Socioecological Perspectives: The Environmental Level
Key Messages Noted by Participants
One critical question from the socioecological perspective is whether the environment is a mediating factor between food insecurity and obesity, said Katherine Alaimo, associate professor in the Department of Food Science and Human Nutrition at Michigan State University, who moderated the session on the environmental level. “Regardless of whether or not there is a causal pathway between food insecurity and overweight we know that [they can] coexist,” she said. “There is a possibility that one of the reasons why both of these things exist is because of [influences from] the environ-
ment.” Three speakers addressed this topic at the workshop, focusing specifically on the availability, quality, and marketing of food.
THE FOOD ENVIRONMENT IN COMMUNITIES
Obesogenic environments are becoming more common, said Angela Odoms-Young, assistant professor in the Department of Kinesiology and Nutrition at the University of Illinois at Chicago. The least expensive food options are typically high in calories and low in nutrients. Households with limited resources tend to spend less on food overall and less on healthful foods such as fruits and vegetables (Alaimo et al., 2001; Drewnowski and Specter, 2004; Hartline-Grafton et al., 2009; Ludwig and Pollack, 2009; Larson and Story, 2010a).
Some evidence suggests that food-insecure families may be more susceptible to obesogenic environments for a variety of reasons including the ways in which food assistance is distributed, maternal stress, and disruptive family routines (Anderson and Whitaker, 2010; Gundersen et al., 2010). In addition, race/ethnicity, poverty, household structure, and location (such as living in a rural or urban area or in the Midwest or South) all interact with both food insecurity and obesity in complicated ways (Kendall et al., 1996; Blanchard and Lyson, 2002; Powell et al., 2007; Nord et al., 2008; Sharma et al., 2009; Chen and Escarce, 2010; Grow et al., 2010; Ogden et al., 2010).
Surprisingly, Odoms-Young said, relatively few studies have looked at the ways in which the environment, food insecurity, and obesity are interconnected. She discussed several possible mechanisms that could tie together these three phenomena as a guide to future research.
The first mechanism is the high availability of energy-dense food options and the low cost of less healthful options. People living in low-income areas and communities of color tend to have less access to outlets that carry more healthful food options and greater access to stores with less healthful options (Cheadle et al., 1991; Morland et al., 2002a, 2002b; Laraia et al., 2004; Lewis et al., 2005; Zenk et al., 2005). Odoms-Young cited one study that looked at the relationship between food pantry clients and the food environment in Pomona, California, which demonstrated that these families had lower access to stores that carried more healthful food options and that only 9 percent lived within walking distance of the pantry (Algert et al., 2006). In this study, 83 percent of food pantry clients were within walking distance of stores with limited or no produce, generally small to midsized convenience marts, while 41 percent of the food pantry clients did not live within walking distance of a store carrying a variety of fresh produce.
Odoms-Young described studies she has conducted in Chicago and Detroit in neighborhoods with reduced access to healthful foods. As one person surveyed in Chicago said, “You go all the way out to the suburbs where the white people live at and you find everything…. It’s even a better variety in [chain supermarkets] when you go to their stores. There’s a difference.” Another person interviewed in Detroit said, “You’ve got to go out in the suburbs now to get some decent food. And therefore, it’s not available for us in this community. By the time you get to that store and get some fresh fruits and vegetables, you’re going to pass about 30 fast-food joints and about 100 liquor stores.” In these cases, added Odoms-Young, the stress of living in neighborhoods perceived to be substandard may further contribute to obesity.
Dietary energy density tends to be inversely associated with dietary quality and cost, so that people eating more calorie-dense foods are eating less healthful and cheaper foods, regardless of socioeconomic status (Monsivais and Drewnowski, 2009; Townsend et al., 2009). These dietary patterns are in turn associated with obesity. For example, Powell et al. (2010) found that a 10 percent increase in the price of fruits and vegetables was associated with a 0.7 percent increase in child body mass index (BMI). The impact of prices on BMI was stronger in both magnitude and significance for children of low compared to high socioeconomic status (SES).
The marketing of foods is another mechanism that could create differences between higher-income and lower-income communities. Yancey et al. (2009) showed that living in an upper-income neighborhood, regardless of the residents’ predominant ethnicity, is generally protective against exposure to most types of obesity-promoting outdoor advertising, including fast food, sugar-sweetened beverages, sedentary entertainment, and transportation advertisements. Food advertising coverage was greatest in low-income Latino neighborhoods, and fast-food advertisement coverage differed by neighborhood income but not ethnicity. The most advertisements for sugar-sweetened beverages were found in low-income African-American neighborhoods. Even though there was less advertising coverage in upper-income than in low-income African-American neighborhoods, it was similar to the coverage levels in low-income white and Latino neighborhoods.
Odoms-Young and her colleagues have done a study with low-income African-American families of how food marketing and environmental factors affect consumption (Odoms-Young et al., 2010). Low-income and food-insecure families can be very sensitive to discount-oriented marketing, she said. In her study, many families received information about food
products from store circulars and other types of community promotions. Many families reported that marketing efforts for unhealthful foods were most intensive at the time people received food benefits. As one person said, “So you’d about spent all your stamps on the junk food, cause you ain’t even got to the meat and stuffs. You are still over here in this one aisle. But there is how it is. All the pop stacked up against the wall right there, you got your box of cookies, big box of cookies over here.”
Community violence plays a role in food choices. In some locations where people access food, violence and other illegal activities are frequent. People may not go at night to certain stores to avoid robberies or other forms of crime.
Zenk et al. (2010) have shown that greater everyday unfair treatment and an acute experience of unfair treatment in the past year were positively associated with greater consumption of comfort foods in the presence of a convenience store in the neighborhood. In contrast, for those with a large grocery store in the neighborhood, greater everyday unfair treatment and neighborhood physical environment stress were negatively related to comfort food intake.
Low-Resource Environments as a Source of Stress
Negotiating a low-resource environment can be a major source of stress. Odoms-Young reported that another interviewee in her study said, “That’s the thing that kills us most because most of us don’t watch what we eat you know…. Most of us in this area are stressed beyond belief. Because they are trying to make ends meet, they’re trying to figure out how they’re going to feed their families or how are they going get their kids to school next week off the $54 paycheck they just got. So you know high blood pressure is a big thing and diabetes is another big thing because of, again, we don’t watch what we eat and we don’t exercise properly.”
In conclusion, said Odoms-Young, the evidence suggests that the environment affects the relationship between food insecurity and obesity. She said that more research is needed on the following:
The cost of food, marketing, and community stressors
The varying impact of social, economic, and geographic factors
The relationship of the food environment to obesity among families that are not food insecure, including high-income families
THE FOOD ENVIRONMENT IN SCHOOLS
The Food Trust, which was founded in 1992, is an organization of about 85 people based in Philadelphia that seeks to increase access to affordable, nutritious food. “Are children, especially those at risk of hunger, eating the right amount of the right kinds of foods to maintain a healthful diet?” This question speaks to the quantity, frequency, and quality of the food that children eat, said Allison Karpyn, director of research and evaluation for The Food Trust.
Eating Opportunities During the School Day
Students have a variety of opportunities to eat at school. Reimbursable school meals include breakfast, lunch, twilight meals (after-school meals provided by the Child and Adult Care Food Program), and snacks, and summer meals when school is not in session. Competitive foods—so called because they compete with the foods provided by schools—include vending machine items, foods from school stores, rewards from teachers, and foods made available at class parties and fundraisers. Foods brought into schools from outside include those prepared at home, bought from stores, and purchased at fast-food restaurants.
For the average child, on a school day 26 percent of daily energy is obtained and consumed at school, according to national survey data (Briefel et al., 2009a). If a child participates in the National School Lunch Program (NSLP), the proportion increases to 35 percent. If a child participates in both the NSLP and the School Breakfast Program (SBP), the figure is 47 percent.
Food Assistance Programs in Schools
Among the children who are certified for reimbursable school meals, more than 40 percent are from families that earn less than $10,000 a year. “This is a striking statistic for me,” said Karpyn. “We are talking about a number of families that come from very low incomes.”
Karpyn displayed a typical breakfast menu (Figure 7-1) and lunch menu (Figure 7-2) for Philadelphia’s public schools. Children get an average of about 400 calories from breakfast and 560 calories from lunch. About 31 million children participated in the NSLP in 2009, which represents about
60 percent of school-aged children in America, at a cost of about $10 billion. About 11 million participated in the SBP, representing a cost of about $3 billion. Among children eligible for free and reduced-price meals, 79 percent of those who are eligible for a free meal on average each day actually take a lunch, while 71 percent of those eligible for a reduced-price lunch do so.
Participation in the NSLP went up 13 percent from 2000 to 2008 (School Nutrition Association, 2009), while the SBP saw an increase in participation of 40 percent over the same period. However, the effectiveness
in reaching low-income students with the SBP varies greatly among cities, from 98 percent in Portland, Oregon, to about 29 percent in New York City and Chicago (Levin et al., 2007).
Participation in the SBP is associated with lower BMI, although the effect size is small (Gleason et al., 2009). Other researchers, such as Millimet et al. (2010), have found null or modestly beneficial effects and cite evidence of nonrandom selection into the SBP as a problem with such studies. Overall, said Karpyn, although some changes in the program are desirable, “it looks like school breakfast is basically a good thing.”
Participation in the NSLP, in contrast, appears to have a null or possibly detrimental connection to BMI, according to Millimet et al. (2010). However, some researchers have found positive influences on dietary intakes, such as reduced intake of sugar-sweetened beverages and increased intake of fruits and vegetables (Briefel et al., 2009b). Data from the National Health and Nutrition Examination Survey (NHANES) show that some children who are participating in the NSLP are eating more nutrient-dense lunches, including more milk, fruits, and vegetables (Cole and Fox, 2008).
According to a nationwide study of the food consumed at school, home, and other locations, about 17 percent of the calories public school children consumed consisted of foods brought into school from outside (Briefel et al., 2009a). About 50 percent of the children studied in a Philadelphia-based project shopped at least once a day in corner stores, about 40 percent shopped twice a day, and at each purchasing opportunity they bought about 350 calories and spent about a dollar on food (Borradaile et al., 2009).
Larson and Story (2010b) have found that limiting access to competitive foods improves diets. In Philadelphia, the top 10 purchased items include bottled water, Doritos, blow pops, gum, Cheetos, and—at number 1—Hugs, which are 8-ounce sugar-sweetened beverages (Borradaile et al., 2009). Vending machines, school stores, and snack bars remain very prevalent in schools and are largely exempt from federal standards. School wellness policies may regulate such food outlets, but these policies generally are not enforced. Schools have competing priorities, because food sales generate revenue.
Models for Improving School Eating
In Philadelphia, The Food Trust worked with the School District of Philadelphia and a number of collaborators on the School Nutrition Policy Initiative. A taskforce of 40 people representing different sectors has established school health and wellness councils. All schools completed a
School Health Index and a School Health Action Plan. Social marketing, food guidelines, and nutrition education were at the center of the initiative. Teachers received 10 hours of nutrition training, and family members and the community were involved. Over a 2-year period, 15 percent of students became overweight in the control schools versus 7.5 percent in the schools where the interventions were implemented (Foster et al., 2008). However, the initiative did not have an effect on the remission of obesity (i.e., moving individuals from overweight or obesity to a normal weight).
Another program that has led to changes in schools is the Healthy Corner Store Initiative. The Food Trust has worked with hundreds of corner stores to change their product mix and promote more healthful products. A school-based program also has been instituted to educate students about how to improve their purchasing patterns in corner stores.
Policy and Practice Considerations
Karpyn listed changes in policy and practice that could have an effect on child obesity:
Enforce wellness policies
Make breakfast part of the school day
Include meal participation rates on school report cards
Increase the reimbursement rate
Provide universal free meals
Reevaluate procurement practices to improve available foods
Provide integrated nutrition education
Establish school wellness councils
Create standards and accountability for competitive foods
Engage in farm-to-school programming
Continue working with corner stores
Karpyn also listed the following research considerations:
What strategies are most effective in upgrading the food consumed from school lunch lines? Possibilities include increases in reimbursement rates, strategic procurement, educational interventions, farm-to-school programs, and taste testing.
In what ways do food marketing, merchandizing, and product placement influence purchasing and consumption in schools and at stores?
How does the availability of competitive food affect participation in food assistance programs in schools?
What can cross-disciplinary studies reveal about diet, educational achievement, and behavioral outcomes?
How can taxpayers be engaged in the support of research and the implementation of research-based policies?
Karpyn concluded by calling to task politicians who blame the hungry for their condition. “We have ignored for too long the pervasive attitude of pointing blame back at the individuals who are struggling. We haven’t done enough to engage the taxpayers to talk about what is in it for them, why this is a societal issue, and why we need to be responsible as taxpayers.”
In the final presentation of the session on environmental factors, Diego Rose, professor in the Department of Community Health Sciences at Tulane University, challenged the argument that environments impact the relationships between food insecurity and obesity, unless one considers a neighborhood or an environment itself as being food insecure. This viewpoint might alter our understanding of the coexistence of poverty, food insecurity, and obesity.
Store Access and Food Consumption
Rose reviewed studies linking neighborhood access to stores and consumption, beginning with the work done by Morland and colleagues (2002a) that linked the presence or absence of a supermarket in a census tract to fruit and vegetable consumption among African Americans. Similarly, Blanchard and Lyson (2003) demonstrated a relationship between residence in a food desert and decreased fruit and vegetable intake.
In the United Kingdom, Wrigley et al. (2002) showed that the opening of a new supermarket leads to increased fruit and vegetable intake. Laraia et al. (2004) and Rose and Richards (2004) also showed that improved access to a supermarket leads to improved diets and increased fruit intake, respectively, findings confirmed by Moore et al. (2008). “What those studies show is that there is a connection between [access to] stores and consumption.”
Rose put these findings into the context of a consumer choice model (Figure 7-3). In traditional models, food purchases are determined by the prices of goods, household income, and tastes and preferences, which are often modeled with proxies such as age, ethnicity, or education. Rose focused instead on food cost, which includes the price for food and how much
it costs to travel to a store. This depends on such factors as the distance to a store, what is offered in a store, and whether a person owns a car. The variety of products, shelf location, and marketing also can affect preferences through promotional effects and social acceptability.
Food purchases are in turn related to consumption and obesity, which would require additional boxes to the right of his model, said Rose. For example, Morland et al. (2006) have linked the presence of supermarkets in a census tract to a decreased prevalence of obesity and the presence of convenience stores to increased obesity. Powell and colleagues (2007) have connected chain supermarket density to decreased BMI and convenience store density to increased BMI. Smaller-scale studies, such as Lopez (2007) and Rose et al. (2009), have produced similar results. In a national longitudinal study, Sturm and Datar (2005) found that the higher the price for fruits and vegetables in area stores, the higher was the BMI for first-through third-grade students.
Neighborhood Food Availability and Consumption
Focusing solely on store access, however, misses the point that not all stores offer the same products. A number of studies have used in-store surveys to study the foods available in a neighborhood and the connection
to consumption. For example, Cheadle et al. (1991) found an association between shelf space for low-fat milk, meats, and high-fiber breads and people’s consumption of those products in 12 communities in California and Hawaii. Fisher and Strogatz (1999) and Edmonds and colleagues (2001) also looked at the links between the foods being offered in stores and restaurants and consumption. Franco et al. (2009) used the Nutrition Environment Measures Survey (NEMS) to develop a score of diet quality in the store and looked at consumption, finding a relationship between low diet quality and low availability of healthful foods.
Rose and his colleagues found associations in four census tracts in New Orleans between the shelf space allotted to vegetables and vegetable consumption (Bodor et al., 2008). In another study of 103 tracts in southeastern Louisiana, the shelf space allotted to energy-dense snacks was linked with greater BMI (Rose et al., 2009). “If you measure the chips, cookies, candies, and sodas and add it all up within a kilometer of where people live, there is an association with body mass index.”
School Food Environments
Rose also discussed the consumption of food in schools. In a study of the NSLP, Gordon and Fox (2007) found that participants in the program had a higher consumption of calories than nonparticipants. However, their lunches tended to include more nutrients along with more calories, and participants in the program had lower consumption of competitive foods.
Several studies have looked at the availability of vending machines and consumption. Kubik et al. (2003) found a negative association between the availability of vending machine snacks and fruit and vegetable consumption in Minnesota middle schools. In Washington State middle schools, the availability of sugar-sweetened beverages in vending machines was positively associated with consumption (Johnson et al., 2009). Rovner and colleagues (2011), based on a national sample from 2006 and 2007, found that vending machines with fruits, vegetables, and candies each showed a positive association with consumption.
In summary, said Rose, neighborhood studies show associations between food environments, dietary intake, and weight. However, most of these studies are cross-sectional. Future research needs to look at interventions or panel studies to determine causality, particularly regarding the effects of prices on consumption and obesity, he said.
Moderator: Katherine Alaimo
During the group discussion period, points raised by participants included the following:
Adam Drewnowski observed that research also needs to look at where people actually shop, not just at the characteristics of the stores in a neighborhood. Many people do not shop in their immediate neighborhood. In Seattle, where people tend to shop by car, they may go to a supermarket considerably farther away than the one nearest their homes. “We need to have data on destinations, not just distance.”
Karpyn noted that Amy Hillier at the University of Pennsylvania is doing qualitative and quantitative work on how people shop. When people are using their WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) vouchers, they tend to go to the nearest corner store because they are not price sensitive, she said. With SNAP (Supplemental Nutrition Assistance Program) benefits, they may go to a supermarket. “I agree with you. It is very complicated.”
Modes of Transportation to Shopping
Odoms-Young pointed out that many studies are not able to capture all of the places where people shop. Her studies have shown that some people are walkers and some are riders, and not all riders have cars. In the latter case, people may need to exchange something for rides, which involves social costs. For example, if someone is coming to another person’s home to do informal work, that person may be able to get a ride to or from home or a store. People also have access to food from other people’s homes and from food pantries, not just from stores.
Rose described a proposed study that would convert shelf space at corner stores from junk food to fruits and vegetables and determine the effects. To prepare for the study, he and his colleagues asked a random sample of 100 people from the neighborhoods selected for the study about everything consumed in the previous 24 hours and where it was purchased. They found that 75 percent of the people did not use the corner store. Of the 25 percent who did, the items targeted for intervention by the study
were a minor dietary factor (which led to changes in the study design). The major source of calories from corner stores was the lunch counter in the back preparing sandwiches and other foods.
Programs for Very Young Children
Alexandra Adams mentioned the importance of preschool and home day care environments. These programs tend to use different food reimbursement programs than do schools, which can affect consumption.
Food Use in Homes
Adams also mentioned that people may use WIC to feed their entire families, not just their children, which could have adverse consequences on some children. Finally, she emphasized not just whether food is available in the home but how it is used. For example, is anyone able to cook food? “A lot of the families that I work with of all ethnicities have really low cooking skills. Because of that, they value getting prepared foods that are more expensive, or they value being able to go out to fast foods.” The role of cooking skills is an important target for research, she said, because simply increasing the availability of food will not necessarily lead to greater use of that food.
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