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Obesity and other diet-related chronic diseases are directly related to the food environment. We describe how to better assess the food environment in specific ethnic minority settings for designing and implementing interventions, based on a review of our previous work on the food environment in American Indian reservations, Canadian First Nations reserves, the Republic of the Marshall Islands, and inner-city Baltimore. The types of food stores available within each setting and the range of healthy foods available varied greatly across these geographic regions. In all settings, proximity to food stores/supermarkets, cost, and limited availability of healthful foods were common features, which limited access to health-promoting food options. Features specific to each population should be considered in an assessment of the food environment, including physical (e.g., openness of stores, mix of types of food sources); consumer (e.g., adequacy of the food supply, seasonal factors); and social (e.g., inter-household food sharing, perceptions of food quality, language differences) aspects. The food environments common in low-income ethnic subpopulations require special focus and consideration due to the vulnerability of the populations and to specific and unique aspects of each setting.
Much recent work has focused on the relationship between the food environment, diet, and rates of chronic diseases.1–3 Several studies have linked the availability of food stores and fast-food restaurants to nutritional status and cardiovascular disease.4,5 Low-income and populations of color appear to be at particular risk of living in poor food environments and bear much of the burden of chronic disease.6–8
Valid measures of food environments are needed to assess these relationships and to inform intervention strategies. Several instruments have been developed to assess the food environment, including the very comprehensive Nutrition Environment Measurement Survey in stores (NEMS-S)9 and Nutrition Environment Measurement Survey in restaurants (NEMS-R).10 These instruments focus on documenting the availability, price, and quality of a range of different foods at retail food stores and restaurants. What is not yet known is whether the information provided by these instruments is sufficient to help develop interventions or to monitor the impact of existing interventions.
Food environments vary dramatically from locale to locale. As a result, instruments such as the NEMS-S require modification to be adapted to new settings. To date, most of the work on food environments has focused on urban settings, with relatively little work in rural settings. For example, to our knowledge, no work has assessed the food environment in American Indian settings.
This paper explores the food environment in four disparate low-income settings, which range dramatically in terms of geographic isolation: urban African Americans from Baltimore City (Maryland); rural American Indians (several tribes in Southwestern U.S.); semi-remote First Nations (Northwestern Ontario, Canada); and the very remote Republic of the Marshall Islands (low-lying atolls in the Pacific Ocean). Based on extensive fieldwork in these four settings over the past 2 decades, this paper presents evidence to address the following questions:
To address these questions, we have considered our previous experience working in both domestic and international settings, which has centered on developing, implementing, and evaluating interventions to reduce the risk of chronic disease. These interventions focus on changing the food environment, primarily by working with food stores. The descriptions that follow reference formative research and intervention programs conducted on two Apache reservations in Arizona,11–17 the Republic of the Marshall Islands,18 –20 eight First Nations reserves in Western Ontario,21–28 and in inner-city Baltimore.29,30 All of these settings are characterized by low-income ethnic minority populations and low food availability.
Based on our fieldwork, we have discovered multiple factors that provide direct challenges to the adequate description of the food environment. Using a modified version of the conceptual framework developed by Glanz and colleagues,31 these challenges have been divided into three main aspects: the physical food environment, the consumer food environment, and social aspects of the food environment (Table 1).
Social aspects of the food environment refer to the ways in which food retailers interact with their customers. It can also refer to relevant social customs and behaviors relating to food.
Based on the challenges and issues described above, several key recommendations have been identified:
Creating an accurate and informative assessment of the food environment in low-income ethnic communities requires attention to a broad variety of characteristics of the physical, consumer, and social food environments. Although all four settings described here are characterized by a low-income consumer base, the food environments across these settings differ dramatically. In Baltimore, residents generally live within walking distance of some food sources (although usually not supermarkets) and a high proportion of small stores have a closed configuration and do not permit customers inside the stores. Of those that do, some limit access to foods within the stores to regular customers, and do not permit children inside.29 Thus, in this urban setting, retail food sources are close geographically, but access to foods within the store may be limited. This contrasts with the American Indian and First Nations settings, in which stores are generally further from where individuals live, but once one reaches those stores, access to foods is unfettered. In both settings, stores carrying a wide range of nutritious food choices are relatively distant from where people live.
This work indicates that the food environment must in many cases be broadly defined. As discovered in interviews with small store owners in Baltimore, stocking nutritious foods was related directly to their availability in wholesale stores. The assessment of the food environment should include food wholesalers and distributors as well. Use of the USDA commodity food program is common within low-income American Indian communities, but practically non-existent among African Americans in Baltimore. All of the differences mentioned suggest that to truly describe access to and use of food, investigators must expand their descriptions to include the physical settings within which foods are selected, the broad types of food sources (wholesale and retail) and suppliers, and the relationships between store managers and their clientele.
How should investigators proceed when faced with assessing a new and unique food setting? It is possible to modify existing instruments when working in diverse settings, as has been done with the NEMS-S for use in low-income urban areas.32 However, inclusion of all potential physical, consumer and social characteristics are likely beyond the means, and more importantly, the needs of individual studies of the food environment. In our own work, which is centered on changing food availability, food environment assessments have been restricted to assessing the presence of key promoted foods (more nutritious alternatives to high-fat, high-sugar foods commonly consumed, and at the same or lower price), as well as on features of local food sources that are likely to impinge or enhance access to these foods (e.g., closed food store layouts in Baltimore). The emphasis on data-gathering for the purpose of monitoring and evaluating the success of food source interventions allowed us to focus the environmental assessments. We recommend that investigators developing environmental assessment tools conduct formative research that will enable them to develop focused instruments that incorporate those physical, consumer and social characteristics of their setting that are relevant to their research purposes.
No financial disclosures were reported by the authors of this paper.