The aim of this review is to describe and evaluate research relating to neighborhood differences in the physical availability of food stores, restaurants, and healthy foods. Associations of neighborhood food access with dietary intake and obesity were found to vary according to the type of food store or restaurant. In general, research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity. 18x18Bodor, J., Rose, D., Farley, T., Swalm, C., and Scott, S. Neighborhood fruit and vegetable availability and consumption: the role of small food stores in an urban environment. Public Health Nutr. 2008;
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Abstract | Full Text | Full Text PDF | PubMed | Scopus (75) | Google ScholarSee all References Much of the evidence suggesting a relationship between restaurant accessibility and obesity levels in the U.S. has come from research that focused on land area units larger than neighborhoods (e.g., states, counties). National and local studies across the U.S. have shown disparities according to income, race, ethnicity, and urbanization in neighborhood access to food stores and restaurants. Although additional studies are needed to address various research limitations, completed studies indicate a need for policy action and other intervention strategies to ensure equitable access to healthy foods across the U.S. Recommendations for future research on disparities in access to healthy foods are summarized in Appendix CAppendix C (online at www.ajpm-online.net).
Common limitations of the studies reviewed here relate to: the validity and reliability of measures; the complexity of defining a relevant neighborhood; and the cross-sectional, observational nature of most research designs. The majority of studies included in this review used commercially (e.g., Dun and Bradstreet, InfoUSA) or publicly available lists (e.g., telephone directories, state departments of agriculture) to identify food stores and restaurants. Few studies identified stores or restaurants by ground truthing or with walking surveys, and only one study was found that reported a detailed comparison of these two methods for measuring residential food environments. That single study reported a considerable discrepancy between the stores found on publicly available lists and the results of ground truthing in rural Texas; nearly 20% of stores on publicly available lists could not be verified, and 36% of stores in the area were missing from those lists. 46x46Sharkey, J. and Horel, S. Neighborhood socioeconomic deprivation and minority composition are associated with better potential spatial access to the ground-truthed food environment in a large rural area. J Nutr. 2008;
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The common use of automatic geocoding tools (i.e., ArcGIS, Automatch, ZP4, Geolytics, and other software that perform batch or interactive address matching) is of further concern. The geocoding process is vulnerable to various types of error that may be introduced during the preprocessing and matching of addresses to spatial areas. 94x94Yang, D.-H., Bilaver, L., Hayes, O., and Goerge, R. Improving geocoding practices: evaluation of geocoding tools. J Med Syst. 2004;
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PubMed | Google ScholarSee all References but very little is known about matching accuracy or the potential impact of positional errors on research findings relating to the food environment. Studies comparing automatic geocoding tools have found considerable variation in the assignment of addresses to census block groups and census tracts. For example, one study found that 28%–36% of addresses geocoded by different tools were not assigned to the same census block group, and 33%–51% of residential addresses were not assigned to the same census tract. 94x94Yang, D.-H., Bilaver, L., Hayes, O., and Goerge, R. Improving geocoding practices: evaluation of geocoding tools. J Med Syst. 2004;
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Discrepancies between researcher- and resident-defined neighborhood boundaries may be a source of bias in studies relating to food access. 97x97Coulton, C., Korbin, J., Chan, T., and Su, M. Mapping residents' perceptions of neighborhood boundaries: a methodological note. Am J Community Psychol. 2001;
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Crossref | PubMed | Scopus (134) | Google ScholarSee all References The average size of a resident-defined neighborhood is comparable to a census tract, but neighborhoods typically include portions of at least two census tracts. Clearly, researchers cannot assume that resident- and census-defined neighborhoods are similar. Discrepancies could result in measurable differences in the social conditions (e.g., ethnic/racial composition, average income) occurring within a neighborhood.
A limited number of studies have considered the distance that residents typically travel beyond their neighborhood to purchase food. 24x24Zenk, S.N., Schulz, A.J., Israel, B.A., James, S.A., Bao, S., and Wilson, M.L. Fruit and vegetable access differs by community racial composition and socioeconomic position in Detroit, Michigan. Ethn Dis. 2006;
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Comparability across studies also depends on the use of standard definitions to classify food stores and restaurants into categories. As summarized in Appendix A, Appendix B (online at www.ajpm-online.net), the studies described in this review have defined categories of food stores and restaurants in various ways. For example, some studies have defined categories of food stores according to the number of cash registers whereas others have categorized stores according to the number of staff employed, the types of food sold, name recognition, or annual sales data. 43x43Morton, L. and Blanchard, T. Starved for access: life in rural America's food deserts. Rural Realities. 2007;
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Abstract | Full Text | Full Text PDF | PubMed | Scopus (41) | Google ScholarSee all References Although different data sources do not always provide the same details relevant to the categorization of food outlets, researchers should work toward a consensus on the use of a standard set of definitions, and future studies should aim to fully describe how food store and restaurant categories are defined.
Research studies that complete observations within stores and restaurants can most directly address differences in the physical availability of healthy foods and beverages. It is critical that studies employing direct observation report on methodologic details and the reliability of employed measures. Just half of the studies in this review that reported on direct observations in stores (n=5 of 11) and neither study that reported on direct observations in restaurants (n=2) were found to include assessments of inter-rater or test–retest reliability. 19x19Sallis, J., Nader, P., Rupp, J., Atkins, C., and Wilson, W. San Diego surveyed for heart healthy foods and exercise facilities. Public Health Rep. 1986;
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The majority of studies included in this review used cross-sectional designs; few longitudinal, multilevel, or intervention studies have been reported. Studies examining relationships among residential food access, dietary intake, and obesity have considered several characteristics of neighborhoods and individuals, including gender, race and ethnicity, income, education, and physical activity. However, several factors contribute to dietary intake and the development of obesity. In order to better understand the relative importance of environmental, demographic, psychological, and social factors, as well as the interaction of these factors, it will be necessary to examine hypothesized pathways of influence and the contributions of each factor within the same study.
Future studies investigating disparities in access to more- and less-healthy food also need to systematically consider covarying characteristics of neighborhoods such as population size, urbanization, region, and commercialization. Several studies included in this review indicate that disparities in access to healthy food vary according to these characteristics of neighborhoods. 42x42Powell, L., Slater, S., Mirtcheva, D., Bao, Y., and Chaloupka, F. Food store availability and neighborhood characteristics in the United States. Prev Med. 2007;
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Additionally, more comprehensive assessments of neighborhood food environments are needed. When only one aspect of the food environment is studied, the results are difficult to interpret, as neighborhoods with greater access to unhealthy food options may also have greater access to healthy food options. A limited number of studies have investigated disparities in access to both food stores and restaurants within the same geographic region and suggest that the nature of neighborhood disparities may differ according to the type of food outlet examined. 36x36Wang, M., Kim, S., Gonzalez, A., MacLeod, K., and Winkleby, M. Socioeconomic and food-related physical characteristics of the neighborhood environment are associated with body mass index. J Epidemiol Community Health. 2007;
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Despite these research limitations, the studies reviewed here indicate a need for policy action and other intervention strategies to ensure more equitable access to healthy foods across the U.S. Very few studies have evaluated strategies for reducing disparities or improving physical access to healthy, affordable food. Several strategies and policy actions have been proposed to attract supermarkets to underserved neighborhoods, improve the availability of healthy foods such as fruits and vegetables, and reduce access to calorie-dense foods in restaurants (Appendix DAppendix D, online at www.ajpm-online.net). 106x106Pothukuchi, K. Attracting supermarkets to inner-city neighborhoods: economic development outside the box. Economic Development Quarterly. 2005;
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