The Journal of Nutrition
Symposium: Access to Healthy Food: The Next Frontier for Research on Domestic Food Security
The Importance of a Multi-Dimensional
Approach for Studying the Links between Food
Access and Consumption1–3
Donald Rose,* J. Nicholas Bodor, Paul L. Hutchinson, and Chris M. Swalm
Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112-2699
Researchon neighborhood food accesshasfocused on documenting disparitiesin thefood environment and on assessing
the links between the environment and consumption. Relatively few studies have combined in-store food availability
measures with geographic mapping of stores. We review research that has used these multi-dimensional measures of
access to explore the links between the neighborhood food environment and consumption or weight status. Early
research in California found correlations between red meat, reduced-fat milk, and whole-grain bread consumption and
shelf space availability of these products in area stores. Subsequent research in New York confirmed the low-fat milk
findings. Recent research in Baltimore has used more sophisticated diet assessment tools and store-based instruments,
along with controls for individual characteristics, to show that low availability of healthy food in area stores is associated
with low-quality diets of area residents. Our research in southeastern Louisiana has shown that shelf space availability of
energy-dense snack foods is positively associated with BMI after controlling for individual socioeconomic characteristics.
Most of this research is based on cross-sectional studies. To assess the direction of causality, future research testing the
effects of interventions is needed. We suggest that multi-dimensional measures of the neighborhood food environment
are important to understanding these links between access and consumption. They provide a more nuanced assessment
of thefoodenvironment. Moreover,giventhetypicaldurationofresearchprojectcycles,changestoin-storeenvironments
may be more feasible than changes to the overall mix of retail outlets in communities.J. Nutr. 140: 1170–1174, 2010.
There have been 2 broad strands of research in the field of
neighborhood food access. Much of this literature has focused
on documenting disparities between groups in their access to
retail food outlets (1–6). A second line of this literature has
explored the connection between the neighborhood environ-
ment and either dietary intakes (7–10) or weight status
outcomes, such as obesity (11–13).
Assessment of the neighborhood food environment underlies
both types of investigation and researchers have relied on 3
broad approaches to this assessment problem. One approach
involves enumerating food stores within a given geographic unit
of analysis, such as a census tract or zip code area. Studies using
this approach either rely exclusively on preexisting business
directories or health department listings (10,13), or, in some
cases, include on-the-ground observations to verify these listings
(5). This approach provides measures of food store access, e.g.
characterizing the food environment by the density of super-
markets per zip code (1,4), the number of supermarkets per tract
(10,12), or even the distance to the nearest supermarket (6,14).
A second approach to studying the food environment
provides measures of in-store availability and relies heavily on
in-store observations. For example, studies have conducted
inventories to assess the availability or pricing of foods in the
Thrifty Food Plan (15–17). Other studies have characterized the
differences between store types (e.g. supermarket vs. small store)
with respect to availability of specific healthy foods (15,18,19).
Availability of different food groups within stores has been
studied using shelf space (20). A comprehensive method for
assessing the availability, price, and quality of foods in a store
environment, known as the Nutrition Environment Measures
Survey, has also been developed and tested (21).
Third, researchers have combined these 2 approaches to
develop a more complete way of characterizing the neighbor-
hood food environment that considers not just where stores are
located but also what products are available inside these stores.
1Presented as part of the symposium entitled “Access to Healthy Food: The
Next Frontier for Research on Domestic Food Security” at the Experimental
Biology 2009 meeting, April 21, 2009, in New Orleans, LA. This symposium was
sponsored the American Society for Nutrition Community and Public Health
Nutrition RIS. Guest Editor for this symposium publication was Aryeh Stein.
Guest Editor disclosure: no conflicts to disclose.
2Supported by the National Research Initiative of USDA, National Institute for
Food and Agriculture (no. 2006-55215-16711), by the National Cancer Institute
(no. R21CA121167), and by the CDC (no. 1U48DP001948-01).
3Author disclosures: D. Rose, J. N. Bodor, P. L. Hutchinson, and C. M. Swalm,
no conflicts of interest.
* To whom correspondence should be addressed. E-mail: firstname.lastname@example.org.
ã 2010 American Society for Nutrition.
First published online April 21, 2010; doi:10.3945/jn.109.113159.
at Tulane Univ on May 25, 2010
We refer to this as a multi-dimensional assessment of access,
because information is provided on the location dimension as
well as dimensions regarding food product availability, pricing,
and other in-store characteristics.
Multi-dimensional assessment of food access is an important
development in this field, because it allows for a more nuanced
way of assessing the food environment. Supermarkets do not
carry just healthy foods, nor are all small stores devoid of them.
In-store observations allow a better understanding of what
specific foods are available in a given food environment and how
much they cost. Combining the 2 types of information is also
useful for orientation on different types of interventions. Not all
communities can support a new supermarket. Deficiencies in
availability of fresh produce among existing stores, e.g., might
be better remedied by a low-cost policy option, such as a loan for
a fruit and vegetable cooler.
This paper reviews work using multi-dimensional measures
of food access, focusing on the links between access, consump-
tion, and weight status. We begin by outlining a conceptual
framework that integrates neighborhood food access with a
typical model of consumer choice. We then describe research,
including our own, that has used multi-dimensional measures of
access to describe associations between access and dietary or
body weight outcomes. We close with a summary and discussion
of future research needs.
Much of the recent research on neighborhood food access,
particularly studies that link access to consumption or health
outcomes, is premised on the idea that environments influence
behavior. In Figure 1, we present a theoretical framework for
this approach that is based on an economic model of food
consumption, adapted to include neighborhood effects. Econo-
mists view individuals as attempting to maximize their utility (or
satisfaction) from goods given their tastes and preferences and
subject to a budget constraint, determined by their income, food
prices, and prices of other goods. Food demand, or purchases, is
a function of income and prices, as well as tastes and
preferences. We use “food cost,” instead of “price,” because
the actual price that a consumer pays is a function of the in-store
price and travel costs to the store where the food is purchased
(22,23). These travel costs are a function of the availability of
food stores, such as supermarkets or small groceries in a
consumer’s vicinity, and the in-store availability of specific
foods. Even though a small grocery might be very close to an
individual, if there is no in-store availability of fresh fruits, e.g., a
consumer wanting those might have to travel to a distant
supermarket. Car ownership could lower overall travel costs if it
shortens travel time to stores.
A detailed specification of demographic characteristics,
including age, race-ethnicity, schooling, and other variables, is
useful for capturing unobserved information on consumers’
tastes and preferences. Such tastes and preferences might be
based on cultural food habits associated with particular ethnic
groups, or they might be based on knowledge and concern of the
consumer regarding diet and health outcomes. In-store food
availability, including shelf space and placement of foods near
registers, has a promotional effect that can influence consumers’
preferences. A high concentration, or relative shelf space avail-
ability, of certain foods, e.g., energy-dense snack foods in corner
groceries, could make these foods appear more socially accept-
able and thus also influence consumers’ preferences. The multi-
dimensional nature of food access is captured in this framework
in that food store locations, as well as features of the in-store
environment, are relevant to consumption behavior.
Figure 1 is clearly a simplification designed to focus attention
on a few aspects of neighborhood access and food consumption
behavior, with many other factors being left out. Time con-
straints influence purchase decisions, because with less time
available, households are more likely to purchase convenience or
prepared foods. This process, as well as decisions regarding
away-from-home foods, have been left out of the figure. We have
drawn arrows in one direction, but food demand certainly
influences supply. We have focused on details regarding the
purchase of foods rather than their actual intake. But it is easy to
envision that the causal chain extends further to the right, such
that purchases affect intakes and ultimately weight status.
Links between access, consumption, and weight status
Cheadle et al. (1991) provide one of the earliest studies in the
public health literature to study the connection between multi-
dimensional measures of access and consumption (24). They
conducted in-store surveys to measure shelf space devoted to
low-fat meat and milk products and high-fiber breads and
compared this with telephone interview responses to a FFQ of
residents living in the same catchment area as these stores. The
study was conducted in 12 communities (or counties), one in
Hawaii and the rest in California. In this cross-sectional study,
the authors found significant correlations between individuals’
consumption and relative shelf space devoted to red meat,
reduced fat-milk, and non-white bread in their communities’
stores. However, in subsequent work that revisited these
integrating neighborhood food access
into a model of consumer choice.
Multi-dimensional food access1171
at Tulane Univ on May 25, 2010
communities as part of a larger intervention project, the authors
did not find significant associations between changes in avail-
ability and consumption across these communities (25).
Fisher and Strogratz (26) conducted similar research, focus-
ing specifically on low-fat milk in New York State. Their phone
interviews with household residents randomly selected from 19
zip code areas assessed which type of milk was present or usually
present in the refrigerator. Surveys conducted in stores randomly
selected from the same areas counted the percent of all milk on
shelves that was low-fat. Analogous to the results of Cheadle
et al. (24) and using the zip code area as the unit of analysis,
they found a positive association between the proportion of low-
fat milk in area stores and the prevalence of low-fat milk
consumption in households.
Edmonds et al. (27) used census tracts as proxies for
neighborhoods in their analyses of fruit, vegetable, and juice
consumption among African-American boys in Houston, Texas.
They found no correlations between consumption of these foods
and availability in grocery stores as measured by shelf space. The
authors conjectured that the census tract may have been too
small a level of aggregation, because many households shop
outside their tract. Interestingly, there were positive correlations
between consumption of juices and vegetables and restaurant
availability of these foods, a finding strengthened by the
observation that many respondents reported patronizing restau-
rants in their census tracts.
Recent work in this area has become more nuanced both in
geographic assessments, in-store observations, and in control-
ling for personal characteristics that affect consumption. Franco
et al. (21,28) used a modified Nutrition Environment Measures
Survey instrument to assess stores at varying distances from an
individual’s household, including the closest store, all stores
within the individual’s census tract, and all stores within 1 mile
of each individual’s residence. In this Baltimore study, they
found that lower availability of healthy foods was associated
with a lower-quality diet, after controlling for age, sex, income,
and education (though not for race-ethnicity) for boththe closest
store and for an average of all stores within the census tract.
Results were not significant when considering all stores within
1 mile of an individual’s residence.
Our initial work in central city New Orleans used telephone
interviews and a modified 24-h recall instrument to assess fruit
and vegetable consumption of residents in 4 census tracts (29).
We assessed fruit and vegetable shelf space in stores in the
immediate vicinity (100 m) of respondents’ residences and found
a significant positive relationship between vegetable availability
in these stores and consumption, after controlling for age,
gender, race-ethnicity, income, food assistance participation,
car ownership, and distance to the nearest supermarket. The
availability of produce in the immediate vicinity of respondent
households may have been important for fill-in shopping
between larger shopping trips conducted at supermarkets.
Fruit and vegetable shelf space, as well as that devoted to
energy-dense snack foods (candies, pastries and cookies, sodas,
and salty snacks) was also assessed in work we did in a larger
sample of urban census tracts (n = 103) randomly selected froma
28-county area of southeastern Louisiana (30). All stores in
these study tracts were observed and hot-deck imputations based
on store type were used to assign shelf space values from these
observed stores to all of the unobserved stores that were situated
in neighboring tracts. This procedure allowed for assessing the
neighborhood food environment at various distances, 500 m,
1 km, and 2 km, from respondents’ residences. Phone interviews
in study tracts with respondents (n = 1243) chosen by random
digit dial techniques assessed self-reported heights and weights
and other sociodemographic variables, such as age, gender, race-
ethnicity, income, education, and car ownership. In regression
models that controlled for all of these variables, neighborhood
shelf space of fruits and vegetables was not associated with BMI,
but aggregate availability of energy-dense snack foods, partic-
ularly within 1 km of respondents’ households, was positively
associated with BMI.
In general, findings from these studies that use multi-dimensional
measures of access, i.e. combining in-store measures with map-
neighborhood food environment and measures of consumption
or weight. Although not directly comparable, the results are
generally consistent with earlier studies that have relied on food
store access measures (i.e. no observations inside the stores). A
number of these earlier studies documented that easier access to
supermarkets, measured in a number of different ways, was
vegetable intakes (10,14), or overall diet quality (8,9). Super-
market access has also been shown to be negatively associated
with obesity (11–13,31,32), whereas easy access to convenience
stores has been positively associated with obesity (12,13,31).
Previous research has indicated that the vast majority of
households eligible for assistance from the Food Stamp Program
shop at supermarkets (33). But this same research indicated that
these households also shop at 3–4 different types of stores
besides their main store and these included neighborhood
groceries, convenience stores, and drug stores. One way to
capture this shopping behavior is to rely solely on indicators of
store type. But multi-dimensional measures of access provide a
more nuanced approach in that they allow for understanding
food-based features of the neighborhood environment. By
combining information from in-store studies with geo-referencing
of food outlets, researchers can study, e.g., the total amount of
shelf space devoted to sugar-sweetened beverages, the variety of
fresh fruits and vegetables, or the average price for low-fat
milk found in a given neighborhood. If environments influence
behaviors, and if shopping throughout the month, or fill-in
shopping, is an important contributor to overall consumption
baskets of low-income households, particularly those without
cars, then understanding these specific food-related features of
neighborhood environments is crucial.
Research in this field is not without limitations. In this review,
we have focused on retail food access for at-home use, but
considerable portions of the diet are consumed away from home
in fast food and other restaurants. A second limitation of the
work reviewed here is the exclusion of price as one of the
dimensions in the overall assessment of access. The price of
foods, of course, is a key determinant of consumer demand. But
previous researchers who have combined in-store observations
with store access maps have yet to include prices as an
explanatory variable for consumption.
Another limitation of the studies reviewed here is that they
are based on cross-sectional designs, so that the direction of
causality cannot be determined. The work by Cheadle et al.
(24,25), described above, was conducted ahead of the current
wave of interest in environmental approaches to the obesity
epidemic. Interestingly, the studies were written assuming
consumption patterns affected food store supplies, rather than
vice versa; that is, the authors were testing whether measures of
the food environment could be used as reliable markers of
consumption. But food stores, like any market, are based on a
at Tulane Univ on May 25, 2010
simultaneous determination of supply and demand, so that
influences work in both directions. Figure 1 is really just one-half
of a conceptual framework, because food purchases would
influence what is offered in stores. This simultaneity is best
addressed with longitudinal studies or experimental designs to
understandthetrueeffects ofmanipulatingthe food environment.
The need to explore causality through investigation of
interventions may be one of the best arguments for why more
work is needed that combines in-store measures with geograph-
ically mapped access. Intervention budgets are limited and
bringing new stores to a neighborhood is a complex, costly, and
time-consuming process. Interventions that make use of the
existing retail environment can focus energies on in-store
changes, which, though not easy, may be less difficult to
accomplish within a research grant time cycle than bringing
new stores to a neighborhood (34,35). In-store changes to the
food environment may also be more sustainable in the long-run,
because they build on an existing infrastructure and therefore
may lead to more appropriate policies.
There has been considerable growth in the development of
food environment measures over the last decade (36). We have
demonstrated how a simple rolling tape measure can be used to
assess relative shelf space availability of key food groups in
different types of stores (20). The Thrifty Food Plan has been
used to assess availability and pricing of a healthy food basket in
stores (15,16). Glanz et al. (21) have developed the Nutrition
Environment Measures Survey, the comprehensive instrument
that gathers availability, price, and quality data on a wide range
of foods sold in retail outlets. More recent efforts are applying
the Healthy Eating Index to food environments (37).
It will be important that future work in this area uses tools
that strike a balance between understanding the complexity of
the food environment and capturing the salient features in a
transparent manner. Investigators are right to be wary of
simplistic descriptions, because they likely do not capture the
nuances that affect food choice. However, overly complex
characterizations of the food environment may not facilitate
understanding the science of how this environment influences
consumption behavior, nor how it can be modified by policy. For
example, what does it mean to have a 10% higher score on a
nutrition environment index? Is it something for which we
should advocate? And if so, is it something we could achieve
through a policy intervention?
Improving access to healthy food has been suggested as one
approach for addressing the obesity epidemic (38). If the
association between the food environment and weight status
were causal, we would expect this to operate through consump-
tion, such that greater availability of low-energy healthy foods
(e.g. fruits and vegetables) would lead to an increase in their
consumption, be substituted for energy-dense foods, and thereby
lower overall energy intake. Our work showed that access to
healthy foods, i.e. fruits and vegetables, was not associated with
BMI, but access to energy-dense foods was, and in the expected
direction (30). This finding is consistent with studies using food
store maps as the measure of access, which have found positive
associations of obesity with convenience store access, even when
controlling for supermarket access (12,13,31). Individuals may
be responding to their food environments but not necessarily
substituting low-energy foods for energy-dense ones. This sug-
gests that the call to increase healthy food access may be only a
part of an environmental approach to the obesity problem,
perhaps necessary, but not sufficient.
Previous marketing research has documented with experi-
mental designs that shelf space and in-store displays can affect
overall sales (39–42), which is reflected in our inclusion of
promotional effects and social acceptability in our conceptual
framework (Fig. 1). If promotional influences on food choice are
roughly equivalent for healthy foods and those that are relatively
unhealthy, our in-store studies suggest that there are significant
challenges that lie ahead. We found that shelf space availability
of energy-dense snack foods was 3–5 times greater than space
allocated to fruits and vegetables in the small stores common to
many low-income neighborhoods (20). Although there has been
a recent trend to document the problems of food deserts (43), the
inundation of our food environments with energy-dense foods, a
phenomenon we refer to as food swamps, may be a more serious
D.R. wrote the paper and had primary responsibility for final
content; J.N.B., P.L.H., and C.M.S. assisted in manuscript
preparation. All authors read and approved the final version of
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