The Flint Food Store Survey: combining spatial analysis with a modified Nutrition Environment Measures Survey in Stores (NEMS-S) to measure the community and consumer nutrition environments

Caregiver-reported barriers to engagement in a paediatric fresh fruit and vegetable prescription programme

Paediatric fruit and vegetable prescription programmes hold promise in improving food security and dietary patterns among youth. However, programme success is largely dependent upon caregiver and family engagement. The current study sought to gain a better understanding of environmental barriers to engagement in a paediatric fruit and vegetable prescription programme in one low-income, urban community (Flint, Michigan, USA). Following the implementation of a paediatric fruit and vegetable prescription programme, researchers conducted thirty-two semi-structured interviews with caregivers. Researchers explored caregivers' understanding of the fruit and vegetable prescription programme, barriers to programme engagement, and recommendations for improvement. Telephone interviews were transcribed for textual analysis. Researchers used thematic analysis to examine qualitative data, determine patterns across transcripts, and develop emerging themes. Researchers concluded interviews when data saturation was reached. The majority of participants were female (94%), African American (66%), and residents of Flint (72%). Five recurrent themes emerged: (1) nutrition security; (2) prescription distribution; (3) prescription redemption; (4) educational supports; and (5) programme modifications. Although caregivers indicated that the prescription programme addressed household food insecurity, environmental barriers to engagement were apparent. Caregivers provided suggestions, such as partnering with large grocery stores and developing digital prescriptions, to address programme engagement challenges. Fundamental to the success of fruit and vegetable prescription programmes is the understanding of barriers to engagement from the perspective of participants. This study explores challenges with one paediatric fruit and vegetable prescription programme and provides actionable solutions, from the viewpoint of caregivers, to address these challenges.

Measuring access to food banks and food pantries: A scoping review of spatial analysis approaches

Food banks and food pantries are crucial in supporting access to food and addressing food insecurity for millions of people. This scoping review identified eighteen articles that applied spatial analysis approaches to measure access to food banks and food pantries. The review summarizes the methods and primary findings of these studies, and examines how these address different dimensions of food access. Findings suggest that the majority of studies measured the accessibility and availability dimensions of food access, and two addressed accommodation. Through a discussion of these studies' methods and broader literature on food environments, we highlight opportunities to integrate advanced geospatial and mixed methods to support an empirically grounded and broader understanding of food bank and pantry access in future research. This will yield a more holistic picture of food environments and provide practical implications for site selection, resource allocation, and food assistance operations.

A Fresh Fruit and Vegetable Prescription Program for Prenatal Patients in Flint, Michigan: Baseline Food Security and Dietary Intake

Although adequate nutritional status during pregnancy is necessary to support optimal fetal development, many low-income women have poor access to fresh, high-nutrient foods. To address these challenges, a pediatric fruit and vegetable (FV) prescription program was expanded to include pregnant women, providing one prescription for fresh FVs worth 15 US dollars during each prenatal office visit for redemption at farmers'/mobile markets. This analysis describes baseline sociodemographic characteristics, food security, and dietary intake among 253 pregnant women in Flint, Michigan in 2022-23. Dietary recall data were collected and analyzed using the Automated Self-Administered 24-h Tool developed by the US National Cancer Institute, with nutrition output reported in relation to adherence to US Dietary Guidelines. Most participants (mean ± SD age 26.51 ± 4.90 years) identified as African American (53%) and were receiving publicly funded health insurance (66%). Most (75%) reported no food insecurity, yet the majority failed to meet dietary recommendations for whole grains (99.3%), vegetables (93.1%), dairy (93.1%), and fruits (69.4%). Moreover, most did not meet micronutrient recommendations through food sources, including vitamin D (100%), iron (98.6%), folic acid (98.6%), vitamin A (82.6%), calcium (68.8%), and vitamin C (62.5%). Results raise deep concerns regarding diet and nutrition among pregnant women in this US city.

Consumer nutrition environment measurements for nutrient-dense food availability and food sustainability: a scoping review

Consumer nutrition environments are defined as places in which consumers interact with the food they eat; these food choices can impact human and planetary health. Assessment measures for consumer nutrition environments are numerous, and vary widely on what, and how, they assess the food environment. The objective of this scoping review was to synthesize existing evidence on nutrition environment measurements and their capacity to assess nutrient-dense food access and food sustainability capacity. Eligibility criteria were developed to capture relevant peer-reviewed literature about auditing measures designed to assess nutrient-dense foods and food sustainability capacity in the consumer nutrition environment. A search strategy was conducted to collect articles published between January 1, 2002-June 4, 2022, using PubMed, Web of Science, Scopus, PsycINFO and the Cochrane library electronic databases. After screening 2457 manuscripts, 58 met inclusion criteria. Study aims, funding source(s), types of retailers assessed, assessment format and name, constructs measured, food categories measured, assessment of validity and/or reliability, and other relevant data were extracted from each manuscript. Results showed that most measures use checklists, surveys, questionnaires or similar methods to assess availability, quality, and price of select food items as assessment constructs. Most do not assess nutrient-dense food availability, and even fewer assess food sustainability. Development of comprehensive, reliable, and valid consumer nutrition environment measures that assess nutrient-dense food availability and food sustainability is important for research, planning, evaluation and advocacy aimed at improving consumer food environments for human and planetary health.

'Nobody Shops at the Neighborhood Store': Leveraging a Community's Pediatric Fresh Produce Prescription Program to Inform Future Participating Store Redemption Locations

Research examining the nature of food shopping often considers proximity to the nearest or overall distance travelled to multiple stores. Such studies make up a portion of new work on so-called 'food deserts' and the issues inherent in the term, including that most people do not shop at their nearest store, and mobility challenges vary vastly from one person to the next. Increasing the knowledge base on shopping characteristics could be useful for behavioral interventions and programs aimed at increasing healthy food shopping. In this study, we examined the shopping characteristics of 627 caregivers whose children were enrolled in a pediatric fresh produce prescription program at one of three large pediatric clinics in Flint, Michigan. We compared these characteristics to the potential of a new food cooperative to improve geographic accessibility to healthy food. In particular, we propose the expansion of the prescription program to this new cooperative for health-related as well as local economic development reasons. Our work bridges topics of interest to researchers and practitioners working in nutrition, food access, and economic development.

Understanding Barriers and Strategies to Accessing Healthy Food in Urban Agriculture for Community Residents in Predominantly Black Communities

BACKGROUND

Some residents in predominantly Black communities face significant challenges in accessing healthy food. However, urban agriculture is a growing sector that aims to increase overall food production, access to affordable and nutritious produce, and potentially improve community food security.

PURPOSE

This study aimed to provide insight into barriers and strategies that urban agriculture growers and advocates identified for accessing urban agriculture markets in their communities.

RESEARCH DESIGN AND STUDY SAMPLE

We interviewed and conducted focus groups with 17 urban growers and local food advocates that work in predominantly Black communities in Chicago.

DATA COLLECTION AND/OR ANALYSIS

Understanding the complexities of access to healthy food can be challenging; therefore, we used the concept of access - accessibility, availability, affordability, accommodation, and acceptability - to better understand these barriers.

RESULTS

Key barriers were the lack of accessibility to traditional food retailers, high availability of processed foods, and cultural acceptability of urban-produced foods.

CONCLUSION

Building urban agriculture networks to support growers, connect with consumers, and emphasize political engagement can help to diversify and grow urban agriculture.

Structural racism and geographic access to food retailers in the United States: A scoping review

This scoping review summarized findings and key measures from U.S.-based studies that 1) examined associations between geographic indicators of structural racism (e.g., redlining, racial segregation) and access to food retailers (e.g., supermarkets, convenience stores) or 2) documented disparities in access by neighborhood racial/ethnic composition. In 2022, relevant scientific literature was reviewed using Covidence software. Independent reviewers examined 13,069 citations; 163 citations advanced to the full-text review stage and 70 were selected for inclusion. Twenty-one studies (30%) linked one or more indicator of structural racism to food retailer access while 49 (70%) solely examined differences in access by neighborhood racial/ethnic composition. All studies featuring indicators of structural racism reported significant findings; however, indicators varied across studies making it difficult to make direct comparisons. Key indicators of structural racism in the food access literature included redlining (n = 3), gentrification (n = 3), and racial segregation (n = 4). Many U.S.-based studies have evaluated food retailer access by neighborhood racial/ethnic composition. Moving forward, studies should model indicators of structural racism and determine their influence on geographic access to large and small food retailers.

A Vanishing Food Infrastructure: The Closure of Food Outlets in Flint in a Pandemic Era

Most food access studies focus on large cities, examine traditional grocery stores, and only consider operational food outlets. This siloed approach exposes a gap in food access literature. Therefore, as a part of our assessment of Flint’s food landscape, we examined closed food outlets in the city and surrounding townships. We investigated the relationship between the racial composition of census tracts and the number and type of defunct food outlets identified. We used Data Axle to collect and verify data on open and closed food outlets between September 2020 and December 2021. We made a final verification of the food outlet closures in June 2022. We used ArcGIS 10.8.1 and SPSS Version 28 to map and analyze the data. We used negative binomial regression models to determine differences in the likelihood of having an additional closed food outlet in census tracts with low and high percentages of Black residents. We also investigated the relationship between a census tract’s median income and the likelihood of having an additional closed food outlet. There were 173 closed food outlets; 81 were in Flint, and 92 were in surrounding townships. The most frequently closed food outlets were restaurants; they accounted for 45.1% of the closures. The mean number of closed food venues in census tracts where less than 40% of the residents were Black was 1.5. The mean was similar in census tracts where 40% or more of the residents were Black; it was 1.6. This difference was not significant. However, the median income of a census tract was a significant predictor of the likelihood of having an additional closed food outlet. Every one-thousand-dollar increase in median income resulted in a 2% less likelihood of having an additional closed food outlet. The results of this study show that there is more to the food landscape of a city than its operational food outlets. Focusing exclusively on active food outlets does not accurately depict a city's food infrastructure.

"The Shelves Are Bare": The Impact of COVID-19 on Families Enrolled in a Pediatric Produce Prescription Program

Objectives A large pediatric clinic in Flint, Michigan, implemented a produce prescription program for youth to address enduring challenges with food access and food insecurity. Approximately 18 months later, on March 23, 2020, the State of Michigan issued a "stay home, stay safe" executive order in response to the COVID-19 pandemic. This study sought to (1) explore caregiver experiences with access to and utilization of the prescription program during COVID-19; and (2) understand perceived changes in the food environment during the "stay home, stay safe" executive order. Methods Researchers collected data through recorded, semi-structured telephone interviews with caregivers of children who received at least one produce prescription and had previously enrolled in a preliminary effectiveness study on the prescription program. We transcribed the recordings verbatim for textual analysis. Examining the qualitative data using thematic analysis, we identified patterns across transcripts and formulated illustrative themes. Results Fifty-six caregivers (mean age, 41.3 ± 10.3 years) participated in interviews. The majority were female (91%), African American (70%), and Flint residents (75%). Recurrent themes, each centered around changes in the food environment resulting from COVID-19, emerged: (1) produce prescription access and utilization; (2) food access constraints; (3) food shopping adjustments; and (4) food insecurity stress. Perceived consequences of COVID-19 included increased anxiety related to food shopping and food insecurity alongside challenges accessing and utilizing the produce prescription program. Conclusions This study highlights the many ramifications of the COVID-19 pandemic on vulnerable families. More comprehensive efforts are necessary to address substantial barriers to healthy food access and affordability caused by the recent pandemic.

Development and Validation of a Set of Instruments to Measure Food Environments

BACKGROUND

There is worldwide interest in measuring local food environments (FEs). The aim of this study was to develop and validate a set of instruments to evaluate FEs in Chile.

METHODS

Based on the development and validation of four instruments to measure FEs, a literature review, an evaluation by experts, and the implementation of a pilot tool in the FEs of schoolchildren from nine public schools in the commune of Chillán, Chile, were used.

RESULTS

A tool to evaluate FEs was provided, based on three dimensions: availability, variety, and advertising of healthy foods. A total of 1928 foods points of purchase were evaluated. The reliability was evaluated by Cronbach's alpha. Some 74% of the foods' points of purchase were store locations. The reliability of the four instruments was high to acceptable (store: 0.90; institution: 0.77; street food: 0.74; restaurant: 0.68). Unhealthy foods were highlighted by the scores obtained: store (6.08 ± 4.07; range: 0-13), restaurant (3.95 ± 1.75; range: 0-10), street food (1.18 ± 1.56; range: 0-7), and institution FEs (3.38 ± 2.78; range: 0-9).

CONCLUSIONS

The results of this tool can provide information to governments for incorporating structural measures to ensure adequate availability, variety, and advertising of healthy foods in different FEs.

Refining the Nutrition Environment Measures Survey (NEMS) for Healthy Community Stores: Adaptations to Capture Alternative Food Retailers and Align with Dietary Guidelines

Inadequate consumption of healthy food is an ongoing public health issue in the United States. Food availability measures of supply versus consumption of healthy foods are disconnected in many studies. There is a need for an objective assessment of the food environment in order to assess how the food supply aligns with the Healthy Eating Index (HEI). Data were collected as part of the Healthy Community Stores Case Study Project, including a refined Nutrition Environment Measures Survey for Healthy Community Stores (NEMS-HCS) and an updated Healthy Food Availability Index that aligns with the Healthy Eating Index (HFAHEI). This paper will focus on the NEMS-HCS development process, findings, and HFAHEI application. All food items were more likely to be found at grocery stores rather than corner stores. Food pricing was often above the Consumer Price Index averages for six food items. The NEMS-HCS assessment better aligned with the HEI because it included a wider variety of meats, frozen fruits and vegetables, and an increased selection of whole grains. HFAHEI scoring was inclusive of non-traditional and alternative community stores with a health focus, making it suitable for use at the local level, especially in neighborhoods where supermarkets and large chain stores are less common.

Mapping the Way to Good Health: The Interdisciplinary Challenges of Geographers in Medical Research

Geography has an important role to play in shaping the direction of medical research. In particular, its tools and theory provide essential understanding to the impacts of place on health behaviors and outcomes. Understanding some of its evolution-particularly into the subfield of medical geography-is therefore useful both for geographers and medical researchers. In this paper, we present some of the debates that geographers have grappled with, the growth of GIS (particularly in the context of medical research), some important methodological considerations that geographers help center, and some recommendations for future work at this nexus. Throughout, we speak from the perspective of geographers who have worked nearly exclusively in the health sciences since obtaining our PhDs.

Balancing Mission and Margins: What Makes Healthy Community Food Stores Successful

Mission-driven, independently-owned community food stores have been identified as a potential solution to improve access to healthy foods, yet to date there is limited information on what factors contribute to these stores' success and failure. Using a multiple case study approach, this study examined what makes a healthy community food store successful and identified strategies for success in seven community stores in urban areas across the United States. We used Stake's multiple case study analysis approach to identify the following key aims that contributed to community store success across all cases: (1) making healthy food available, (2) offering healthy foods at affordable prices, and (3) reaching community members with limited economic resources. However, stores differed in terms of their intention, action, and achievement of these aims. Key strategies identified that enabled success included: (1) having a store champion, (2) using nontraditional business strategies, (3) obtaining innovative external funding, (4) using a dynamic sourcing model, (5) implementing healthy food marketing, and (6) engaging the community. Stores did not need to implement all strategies to be successful, however certain strategies, such as having a store champion, emerged as critical for all stores. Retailers, researchers, philanthropy, and policymakers can utilize this definition of success and the identified strategies to improve healthy food access in their communities.

Assessing the Influence of Food Insecurity and Retail Environments as a Proxy for Structural Racism on the COVID-19 Pandemic in an Urban Setting

A collaborative partnership launched the Great Grocer Project (GGP) in March 2021 in Detroit, Michigan where health inequities, including deaths due to COVID-19, have historically been politically determined and informed by socially entrenched norms. Institutional and structural racism has contributed to a lack of diversity in store ownership among Detroit grocers and limited access to high-quality, affordable healthy foods as well as disparate food insecurity among Detroit residents. The GGP seeks to promote Detroit's healthy grocers to improve community health and economic vitality through research, programs, and policies that have the potential to advance health equity. A cross-sectional design was used to explore relationships between scores from the Nutrition Environment Measures Surveys-Stores (NEMS-S) in 62 stores and city-level data of COVID-19 cases and deaths as well as calls to 211 for food assistance. Regression and predictive analyses were conducted at the ZIP code level throughout the city to determine a relationship between the community food environment and food insecurity on COVID-19 cases and deaths. COVID-19 cases and deaths contributed to greater food insecurity. The use of ZIP code data and the small sample size were limitations within this study. Causation could not be determined in this study; therefore, further analyses should explore the potential effects of individual grocery stores on COVID-related outcomes since a cluster of high-scoring NEMS-S stores and calls to 211 for food security resources inferred a potential protective factor. Poor nutrition has been shown to be associated with increased hospitalizations and deaths due to COVID-19. It is important to understand if a limited food environment can also have a negative effect on COVID-19 rates and deaths. Lessons learned from Detroit could have implications for other communities in using food environment improvements to prevent an uptick in food insecurity and deaths due to COVID-19 and other coronaviruses.

Ultra-Processed Food Availability and Sociodemographic Associated Factors in a Brazilian Municipality

The availability of ultra-processed foods in a municipality tends to be related to different types of food retailers and their location in the territory, besides social, economic, and demographic factors. The aim of this study was to evaluate the availability of ultra-processed foods according to different types of food retailers and sociodemographic factors. This is a cross-sectional observational study carried out with audit data from food retailers in the municipality of Jundiaí, SP. Using a validated instrument, data on the availability of 18 types of ultra-processed foods were used to create a score of ultra-processed foods, ranging from 0 to 100 points, and five subscores referring to the ultra-processed food subgroups. Descriptive statistics and means comparison tests were performed to verify differences in the ultra-processed food availability score, according to the food retail type, household income, number of household members, and percentage of people of the color population in the census tract in which food retailers were located. Geo-referenced maps were used to characterize the score of ultra-processed in the territory, according to sociodemographic variables. A total of 649 food retailers were analyzed, most of which were classified as neighborhood markets (25.4%). The supermarkets were the category with the highest ultra-processed food availability score. Among the subgroups of ultra-processed foods analyzed, candies, soft drinks, and snacks were available in 60% of the food retailers. Higher ultra-processed food availability score was observed in regions with lower income, higher percentage of people of color population, and higher number of members per household. The findings show that the greater availability of ultra-processed foods is related to supermarkets and markets and regions of greater social vulnerability, which can put this population at nutritional risk.

Food insecurity in Detroit: exploring the relationship between patient-reported food insecurity and proximity to healthful grocery stores

OBJECTIVE

The objective of the current study was to determine if patients of a large health care system in Detroit who self-identify as food insecure live further away from healthy grocery stores compared with food secure patients. Second, we explored whether food insecurity and distance to healthy grocery stores are related to ecological measures of vehicle availability in the area of residence.

DESIGN

A secondary data analysis that uses baseline data from a pilot intervention/feasibility study.

SETTING

Detroit, Michigan, USA.

PARTICIPANTS

Patients of Henry Ford Health System were screened for food insecurity to determine eligibility for a pilot intervention/feasibility study (i.e. Henry's Groceries for Health), conducted through a collaboration with Gleaners Community Foodbank of Southeastern Michigan. Only patients residing in Detroit city limits (including Highland Park and Hamtramck) were included in the secondary analysis. Of the 1,100 patients included in the analysis, 336 (31 %) were food insecure.

RESULTS

After accounting for socio-demographic factors associated with food insecurity, we did not find evidence that food insecure patients lived further away from healthier grocery stores, nor was this modified by ecological measures of vehicle access. However, some neighbourhoods were identified as having a significantly higher risk of food insecurity.

CONCLUSIONS

Food insecure patients in Detroit are perhaps limited by social and political determinants and not their immediate neighbourhood geography or physical access to healthy grocery stores. Future research should explore the complexity in linkages between household socio-economic factors, socio-cultural dynamics and the neighbourhood food environment.

Effect of a pediatric fruit and vegetable prescription program on child dietary patterns, food security, and weight status: a study protocol

Background

Although nutrients in fruits and vegetables are necessary for proper development and disease prevention, most US children consume fewer servings than recommended. Prescriptions for fruits and vegetables, written by physicians to exchange for fresh produce, address access and affordability challenges while emphasizing the vital role of diet in health promotion and disease prevention. Michigan’s first fruit and vegetable prescription program (FVPP) exclusively for children was introduced in 2016 at one large pediatric clinic in Flint and expanded to a second clinic in 2018. The program provides one $15 prescription for fresh produce to all pediatric patients at every office visit. Prescriptions are redeemable at a year-round farmers’ market or a local mobile market. The current study will assess the impact of this FVPP on diet, food security, and weight status of youth.

Methods

Demographically similar pediatric patient groups with varying levels of exposure to the FVPP at baseline will be compared: high exposure (> 24 months), moderate exposure (12–24 months), and no previous exposure. Data collection will focus on youth ages 8–16 years. A total of 700 caregiver-child dyads (one caregiver and one child per household) will be enrolled in the study, with approximately 200 dyads at clinic 1 (high exposure); 200 dyads at clinic 2 (moderate exposure), and 300 dyads at clinic 3 (no previous exposure). Children with no previous exposure will be introduced to the FVPP, and changes in diet, food security, and weight status will be tracked over two years. Specific aims are to (1) compare baseline diet, food security, and weight status between pediatric patients with varying levels of exposure to the FVPP; (2) measure changes in diet, food security, and weight status before and after never-before-exposed children are introduced to the FVPP; and (3) compare mean 12- and 24-month follow-up measures of diet, food security, and weight status in the initial no exposure group to baseline measures in the high exposure group.

Discussion

Completion of study aims will provide evidence for the effectiveness of pediatric FVPPs and insights regarding the duration and intensity of exposure necessary to influence change.

Trial registration

The study was registered through clinicaltrials.gov [ID: NCT04767282] on February 23, 2021.

Increasing Healthy Food Access for Low-Income Communities: Protocol of the Healthy Community Stores Case Study Project

Improving healthy food access in low-income communities continues to be a public health challenge. One strategy for improving healthy food access has been to introduce community food stores, with the mission of increasing healthy food access; however, no study has explored the experiences of different initiatives and models in opening and sustaining healthy food stores. This study used a case study approach to understand the experiences of healthy food stores in low-income communities. The purpose of this paper is to describe the methodology used and protocol followed. A case study approach was used to describe seven healthy food stores across urban settings in the U.S. Each site individually coded their cases, and meetings were held to discuss emerging and cross-cutting themes. A cross-case analysis approach was used to produce a series of papers detailing the results of each theme. Most case studies were on for-profit, full-service grocery stores, with store sizes ranging from 900 to 65,000 square feet. Healthy Food Availability scores across sites ranged from 11.6 (low) to 26.5 (high). The papers resulting from this study will detail the key findings of the case studies and will focus on the challenges, strategies, and experiences of retail food stores attempting to improve healthy food access for disadvantaged communities. The work presented in this special issue will help to advance research in the area of community food stores, and the recommendations can be used by aspiring, new, and current community food store owners.

Linking the Flint Food Store Survey: Is Objective or Perceived Access to Healthy Foods Associated with Glycemic Control in Patients with Type 2 Diabetes?

Type 2 diabetes mellitus (DM-2) remains a significant public health concern, particularly in low-income neighborhoods where healthy foods may be scarcer. Despite the well-known relationship between diet and diabetes, little evidence exists on the connections among the objectively measured community and consumer food environment, perception of food access, and diabetes management or outcomes. This cross-sectional, ecological study represents the first example of combining a GIS-based, objectively measured food store audit considering quality, variety, and price of foods in stores with a clinical survey of patients with DM-2 (n = 126). In this way, we offer evidence on the relationship between healthy food access-measured more robustly than proximity to or density of certain store types-and diabetes management knowledge, medication adherence, and glycemic control. Better glycemic control was not correlated with better overall food store score, meaning that people in neighborhoods with better access to healthy foods are not necessarily more likely to manage their diabetes. While perceived healthy food access was not correlated with glycemic control, it was strongly correlated with objective healthy food access at shorter distances from home. These results have great importance both for clinical understanding of the persistence of poor diabetes management outcomes and for the understanding of the influence of the food environment on health behaviors.

Influence of a Pediatric Fruit and Vegetable Prescription Program on Child Dietary Patterns and Food Security

Limited access to fresh foods is a barrier to adequate consumption of fruits and vegetables among youth, particularly in low-income communities. The current study sought to examine preliminary effectiveness of a fruit and vegetable prescription program (FVPP), which provided one USD 15 prescription to pediatric patients during office visits. The central hypothesis was that exposure to this FVPP is associated with improvements in dietary patterns and food security. This non-controlled longitudinal intervention trial included a sample of caregiver–child dyads at one urban pediatric clinic who were exposed to the FVPP for 1 year. Patients received one USD 15 prescription for fresh produce during appointments. A consecutive sample of caregivers whose children were 8–18 years of age were invited to participate in the study. Dyads separately completed surveys that evaluated food security and dietary behaviors prior to receipt of their first prescription and again at 12 months. A total of 122 dyads completed surveys at baseline and 12-month follow-up. Approximately half of youth were female (52%), and most were African American (63%). Mean caregiver-reported household food security improved from baseline to 12 months (p < 0.001), as did mean child-reported food security (p = 0.01). Additionally, child-reported intake of vegetables (p = 0.001), whole grains (p = 0.001), fiber (p = 0.008), and dairy (p < 0.001) improved after 12 months of exposure to the FVPP. This study provides evidence that pediatric FVPPs may positively influence food security and the dietary patterns of children.

Linking historical discriminatory housing patterns to the contemporary food environment in Baltimore

Food access literature links disinvested communities with poor food access. Similarly, links are made between discriminatory housing practices and contemporary investment. Less work has examined the relationship between housing practices and food environment disparities. Our central premise is that these practices create distinctions in food environment quality, and that these disparities may have implications for food system advocacy and policymaking. In this paper, we link an objective food environment assessment with a spatial database highlighting redlining, blockbusting, and gentrification in Baltimore, Maryland, USA. Standard socioeconomic and housing characteristics are used to control for race, income, and housing composition in a multivariate regression analysis. Our findings highlight that blockbusting-rather than redlining-most strongly shapes poor food access. Redlining and gentrification, meanwhile, are associated with better food access. These findings raise important points about future policy discussions, which should instead be focused on ameliorating more contemporary patterns of housing inequality.

Flint Kids Cook: positive influence of a farmers' market cooking and nutrition programme on health-related quality of life of US children in a low-income, urban community

OBJECTIVE

To examine changes in health-related quality of life (HRQoL) among youth who participated in Flint Kids Cook, a 6-week healthy cooking programme for children, and assess whether changes in HRQoL were associated with changes in cooking self-efficacy, attitude towards cooking (ATC) and diet.

DESIGN

Pre-post survey (Pediatric Quality of Life Inventory, Block Kids Food Screener, 8-item cooking self-efficacy, 6-item ATC) using child self-report at baseline and programme exit. Analysis involved paired sample t-tests and Pearson's correlations.

SETTING

Farmers' market in Flint, Michigan, USA.

PARTICIPANTS

Children (n 186; 55·9 % female, 72·6 % African American) participated in Flint Kids Cook from October 2017 to February 2020 (mean age 10·55 ± 1·83 years; range 8-15).

RESULTS

Mean HRQoL summary score improved (P < 0·001) from baseline (77·22 ± 14·27) to programme exit (81·62 ± 14·43), as did mean psychosocial health summary score (74·68 ± 15·68 v. 79·04 ± 16·46, P = 0·001). Similarly, physical (P = 0·016), emotional (P = 0·002), social (P = 0·037), and school functioning (P = 0·002) improved. There was a correlation between change in HRQoL summary score and change in ATC (r = -0·194, P = 0·025) as well as change in cooking self-efficacy (r = -0·234, P = 0·008). Changes in HRQoL and psychosocial health summary scores were not correlated with dietary changes, which included decreased added sugar (P = 0·019) and fruit juice (P = 0·004) intake.

CONCLUSIONS

This study is the first to report modest yet significant improvements in HRQoL among children and adolescents who participated in a healthy cooking programme. Results suggest that cooking programmes for youth may provide important psychosocial health benefits that are unrelated to dietary changes.

Participation in a Fruit and Vegetable Prescription Program for Pediatric Patients is Positively Associated with Farmers' Market Shopping

Objectives: The primary objective was to investigate the association between participation in a farmers’ market fruit and vegetable prescription program (FVPP) for pediatric patients and farmers’ market shopping. Methods: This survey-based cross-sectional study assessed data from a convenience sample of 157 caregivers at an urban pediatric clinic co-located with a farmers’ market. Prescription redemption was restricted to the farmers’ market. Data were examined using chi-square analysis and independent samples t-tests. Results: Approximately 65% of respondents participated in the FVPP. Those who received one or more prescriptions were significantly more likely to shop at the farmers’ market during the previous month when compared to those who never received a prescription (p = 0.005). Conclusions: This is the first study to demonstrate that participation in a FVPP for pediatric patients is positively associated with farmers’ market shopping.

Community-Based Participatory Approach to Increase African Americans' Access to Healthy Foods in Atlanta, GA

African Americans in Atlanta, Georgia disproportionately reside in communities with limited access to healthy foods. Collaborations with local corner stores to provide healthy food options have been identified as an evidence-based intervention that could be used to increase food access. This paper describes the community-based participatory approach used to culturally-tailor a Healthy Corner Store Initiative (HCSI) in five Atlanta communities. A mixed method approach (qualitative/quantitative) was utilized. Spatial analysis and an environmental assessment were conducted to locate all corner stores in the partner communities that were listed in a business database. An environmental assessment was conducted at 34 corner stores using a structured log and checklist. Among them, 11 were selected and signed memorandums of understanding to implement the HCSI. A customer intercept survey was administered to 100 African American corner store customers at five of the healthy corner store sites. Descriptive statistics were used to analyze log/checklist and survey data. Corner store customers indicated that they typically purchase snacks, tobacco, and breads, but would purchase certain healthy foods, if offered. They also indicated that freshness of fruits and vegetables and positive relationships with corner store owners would influence healthy food purchases. Findings demonstrate that working collaboratively with community members, researchers and business owners is a critical step in nurturing trust, strengthening credibility, and building partnerships towards increased healthy food access and improved community health.

Looking Back and Moving Forward: The Evolution and Potential Opportunities for the Future of Alcohol Outlet Density Measurement

The literature consistently finds that areas with greater density of alcohol outlets (places that sell alcohol) tend to have higher levels of public health harms. However, conflicting findings arise when researchers drill down to identify the type(s) of alcohol outlets with the strongest associations with harms and the mechanisms that explain these associations. These disagreements could be a result of the outdated methods commonly used to quantify the alcohol environment: counts of the number of outlets in an area. This manuscript reviews the events and ideas that shaped the literature on the physical alcohol environment. It then defines the three main methods used to measure alcohol outlet density, conducts an exploratory factor analysis to explore the constructs underlying each method, and presents a novel conceptual framework that summarizes the three methods, their respective underlying constructs, and the setting(s) in which each may be most appropriate. The framework proposes that counts of alcohol outlets measure availability, proximity to the nearest outlet measures accessibility, and spatial access measures measure access, which comprises both availability and accessibility. We argue that researchers should consider using proximity and spatial access measures when possible and outline how doing so may present opportunities to advance theory and the design and implementation of alcohol outlet zoning regulations. Finally, this manuscript draws on research from other areas of the built environment to suggest opportunities to use novel methods to overcome common hurdles (e.g., separating subtypes of outlets, ecologic designs) and a new challenge on the horizon: home delivery.

A method for assessing links between objectively measured food store scores and store & neighborhood favorability

Worldwide, interest in research on methods to define access to healthy food at the local level has grown, given its central connection to carrying out a healthy lifestyle. Within this research domain, papers have examined the spatial element of food access, or individual perceptions about the food environment. To date, however, no studies have provided a method for linking a validated, objective measure of the food environment with qualitative data on how people access healthy food in their community. In this study, we present a methodology for linking scores from a modified Nutrition Environment Measures Survey in Stores (conducted at every store in our study site of Flint, Michigan) with perceptions of the acceptability of food stores and shopping locations drawn from seven focus groups (n = 53). Spatial analysis revealed distinct patterns in visiting and avoidance of certain store types. Chain stores tended to be rated more highly, while stores in neighborhoods with more African-American or poor residents were rated less favorably and avoided more frequently. Notably, many people avoided shopping in their own neighborhoods; participants traveled an average of 3.38 miles to shop for groceries, and 60% bypassed their nearest grocery store when shopping. The utility of our work is threefold. First, we provide a methodology for linking perceived and objective definitions of food access among a small sample that could be replicated in cities across the globe. Second, we show links between perceptions of food access and objectively measured food store scores to uncover inequalities in access in our sample to illustrate potential connections. Third, we advocate for the use of such data in informing the development of a platforms that aim to make the process of accessing healthy food easier via non-food retail based interventions. Future work can replicate our methods to both uncover patterns in distinct food environments and aid in advocacy around how to best intervene in the food environment in various locales.

Moderation of the Association Between Individual Food Security and Poor Mental Health by the Local Food Environment Among Adult Residents of Flint, Michigan

Purpose: Food insecurity is a psychosocial stressor with deleterious effects on mental health. This study examined whether the local food environment moderates the association of individual food insecurity with poor mental health. Methods: Cross-sectional survey data were collected from adult residents of Flint, Michigan (n=291), in 2015. Multivariate logistic models assessed whether quality of the local food environment moderated the relationship of food insecurity with poor mental health. A binary indicator of poor mental health was created. Participants were asked to rate their overall "mental or emotional health" using a 5-point Likert scale. Individuals were classified as having either good mental health (i.e., ratings of good, very good, or excellent) or poor mental health (i.e., ratings of fair or poor). Results: In fully adjusted models, food insecurity was associated with 3.2 (95% confidence interval [CI]: 1.6-6.2) times higher odds of poor mental health. However, increased proximate access to vegetables and fruits moderated this association. For example, those in the bottom 25th percentile of access to vegetables had 7.4 (95% CI: 2.7-20.5) times higher odds of poor mental health. In contrast, for those in the top 25th percentile of vegetable access, food insecurity was only marginally associated with poor mental health (odds ratio=2.2; 95% CI: 1.0-4.7). Conclusion: Greater proximate access to vegetables and fruits moderated food insecurity's association with poor mental health. Longitudinal evaluation of programs and policies that improve availability of nutrient-rich foods in food insecure communities is needed to determine whether they yield a mental health benefit.

Data Collection Instruments for Obesogenic Environments in Adults: A Scoping Review

The rise in obesity prevalence has increased research interest in the obesogenic environment and its influence on excess weight. The aim of the present study was to review and map data collection instruments for obesogenic environments in adults in order to provide an overview of the existing evidence and enable comparisons. Through the scoping review method, different databases and webpages were searched between January 1997 and May 2018. Instruments were included if they targeted adults. The documents were categorised as food environment or built environment. In terms of results, 92 instruments were found: 46 instruments measuring the food environment, 42 measuring the built environment, and 4 that characterised both environments. Numerous diverse instruments have been developed to characterise the obesogenic environment, and some of them have been developed based on existing ones; however, most of them have not been validated and there is very little similarity between them, hindering comparison of the results obtained. In addition, most of them were developed and used in the United States and were written in English. In conclusion, there is a need for a robust instrument, improving or combining existing ones, for use within and across countries, and more sophisticated study designs where the environment is contemplated in an interdisciplinary approach.

Community-engaged development of a GIS-based healthfulness index to shape health equity solutions

Addressing health disparities requires both community engagement and an understanding of the social determinants of health. Although elements of the built environment can influence behavior change in public health interventions, such determinants have not been explicitly teased out via participatory mapping. An opportunity exists to integrate community voice in the development of such metrics. To fill this gap and inform the deployment of public health interventions in the Flint (USA) Center for Health Equity Solutions (FCHES), we created a means of assessing spatially-varying community needs and assets in a geographic information system (GIS), what we refer to as a healthfulness index. We engaged community and academic partners in their expert opinions on features of Flint's built environment that may promote or inhibit healthy behaviors via a multiple-criteria decision analysis framework. Experts selected from and ranked 29 variables in 6 categories (including amenities, environment, greenspace, housing, infrastructure, and social issues) using the analytic hierarchy process. The resulting matrices of expert opinions were aggregated and appended as weights for each variable's corresponding map layer. When combined through map algebra, composite scores yield spatially-varying healthfulness indices which signal any neighborhood's relative health promoting qualities (along a 0-100 scale). Results varied substantially across Flint, with the middle belt scoring highest and older neighborhoods in the northeast and north center of the city scoring lowest. Scores were aggregated to 38 Flint neighborhoods; for each of two project-specific indices, these ranged from lows of 38.7 (Hilborn Park) and 41.8 (Columbia Heights) to highs of 52.9 (College Cultural) and 58.0 (University Ave Corridor). We hypothesize that-even when controlling for individual-level factors-we will measure better and more sustained behavior change among participants living in neighborhoods with high healthfulness scores. Future work will examine this hypothesis and determine the importance of such indices in other similar communities.