A food desert is any area in the industrialized world where healthful, affordable food is difficult to obtain. Food deserts are prevalent in rural as well as urban areas and are most prevalent in low-socioeconomic minority communities. They are associated with a variety of diet-related health problems.[1] Food deserts are also linked with supermarket shortage.
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The food desert concept was first introduced in the United Kingdom in the early 1990s to examine disparities in food pricing and to describe geographical areas with limited access to retail grocery stores (Ford). A food desert is a food environment unsupportive of health; it is defined by barriers which restrict access to healthful foods. Barriers may include lack of access to food retailers, availability of nutritious foods, or affordability of foods. Research has defined food deserts quantitatively or by neighborhood characteristics such as economic and social barriers. In 1996, a British Low Income Project Team defined food deserts as “areas of relative exclusion where people experience physical and economic barriers to accessing healthy foods” (Reising and Hobbiss, 2000). The exclusion refers to the shift of food retailers away from urban areas, an outcome of urban sprawl and segregation.
Food deserts are generally described areas with high poverty rates and low access to healthful food [1] (Story, Kaphingst, Robinson-O’Brien, & Glanz, 2008). This definition can apply to both rural as well as urban areas. A definition by Furey et al., reflects these characteristics, describing an area where “high competition from large chain supermarkets has created a void” (Furey et al. 2001). Cummings and Macintyre define a food desert as a “poor urban area, where residents cannot buy affordable, healthy food” (2002). Recently, the Mari Gallagher Research and Consulting Group has defined “food deserts” as large isolated geographic areas that cluster and are lacking or remain distant from mainstream grocery stores. White House representatives of the Let’s Move campaign have referenced the 2008 Farm Bill definition as “an area in the United States with limited access to affordable and nutritious foods, particularly in a low-income area” (USDA). More information, including maps, showing the distribution of food deserts in the Unites States can be found in Morton and Blanchard's 2007 article, "Starved for Access: Life in America's Rural Food Deserts," listed in the reference section (2007).
Despite differences in terminology, most research in the United States supports the hypothesis that on the neighborhood level, there are disparities in the retail food environment (Ford).
“Land-use policies that facilitate development of predominately wealthy and white suburban neighborhoods” have altered the distribution of food store. In the interest of profitability, larger supermarkets have followed this trend and are most prevalent in these white suburban neighborhoods (Morland, 2002). Prevalence of food deserts in poorer neighborhoods is driven by lack of consumer demand, as the poor have less money to spend on healthful, nutritious food. From an economic standpoint, low demand does not justify supply. Food retailers are also discouraged from opening chains in low-income rural and urban communities because of crime rates, transportation costs and low return on investment (Bitler & Haider, 2009). As a result, the food supply within inner-cities includes less variety, denying some urban residents the benefits of healthful foods at affordable prices (Yeh, 2006). Remaining food retailers in inner-cities are gas stations, convenience stores, and liquor stores. A diet based on foods from these locations consists primarily of processed foods high in calories, sugars, salt, fat, and artificial ingredients. Health disparities related to food access and consumption are associated with residential segregation, low incomes, and neighborhood deprivation.
The main factor used to classify a community as a food desert is distance from nutritional food retailers. There is no standard for “inadequate” access or “adequate” access to foods. This can be a limited classification and scientific limitation as individuals may live close to a retailer that provides nutritious food, but this food may be more expensive, creating an additional barrier to access. Access to food is calculated by distance of consumer residence to nearest supermarket or grocery store. Distance is measured from centroid of area an area (by zip code, census tract, or block) to nearest supermarket or grocery store. Standards of access and methods of measurement vary among researchers to determine food deserts. Research suggests food deserts exist if consumer residence is one to ten miles away from the nearest supermarket. Other measurements include “urban areas with 10 or fewer stores with no more than 20 employers” (Hendrickson et al. 2006). The USDA’s Thrifty Food Plan aims to standardize the methods of assessment for the availability and price of foods in stores.
Residents of food desert areas have no alternative but to utilize private cars, travel several miles on foot, or use public transit to gain access to healthful food. Consumers without cars are dependent on food sources in their closest proximity. Ownership and access to a vehicle may be the best marker for access regardless of Socioeconomic status. A study by Inagami reveals that the distance traveled to food stores is an independent predictor of BMI (Ford 61). The problem increases in rural food desert areas, where closing the distance to nutritional food access is impossible on foot.
Researchers have determined that distance to food is also psychological. The physical distance from fresh foods determine eating behaviors and preferences for palatable, processed foods. To create a healthy relationship with food, researchers recommend creating a direct connection between fresh produce and consumer. Examples of this include urban farm programs and incorporating healthful foods in schools.
According to a report to Congress prepared by the U.S. Department of Agriculture, assessing the extent of limited access to affordable, nutritious food, approximately 2.4 million households in the United States are more than a mile from a supermarket and lack access to a vehicle.[2] The physical distance from full service supermarkets leaves residents of these areas to be more likely to purchase food from convenience stores or corner shops that stock mainly cheap, processed foods or foods high in fats and sugars.[3]
Research indicates that low-income households shop where food prices are lower, and generally cannot afford healthful foods. Compared with residents of higher-income neighborhoods, low SES individuals generally have diets higher in meat and processed foods with a low intake of fruits and vegetables (Yeh, 2006). It has been suggested that people of low socioeconomic status ultimately spend up to 37% more on their food purchases, due to smaller weekly food budgets and poorly stocked grocery stores (Morland, 2002).
Fringe food retailers in food deserts can have a 30-60% markup on prices, provide a limited selection of products and a dominant marketing of processed foods. Comparing prices that consumers pay for similar foods purchased at a different outlets determines disparities in real food prices. Low-income individuals are more likely to purchase inexpensive fats and sugars over fresh fruits and vegetables that are more expensive on a per calorie basis (Story, Kaphingst, Robinson-O’Brien, & Glanz, 2008).[4] Nutritious foods such as whole grain products and fresh fruits and vegetables are more expensive than high calorie junk foods. “Energy-dense [junk foods] cost on average $1.76 per 1,000 calories, compared with $18.16 per 1,000 calories for low-energy but nutritious foods”.
A rural food desert is generally classified as a county where residents must drive more than 10 miles to the nearest supermarket chain or supercenter, whereas an urban food desert is classified as having to drive more than a mile. Using this definition, twenty percent of rural counties are considered food deserts (Policy Link and the Food Trust, 2010). Within these counties, there are approximately 2.4 million individuals determined to have low access to a large supermarket (USDA ERS, 2011). This number may underestimate those truly at risk of food insecurity since it only takes into account the number of individuals 10 miles or more away from the nearest supermarket. There may be individuals that live closer, however if they don’t have a vehicle or public transportation, then even being just a mile away can present access issues. This is a scientific limitation in studies of rural food deserts.
There is an increased risk of rural food deserts as market pressures continue to negatively impact small grocers. According to VerPloeg et al (2009), smaller grocers in rural areas struggle to be profitable for many reasons, such as low sales volumes, which can cause costs of goods to increase or make it difficult to purchase large volumes of perishable foods. This in turn creates issues with meeting wholesale food supplier’s minimum purchasing requirements (VerPloeg et al, 2009). “Economies of scale, which is when the costs of operating a store decrease as store size increases, and economies of scope, which is when the costs decrease as more product variety increases, suggests that larger stores that offer greater variety can do so and offer lower prices. Both factors may account for the ability of larger stores to survive more easily than smaller stores.” (Bitler, 2009) Small grocers tend to offer less variety and less produce as a result.
The market pressures experienced by small grocers in rural areas also lend to groceries being more expensive in these areas than in urban areas. For example, in New Mexico the same basket of groceries cost $85 for rural residents, and $55 for urban residents (Policy Link and The Food Trust, 2010). However, this is not true of all rural areas. A study in Iowa showed that four rural food desert counties had lower costs on key foods that make up a nutritionally balanced diet than did the nearby larger supermarkets (Morton, 2007). This suggests an area in which further research is needed.
Barriers to food access for elderly living in rural food deserts
As of 2007, the elderly made up 7.5 million of the 50 million people living in rural America (Rural Assistance Center, 2011). The U.S Census website includes maps showing the percentage of residents aged 65 and older (CensusScope, 2011). Of these elderly citizens, nearly a half million live in rural food deserts and are food insecure, while many more may be at risk (USDA ERS, 2011).
There are many barriers to healthful, affordable food for elderly living in rural food deserts. First of all, most elderly live on a fixed income. According to a study of rural seniors living in the Brazos Valley by Sharkey, et al. (2010), about 14% of respondents indicated that on a monthly basis household food supplies did not last, 13% could not afford to eat balanced meals, and 8.3% of respondents had to cut the size of their meals or skip meals altogether. A second issue faced by seniors is that they struggle with limited mobility. This can mean anything from having difficulty cooking and moving about their home, to not having a car or anyone nearby who could drive them to a store. Older persons and those with limited incomes are more likely to be dependent on family, friends, neighbors and others for transportation to purchase food (Bito et al, 2003). Older women are more likely than men to stop driving at younger ages or to have never driven, and minority women are even less likely to drive (Quandt, 2000). Additionally, the death rate from motor vehicle accidents among those ages 75 and older is second only to (and virtually identical with) the highest risk group of those ages 15-25 (CDC, 2009).
A third concern is that elderly have higher nutrient needs and are less able to tolerate the high sodium and sugar content typically found in processed foods. As people age, the degree of nutrient absorption in their digestive tract declines. Also, elderly tend to have existing diseases and/or take medications that interfere with nutrient absorption. There is evidence that elderly people living in rural areas suffer from inadequate nutrition intake due to low diet variety (Marshall et. al, 2001). If an elderly individual does not have a reliable source and access to an adequate amount of fruits and vegetables, as is the case in rural food deserts, their health is put in jeopardy and sets them up for future ailments.
Lastly, some seniors have time constraints that make it difficult to perform daily activities such as food shopping, especially when they are living with a sick spouse requiring a lot of their time and care. And for those who have recently lost a spouse and are sufferenig from depression, the desire to go to the store or cook for themselves can be greatly diminished, especially in the case of widows (Quandt, 2000).
Health disparities and adverse health outcomes are associated with residential segregation, poverty and neighborhood deprivation.
In a study on urban food environments, participants described the lack of supermarkets as both a “practical impediment to healthful food purchase and a symbol of their neighborhoods’ social and economic struggles” (Canuscio, 2010). Within cities, there are more than three times as many supermarkets in wealthier neighborhoods compared with poorer areas (Yeh, 2006). Residents in low-income urban areas are often “forced to depend on small stores with limited selections of foods at substantially higher prices” (Morland, 2002).
Research has found parallel trends between high rates of obesity and individuals of low SES and non-white ethnicity, particularly in the case of women. (Robert et al. & Schulz et al.). Research by Morland et al., found that areas with a majority of convenience stores have a higher prevalence of overweight and obese individuals, compared to areas with only supermarkets (Morland 42). Fast food restaurants are disproportionately placed in low-income and minority neighborhoods, and are often the closest and cheapest food options (USDA). “People living in the poorest SES areas have 2.5 times the exposure to fast-food restaurants as those living in the wealthiest areas” (Yeh, 2006). The lack of adequate food sources and limited transportation available to low-income communities are contributing factors to malnutrition among those living in low SES neighborhoods (Morland, 2002).
Research has documented inequalities of access to supermarkets in urban city areas, and found a difference in access to supermarkets in poor vs non-poor areas. A study by Baker et al., found that mixed-race areas were significantly less likely to have access to foods that adhere to a healthful diet compared to predominantly white, high income areas (Ford). Research by Mari Gallagher has found that African Americans are farther from healthful foods than other racial groups (Gallager) According to research, the availability of supermarkets in African American neighborhoods was 52% of their prevalence in white neighborhoods (Leone et al., 2008).[5] Moreover, Morland’s study of food-frequency data in the Atherosclerosis Risk in Communities (ARIC) study revealed that dominantly white populations had five times more supermarkets than neighborhoods with a dominantly non-white population. African Americans who lived in the same census tract with access to a supermarket were more likely to meet dietary guidelines for fruit and vegetable consumption. For each additional supermarket, an increase of 32% in fruit and vegetable intake was found. (Morland et al. 42).
A 2010 study by Michael Correll published by the Duke Journal of Gender Law & Policy entitled “Getting Fat on Government Cheese: The Connection Between Social Welfare Participation, Gender and Obesity in America," analyzed data from the Centers for Disease Control and the U.S. Department of Health and Human Services to assess the health outcomes of women participating in the government Food Stamps and Temporary Aid to Needy Families programs. The study primarily examines and critiques the structure of current social welfare policies, but it also notes: 1) Many of the participants in the food stamps program live in “food deserts." Some 25% of food stamps participants do not have easy access to a supermarket; and 2) Under welfare-to-work reforms enacted in 1996, an adult recipient must have 30 hours a week of “work activity” to receive these benefits. Because many women are single with children and thus have limited time, this work obligation may limit their ability to travel to find nutritious foods, prepare healthful meals for themselves and their families, and exercise.[6]
Prevalence of obesity is generally higher in rural areas as compared to urban areas. Socioeconomic factors inhibit access to private cars as well as limited reliable public transportation.
Initial research on food deserts explored the impact of retail flight from the urban core (Ford). More recent studies have explored the impact of food deserts in other geographic areas (e.g., rural and frontier), as well as among specific populations, such as minorities and elderly people. Studies of urban and rural food environments reveal significant potential for evidence-based interventions and policies to combat the growing obesity epidemic, and to decrease some health disparities. “Multilevel, mixed methods studies offer the potential to provide a more complete picture of the direct and perceived environmental influences on healthy behaviors” (Ford and 71).
A 2011 study published in the Archives of Internal Medicine, “Fast Food Restaurants and Food Stores,” used 15 years of data on more than 5,000 young adults 18–30 years old in a variety of places around the United States. The study's findings include: 1) Higher levels of fast food consumption were strongly correlated to fast food availability, particularly among low-income men with fast food restaurants within 1.00 to 2.99 km of their homes. A 1% increase in fast food availability within 1 km and 3 km of the home was associated with a 0.13% and 0.34% increase in fast food consumption, respectively; 2) Greater proximity to supermarkets was not correlated in any consistent fashion with diet outcomes, nor was it associated with fruit and vegetable intake levels; 3) There were no consistent or strong correlations between neighborhood fast food availability and individual consumption of fast food for women of any income level; 4) On average, men of all income levels consumed fast food 2.1 times a week, while their female counterparts consumed such food only 1.6 times. The study’s authors conclude that by “promoting greater access to supermarkets, several U.S. policies aim to improve diets through provision of affordable healthful foods, particularly fresh produce in underserved areas. Our findings do not support this initiative in young to middle-aged adults. Rather, they suggest that adding neighborhood supermarkets may have little benefit to diet quality across the income spectrum and that alternative policy options such as targeting specific foods or shifting food costs (subsidization or taxation) should be further considered.”[7]
A 2009 study of rural food deserts found a number of key differences in overall health, access to food, and the social environment when compared with urban environments (Smith and Morton). In terms of health, rural residents report overall poorer health and more physical limitations, with 12% of them rating their health as fair or poor, compared to 9% of urban residents (Smith and Morton USDA). Communities that are smaller and isolated from urban influences have decreased access to the broader global market and consequently have fewer choices in food retailers. Lack of competition in the community not only restricts access to food resources, but can also result in higher food costs. Respondents in this study felt that food quality and variety in their area were poor at times. The authors also found that although personal factors impact eating behavior for rural people, it is the physical and social environments that place constraints on food access, even in civically engaged communities.
But the study of food deserts requires further research, including longitudinal studies of food environments, to support associations with obesity and to support neighborhood interventions. Longitudinal studies “permit temporal associations” between exposure to nutritious food and obesity (Ford). They also provide historical data on grocery store location, nutritional environments, and data associated with life-course exposure to food (Ford).
Future research is required to overcome the barriers facing residents of food deserts, including retail trends and location of supermarkets, in order that food retailers and city planners may develop multilevel interventions to address barriers to health at the individual and environmental level. Studies that examine geographic differences in the access and availability of food, as well as nutritional quality of food, provide information for public health to explain disparities.
Other recent studies have shown some correlations between food availability and health, including a 2010 study that correlated distance from supermarkets with increases in body mass index (see DataHaven document, below). Among elderly people in particular, malnutrition caused by inadequate access to food can lead to other health risks. For those suffering from weight loss and undernutrition, risks include increased and longer hospitalizations, early admission to long term care facilities, and overall increased morbidity and mortality (Martin et al, 2006). Nutritional disorders with co-morbidities are the ninth most frequent diagnostic category among hospitalized rural elderly Medicare beneficiaries. Elderly adults struggling with obesity and overnutrition related to limited food choices are at risk of exacerbating existing chronic conditions, such as heart disease and diabetes, and increased functional decline (Martin et al, 2006; Jensen and Friedmann, 2002).
Access is not the only determinant to healthful eating. There are many environmental determinants that predict a positive outcome in healthful eating for residents of current food desert areas, such as transportation, culture, social capital, and food price. A criticism of current research on food access and obesity assumes a “simplistic deprivation effect associated with poor-quality food environments” (Ford).
Prevalence of food deserts in poorer neighborhoods is driven by lack of consumer demand, as the poor have less money to spend on healthful, nutritious food. From an economic standpoint, low demand does not justify supply. Food retailers are also discouraged from opening chains in low-income rural and urban communities because of crime rates, transportation costs and low return of investment (Bitler & Haider, 2009).[8]
However, audit research suggests that supermarkets are the most effective way to supply communities with a wide selection of fresh and relatively affordable healthful food. Moreover, supermarkets typically are open year-round, provide convenient hours of operation, and generally accept EBT (electronic benefit transfer).[9] As a result, many programs focus on increasing incentives for supermarkets to operate in these underserved areas. Some incentives include property or sales tax breaks. Community-level interventions that focus on getting healthful food to low-income areas through farmers markets, mobile carts or community gardens (Ploeg 2009).
One community intervention that increases food access is the community garden. Community gardens enable individuals to grow their own food on a designated area of land that is shared with other community members. Community garden programs successfully increased access to affordable, nutritious food in rural, suburban and urban areas. They also help strengthen community and social support for participants (Hale et al., 2011).
The USDA released an extensive report to Congress in 2009 as a request to reform the Food, Conservation, and Energy Act of 2008. The study outlines a list of recommendations for addressing access issues in food deserts that include the above options, but also includes transportation reform as a solution (USDA). Transportation is a significant barrier in rural food deserts (rural realities). Evaluating current transportation in these communities and developing community-specific solutions can target populations limited by current transportation options (rural realities). According to Morton and Blanchard, there is a need to address the added complications of individuals living in these isolated communities. Proposed solutions include utilizing a combination of public and private resources. Current transit assistance and meal-provisioning programs that are already established in many communities, such Meals on Wheels, have initiatives that focus on providing food residents with limited mobility and ability to shop at traditional food retailers (Meals on Wheels, 2011).
In early 2010 the Obama administration unveiled the Healthy Food Financing Initiative (HFFI) that will promote a range of interventions that expand access to nutritious foods, including developing and equipping grocery stores and other small businesses and retailers selling healthful food in communities that currently lack these options. The initiative provided more than $400 million in funding intended to bring grocery stores and healthful food retailers to low-income rural and urban communities. This effort is in concert with Michelle Obama’s “Let’s Move” campaign to counter childhood obesity. The initiative receives funding from the Treasury Department, Department of Agriculture and Department of Health and Human Services(HHS)
Several states and cities within the United States are also implementing comprehensive programs that involve public-private partnership and a combination of financing initiatives and community-level interventions[10].. The Pennsylvania Fresh Food Financing Intitative, for example is a public-private partnership aimed at encouraging the development of new supermarkets by providing grants of up to $250,000 or loans of up to $2.5 million per store to defray the infrastructure costs of developing a new store. So far, $41.8 million in grants and loans have funded 58 stores[2] (Ploeg, 2009).
The New York City FRESH program (Food Retail Expansion Health) is one of the most comprehensive attempts to increase access to full-service grocery stores in underserved areas. They offer an abatement of land or building taxes for a period of 25 years and a sales tax exemption on building materials[5] (Leone et al., 2008).
Community-level interventions are useful in that they are less expensive and easier to implement than programs that encourage the creation of new stores. They require less space, promote local farmers and increase community and social capital.
Citizens of a rural community in North Carolina collaborated to develop and implement a solution to the problem of access to food in Bertie County, the poorest in the state (Schwartz, 2011). Community members, in conjunction with a class at the public high school, designed and constructed a pavilion to serve as the home for a local farmers’ market. This is one example of committed civic engagement, which can be a strong determinant in the successful development of community-specific solutions and improved access to food. Community involvement and the incorporation of local organizations and volunteerism can improve the effectiveness of food safety nets and alternative solutions such as community gardens (Smith, Morton, 2009).
However, farmers markets can be costly for low-income individuals living in these communities (Leone et al., 2008).[5] The City of New York has implemented several community-level initiatives such as increasing the number farmers markets in underserved areas and increasing their use by residents through the Health Bucks program. This program offers $2 coupons purchasing fresh fruits and vegetables at participating farmers markets. This program was intended to reduce barriers to access based on affordability. Through this program, EBT sales at farmers’ markets more than doubled from $40,000 in 2007 to over $89,000 in 2008 (Nonas, 2009). The program is being expanded into upstate New York as the Fresh Bucks program.
Another proposed solution involves increased local food production and distribution in urban centers. The New York City Regional Foodshed is an initiative examining the local food production capacity of the New York City Metropolitan Region.