ends up being not an
insignificant amount of cash when you’re on a budget. This is one of my favorite
topics, food marketing. I identify this as
a social barrier because I think it really
affects our social norms and how we eat and
where we choose to eat. And I always like
to think that I’m too smart to be
pulled into marketing, and nobody’s going to
pull it over on me. I’m not going to buy something
because they said that. And yet, I find myself
oftentimes going, oh, maybe I’ll just try this. So I think this has a huge
influence on the way we shop and how we shop. And lots of money gets spent
on this to study humans and what their behaviors are. And what we have found– one of the studies that showed
that if you looked at shows that were deemed African
American in terms of the audiences
they were reaching, more unhealthy foods were
marketed during that time, and that there were just more
food commercials in general. And another study looking
at low-income children and how much they watch
TV, and that they do have more exposure. And so again, this goes
back to the dose response of the types of foods that
you’re being regularly exposed to from a marketing perspective
can be dramatically different. And you don’t really
see commercials for fruits and vegetables. I mean, there was raisin
commercials I think years ago, but that’s about
the extent of it. We eat a lot of our
calories away from home. And because of that, we have
to look at restaurants– fast food restaurants, sit-down
restaurants, et cetera. I think some of the more robust
research we’re finding now, because people are starting to
realize that we aren’t really– yes, there are a lot of
people going back to cooking. But in fact, a lot of
people still don’t cook, and they’re spending
a lot of money out– that the fast food issue and
the zoning issues around those, and the density of fast
food, has become a big topic to be studied. So a couple of these are
some of the newer studies that have come out on this. So if you have a fast food
restaurant within walking distance– and I think
in some of the studies– I’m not sure what the measure
was for this first one by Dr. Lee. But in some of the
studies, they were saying if it was within
a mile of your house, you were much more likely
to have a diet that was higher in fast food. So it’s just that
convenience factor. It’s there. You’re going to have
more opportunities to shop there or buy food there. In general, the
other thing we find is that low-income
areas have more access to all types of food. And so everything from
sit-down restaurants, to fast food restaurants,
to convenience stores, to grocery stores– I mean, this was a
relatively new finding. Again, I go back to the
quality of the grocery store, what does that mean. But they’re densely populated
with all kinds of food. And so if you look at it
from, again, a dose response, you’ve got lots of opportunities
to be eating all the time. And then they did a little bit
of modeling on this last study that looked at the availability
and what would happen. And it seems as though
if you had some kind– and I don’t know how
you would do this. Maybe Holly has some ideas. But if you have some kind of
protective barrier in terms of how far away should those
fast food restaurants be from residential areas,
could you actually lower consumption in some cases? And they do think that
if it wasn’t as densely populated with some
of these stores, the opportunities to
lower consumption rates could be quite significant. Again, more on the
social barriers. What you’ll find is disparities
between populations. So if you’re an
African-American student living in an urban area, you’re going
to have a much greater exposure than your white counterparts. The chain restaurants in
low-income neighborhoods tend to be more unhealthy. And this had to
have been using– there’s like a nutrition
environment measurement survey that’s done for
restaurants as well. The restaurant issue gets
a little dicey sometimes when you’re talking about
measurement because I don’t think there’s a lot of evidence
that sit-down restaurants are healthier. But somehow, they’ve
been deemed healthier. I think you can eat
probably just as much. And calorie-wise, I don’t know
that there’s any evidence. But there seems to be some
understanding out there that perhaps you
have more options, and so you would have healthier
options than you would at a fast food restaurant. And then the other
part of that is– the last bullet is talking
about the sensitivity to cues and just the presence. They did find that if you
looked at low-income residents and having access to
all these fast food restaurants, that you had
greater exposure, greater opportunities to eat. But that finding, actually,
was really significantly true for men, but not nearly
as significant for women. So that’s kind of
an interesting– and I think this was also– across age ranges,
this was true. Women maybe are cooking more. They didn’t really
hypothesize it. I think that’s probably
what you’re seeing more of. Then just looking a little
bit more at social barriers and what happens when we get
introduced to certain types of foods at a really young age. So if you’re growing
up in a neighborhood, and you have a lot of
exposure to fast foods and unhealthy foods– fried foods,
whatever– they tend to be the foods that
you know as your food. And that becomes part
of your food culture. And it is very hard to
change people’s food culture. I think you have to be
very deliberate about it. You have to have
a lot of agency, and wherewithal, and
resources in order to shift your eating habits. And I think one
thing that we don’t talk a lot about in the food
system studies is taste. You get accustomed
to certain tastes, and those taste good to you. And let’s face it– if you have a bag of
chips in front of you and you have an apple
in front of you, I immediately go, oh, I
should have the apple, but what I really
want are the chips. So if you don’t have those
apples in front of you– maybe you’re not eating those– maybe it’s this kind of baked
chip versus a fried chip– that those are the tastes
that you begin to know. And they become the
ones that you want. And again, that’s a really
tough thing to change. And I think they certainly know
in terms of studies introducing kids to healthier food when
they’re younger, their ability and their taste buds– they actually become
more accustomed to those. This goes back to
a little bit more of the social barriers in terms
of the disparities in general. We know that there
are disparities amongst low-income populations
and middle and upper income. And that can go everything
from education and literacy to time available, to just
daily stress in your life. The less you have
sort of a social fiber and a social network around
you to help support you in any of your life
activities, the less likely you are to probably
feel like you have the opportunities to
make changes or do things differently. Many low-income people are
working, and sometimes working more than one job. Time cooking becomes
a very big barrier. The Thrifty Food
Plan, which I believe is used by USDA to help
determine food stamp benefits, that we now call SNAP benefits. And they say that based
on what they allow people and what’s allocated
to them, they should be cooking 14 hours a week. So in reality,
most women, if you look at a nationally
representative population, cook about seven hours a week. So that’s even a
greater disconnect when you add the other things
into a low-income person’s lifestyle and what
they’re having to do in terms of child care,
and if they don’t own a car, they’re taking public
transportation. The chances of them
cooking for 14 hours a week to fill that Thrifty
Food Plan are probably pretty unlikely. So that becomes yet
another barrier. Then I want to talk about
educational barriers. There are some interesting
findings with this. And some of these have
come out relatively new. But we know that
education level does impact how people choose to shop
and what they choose to buy. What I think is
probably less clear is that which comes first. Is it because those
unhealthy foods are there and they’re cheap? And just how cheap is cheap? Do they have the extra
income to spend more on healthier whole foods? So it’s not clear, really,
I think, what direction that’s going in. So yes, they have unhealthier
food purchasing patterns. But what’s actually driving
those purchasing patterns? And I think there’s a lot
of things that drive it. We also know that
if you give people a little bit of
nutrition education around food choices, that they
do make different choices. And they do a lot. They change shopping patterns. They’re more likely
to try new foods. So you’re increasing
purchasing and consumption. You see increases
in consumption. But that isn’t necessarily
going to always be enough, because there are a
lot of other things that factor into how they
make their decisions. And I think one of
the things we’re learning on this
supermarket study is just how
complicated it can get and where are those levers that
you can push that are maybe a little bit easier to tip it
over that line versus something that’s going to be a
very dramatic shift. Can you get people to purchase
entirely new types of food, or is that even necessary? Is it more about what’s a
healthy, affordable food– and then how can
they take that food and create a healthier
meal versus you need to buy a lot more of these
foods that you’ve never tried and maybe aren’t as familiar? So there’s probably
a sweet spot in there that I hope we’re going to find
with our supermarket study. But right now, we know obviously
information is not enough. It really needs to be more. And then this, I think,
I covered already. I believe environments
really do have a lot to do with how people
choose to shop. Even if you walk
into a store and see what’s immediately
available to you, what’s available at
eye level, what’s available at the cap aisles– all of those are
very strategically located within a
store to make you want to purchase those items. Most of the time, those items
are not healthier food choices. And if you’re in a
neighborhood that already has a supermarket
that isn’t selling particularly a lot
of healthy food, you’re going to be prone to it. You’re going to see a
lot more of food items in there that are not healthy. And so your
opportunities, again, are going to be much
greater than if you’re in a supermarket that
doesn’t have as many of these processed
food products. And then last– I’ve covered this. The strategies that people use
to overcome these obstacles. And our paper hasn’t
been published yet, but it will be coming out soon. So hopefully I’ll
be happy to share with anybody who’s interested. But this does really look at,
from a qualitative perspective, how these decisions
are being made. I think that’s the end of mine. I’m going to turn
it over to Holly, and just I hope given you
guys some appreciation for just the system that’s
in place that makes our food choices difficult. There we go. It makes it difficult for
people in low-income areas. So thanks.