330 American Journal of Health Promotion
CIENCE OF HEALTH PROMOTION
Critical Issues and Trends
Healthy Nutrition Environments:
Concepts and Measures
Karen Glanz, PhD, MPH; James F. Sallis, PhD; Brian E. Saelens, PhD; Lawrence D. Frank, PhD
The widespread prevalence of obesity is poorly ex-
plained by individual-level psychological and social corre-
lates of diet and physical activity behaviors. Moreover, ad-
vice to simply ‘‘eat less and move more’’ ignores the com-
plex inﬂuences of the social and built environments on
individuals’ access to affordable, healthful food and activi-
ty-friendly communities. Although the body of research
on active living environments has recently grown expo-
the same cannot be said for our understand-
ing of healthy nutrition environments.
Eating, or ‘‘nutrition environments,’’ are widely be-
lieved to contribute to the increasing epidemics of child-
hood and adult obesity in the United States and globally.
Numerous authors and agencies, including the World
the Institute of Medicine,
International Obesity Task Force,
and the Centers for
have identiﬁed environmental and poli-
cy interventions as the most promising strategies for creat-
ing population-wide improvements in eating, physical ac-
tivity, and weight status.
To make signiﬁcant progress
in this area of inquiry, and to inform public health policy,
well-deﬁned concepts and valid, reliable measures of nu-
trition environments are needed. The purposes of this ed-
itorial are to provide a brief selective overview of the liter-
ature on food environments, propose a conceptualization
of nutrition environments, and describe our work to de-
velop and test measures of nutrition environments.
Karen Glanz is with the Rollins School of Public Health, Emory
University, Atlanta, Georgia. James F. Sallis is at San Diego
State University, San Diego, California. Brian E. Saelens is at
the University of Cincinnati, Cincinnati, Ohio. Lawrence D.
Frank is with the University of British Columbia, Vancouver,
British Columbia, Canada.
Send reprint requests to Dr Karen Glanz, Rollins School of Public
Health, Emory University, 1518 Clifton Road, NE, Room 526, Atlanta,
GA 30322; firstname.lastname@example.org.
This manuscript was an invited submission.
Am J Health Promot 2005;19(5):330–333.
2005 by American Journal of Health Promotion, Inc.
SUMMARY OF THE LITERATURE ON
Several studies have examined schools as important
sources of children’s food.
For example, fruit and veg-
etable availability and school lunch selection correlate
with youth fruit and vegetable consumption.
The nutrition environment might explain some of the
racial/ethnic and socioeconomic disparities in nutrition
and health outcomes. For instance, fast-food restaurants
are more prevalent in minority neighborhoods, whereas
supermarkets are less prevalent.
Some healthy foods,
such as low-fat dairy products
and fruits and vegetables,
are less available or of poorer quality in minority and low-
er income areas.
A recent, important publication re-
ported that African-American adults’ fruit and vegetable
intake increased with each additional supermarket in a
The nutrition environment in the United States has
been changing rapidly. The increasing popularity of din-
ing out over the past two decades has raised the propor-
tion of nutrients obtained at away-from-home food sourc-
Away-from-home foods typically contain more fat and
saturated fat and less ﬁber than foods prepared at
Expanding portion sizes appear to be contribut-
ing to the obesity epidemic.
Price and availability are inﬂuential features of the nu-
trition environment—and the inﬂuences are not necessar-
ily health promoting. Cost has been reported as the sec-
ond most important factor in food decisions, behind
Government regulations that affect price are con-
sistent inﬂuences on the purchase of fruits, vegetables,
beef, and pork.
Vending machine purchases have also
been shown to relate to price. A recent study showed a
93% increase in low-fat snack sales after a 50% price re-
Although the literature to date is limited, di-
verse studies support the principle that nutrition environ-
ments might be important inﬂuences on eating behavior
and could help explain disparities in behavior and dis-
ease. In the context of an obesity epidemic,
it is essen-
tial to improve our understanding of food environments
as rapidly as possible.
CONCEPTUALIZING AND MEASURING
We propose a conceptual model for the study of nutri-
tion environments based on an ecological model of health
May/June 2005, Vol. 19, No. 5 331
Model of Community Nutrition Environments
and ongoing work by the authors supported
by the Robert Wood Johnson Foundation. The model in-
corporates constructs found or hypothesized to be related
to the healthy eating outcomes from the ﬁelds of public
health, health psychology, consumer psychology, and ur-
ban planning. The model in Figure 1 identiﬁes four types
of nutrition environments that need to be studied, and
those environments are affected by policies of govern-
ments and other organizations. Food environments are
shown as having two pathways of inﬂuence on eating pat-
terns. Environmental effects can be moderated or mediat-
ed by demographic, psychosocial, or perceived environ-
ment variables. Environmental, social, and individual fac-
tors inﬂuence eating patterns, which in turn affect risk of
many chronic diseases.
This model has been used to guide the development of
nutrition environment measures that are needed to sup-
port studies of environments and eating behaviors. Be-
cause of the large number of potential variables that
could be measured, we have identiﬁed the ‘‘community
nutrition environment’’ and the ‘‘consumer nutrition en-
vironment’’ as highest priority because they have been less
studied and could have broad effects.
At the general community environment level, we can
observe the distribution of food sources, that is the num-
ber, type, and location and accessibility of food outlets.
Accessibility can include drive-through windows and hours
of operation. Stores and restaurants are the most numer-
ous food outlets. We term other sources of food, such as
homes and cafeterias in schools, worksites, and other loca-
tions such as churches and healthcare facilities as ‘‘organi-
zational nutrition environments’’ that generally are avail-
able to deﬁned groups rather than to the general popula-
tion. Several sources of data could be used for identifying
food outlets in communities: GIS-based analyses of land
use data, census data, food license lists from health and
agriculture departments, Web site searches, and online
Yellow Pages and phone books. Each method has advan-
tages and limitations, and a combination is probably the
best way to assure coverage.
The home environment could be the most complex
and dynamic food source. Food at home is affected by
food availability at other outlets. Frequency of shopping
can affect the environment’s effect on food choice. The
primary food shopper and preparer has particular inﬂu-
ence on the eating patterns of others in the household,
so there is a strong social inﬂuence component. The avail-
ability of food and parental inﬂuence are especially strong
Several recently reported studies examined community-
level access to food sources, such as grocery stores and
fast-food restaurants, and have found community-level as-
sociations related to socioeconomic, racial, and ethnic
Others have found correlations of
neighborhood characteristics with individual food pur-
chasing or consumption behaviors.
Although these re-
lationships are particularly intriguing, such ecological
studies might oversimplify complex systems.
gest broad policy opportunities for health promotion, but
such efforts might be misdirected if the root causes are
not examined more closely. These ﬁndings are consistent
with the ‘‘gravity model,’’ which is employed in transpor-
tation and urban planning research; it predicts aggregate
human behaviors related to spatial interaction, such as
trafﬁc ﬂow and shopping activities.
Recent results also
support the usefulness of Zipf’s Principle of Least Effort,
332 American Journal of Health Promotion
which suggests that relative proximity in space of healthy
vs. unhealthy food products affects the odds of a healthy
vs. an unhealthy diet.
Consumer environment data reﬂect what consumers
encounter within and around a retail food outlet (i.e.,
store or restaurant), and most of these characteristics also
will apply to food sources in organizational environments,
although the home might be a special case. Relevant char-
acteristics can include nutritional qualities, price, promo-
tions, placement, range of choices, freshness, and nutri-
tional information. In retail food stores, the target catego-
ries of food of broadest interest would be those most
closely related to obesity and other chronic diseases (i.e.,
those that contribute most to fat and calories
that are most recommended for healthful eating
are consistent with the Dietary Guidelines for Americans
and the Food Guide Pyramid
). Therefore, the categories
of foods of highest priority are proposed as dairy products,
meat and poultry, fruits and vegetables, packaged main
dishes, and baked goods/sweets.
Our current work developing environmental assess-
ments in retail food stores (grocery/supermarket and
convenience stores) measures two factors for fresh and
packaged food products: availability of healthy food op-
tions (low-fat, vegetables, fruits or unsweetened fruit juic-
es) and cost. Cost is assessed per pound for fruits and veg-
etables and for ‘‘healthy’’ vs. ‘‘regular’’ options for compa-
rable products, such as low-fat dairy products, lean meats,
and prepackaged main dishes. Speciﬁc criteria for what is
‘‘healthful’’ have been suggested by various health re-
searchers and community and government agen-
and these criteria should be adapted for use
in consumer nutrition environment indicators.
Some of the earliest published measures of availability
were reported by Cheadle and others,
the percentage of shelf space used for healthy food op-
tions, such as low-fat milk and cheese and lean meats.
These measures are theoretically robust but could be
more difﬁcult to apply in contemporary grocery stores
that are larger and more varied in layout than they were a
decade ago. Other opportunities for consumer-level mea-
sures in stores include assessing product promotion and
placement related to children (e.g., store displays market-
ing energy-dense foods; unhealthy products on lower
shelves). These issues have been found to be important in
tobacco control efforts.
Assessments of the consumer nutrition environment at
restaurants, including fast-food restaurants, are more chal-
lenging than food store measures, and there are few pub-
We propose restaurant evaluations
initially focus on four indicators of the availability of
healthy choices or options: healthy main dish choices
(low-fat, low-calorie, healthy main dish salads), availability
of fruit (without added sugar or sauce), availability of
nonfried vegetables (and vegetables without fat-laden
sauces), and portion sizes (availability of small portions
and, for chain restaurants, presence of ‘‘super-sizing’’).
These selected key variables are recognized in the descrip-
tive literature as contributing to consumer food choice
and are most likely to affect weight and cardiovascular
risk factors. Because many restaurant chains and most fast-
food restaurants publish their menus and nutrient values,
it is possible to obtain nutritional information from books
or on the internet. However, an important caveat is that
such information is seldom available at the point of
choice, where it would be most informative to customers.
Other key data sources for restaurant environments in-
clude reviewing menus, interviewing managers or making
inquiries to waiters, and visual scanning of the restaurant
environment. Although it might be easy to determine
whether restaurants offer super-sized items, other dimen-
sions of restaurant offerings are more difﬁcult to evaluate
if nutrition information is not provided.
We identify the ‘‘information environment’’ as a
fourth, independent type of environment whereby media
reports and advertising are affected by government and
industry policies, and could in turn affect attitudes and
the appeal of certain foods and food sources. The infor-
mation environment is unique because it can operate on
a national or regional level, as well at the neighborhood
and store or restaurant level.
Although there are an increasing number of reports of
various dimensions of nutrition environments, there is no
guidance in the literature on how best to measure nutri-
tion environments in a comprehensive manner. Our typol-
ogy is based on an ecological model, our ﬁeld experience,
criteria put forward by authoritative health groups, and
preliminary studies. Our Nutrition Environment Measure-
ment Study (NEMS), currently underway, is an effort to
develop a comprehensive set of tools that is reliable and
demonstrates criterion validity to characterize nutrition
environments in neighborhoods. In deﬁning these mea-
sures, we have been attentive to the nutritional meaning-
fulness of indicators, relevance and feasibility of measures,
and potential for linking environmental and individual as-
sessments in subsequent studies.
The model in Figure 1 is presented as a starting point
for conceptualizing nutrition environment variables that
are believed to be related to eating behaviors. On the ba-
sis of a broad consideration of nutrition environments,
our group prioritized speciﬁc variables in the community
and consumer environments. Measures are being devel-
oped that will allow associations between environments
and eating behavior to be tested. It is likely other investi-
gators will prioritize other food environment variables, so
additional measures will need to be developed. More set-
ting-speciﬁc models might be needed as well. The com-
plexity of the research area is clear, but given the public
health imperative to improve eating behaviors in the pop-
greater priority needs to be given to under-
standing the role of food environments on individual’s
This work was supported in part by a grant from the Robert Wood Johnson Founda-
tion for the Nutrition Environment Measures Study (NEMS).
May/June 2005, Vol. 19, No. 5 333
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