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A C A D E M I C P A P E R

Health disparities: Using policies to rethink our strategies for eliminating the impact of food deserts by focusing on unhealthy dietary patterns

Edward V. Wallace

Department of Africana Studies, University of

Cincinnati, Cincinnati, Ohio, USA

Correspondence

Edward V. Wallace, Department of Africana

Studies, University of Cincinnati, 3609

French Hall, P.O. Box 210370, Cincinnati,

OH 45221‐0370, USA. Email: [email protected]

For years, we have been interested in understanding the relationship between dietary

patterns and diseases, and most recently, we have put efforts toward analyzing the

impact of food deserts as they relate to dietary patterns. Unhealthy eating has

become an epidemic in low‐income neighborhoods that are considered to be food

deserts due to the fact that people are not meeting their recommended daily intake

of nutritionally dense foods. Adults should be consuming at least 20 to 35 g of fiber

daily, however, many Americans only consume 12 to 17 g of fiber daily at best. Fur-

thermore, as a society, we Americans consume way too much added sugar, saturated

fat, and salt. Although there are a number of reasons that unhealthy dietary patterns

exist in our society especially in low‐income communities, it is important that we pay

particular attention to how food deserts have developed and how they are major con-

tributors to the overall poor health of low‐income Americans. Therefore, the purpose

of this is paper is to encourage its audience to rethink how we can implement policies

to address the issue of unhealthy dietary patterns by reducing or eliminating food

deserts. Specifically, we explore the effect of implementing evidence‐based policies

such as nutrition initiatives, corner store initiatives, menu labeling, food assistance

programs, and the punitive taxation of sugary beverages and unhealthy foods similar

to the punitive taxes placed on tobacco.

1 | INTRODUCTION

For years, researchers have been interested in understanding the rela-

tionship between dietary patterns and diseases (Akhlaghi et al., 2017).

According to the National Institute for Health and Care Excellence, the

majority of the research in the past 20 years has been on malnutrition,

particularly in groups of people who have neurodegenerative disease,

acute illness, and people with social issues, including the inability to

cook and shop for food (McEvilly, 2016). Those living in poverty suffer

the greatest consequences and are at higher risk for disease (Harris &

Jack, 2011).

Most recently, researchers have focused on the impact of food

deserts as it relates to dietary patterns. In October 2015, the American

Medical Association urged physicians to screen children who reside in

food desert neighborhoods and identify the negative health outcomes

associated with inadequate access to food (Tomayko et al., 2017).

Data from the Unites States Department of Agriculture indicated that

the highest number of food deserts exist in states with the largest

populations (Yousefian, Leighton, Fox, & Hartley, 2011).

Unhealthy eating has become an epidemic in low‐income neigh-

borhoods that are considered to be food desserts due to the fact that

people are not meeting their recommended daily intake of nutrition-

ally dense foods (Wig, Bhatt, Sakhuja, Srivastava, & Agarwal, 2008).

In the United States, it is recommended that the average American

diet should consist of 20 to 35 g of fiber daily; however, many people

only consume 12 to 17 g of fiber in their daily diet (Green, 2015). Fur-

thermore, as a society, we consume more than the recommended daily

This manuscript is not being considered for publication elsewhere at this time

and has not been previously accepted or published elsewhere.

The author (Edward V. Wallace) of this manuscript transfers copyright owner-

ship to The Journal of Public Affairs–Special Issue Food Desert/Security upon publication.

Received: 3 April 2018 Revised: 28 August 2018 Accepted: 26 September 2018

DOI: 10.1002/pa.1875

J Public Affairs. 2019;19:e1875. https://doi.org/10.1002/pa.1875

© 2018 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pa 1 of 7

allowance of sugar (Mantzari, Hollands, Pechey, Jebb, & Marteau,

2017), solid fats (Jahns & Kranz, 2014), and iodized salt (Rafieifar

et al., 2016).

Although there are a number of reasons why unhealthy dietary

patterns exist in low‐income communities, it is important that we

pay particular attention to the role of how food deserts have contrib-

uted to this problem. Therefore, the purpose of this paper is to

encourage its audience to rethink how we implement policies to

address the issue of ways we can reduce unhealthy dietary patterns

by reducing or eliminating food deserts. Specifically, we explore evi-

dence‐based policies such as nutrition initiatives, corner store initia-

tives, menu labeling, food assistance programs, and taxation of

unhealthy foods.

2 | NEIGHBORHOOD NUTRITIONAL ENVIRONMENTS

The United States Department of Agriculture defines food deserts as

low income (poverty rate greater than or equal to 20% or median fam-

ily income at 80% or lower of the area median family income) commu-

nities where at least one‐third of tract residents live more than 1 mile

(or 10 miles away in the case of rural areas) from a supermarket or a

large grocery store (United States Department of Agriculture, 2012).

Traditionally, we have always made the assumption that the solution

to “fixing” America's food deserts and reducing health disparities was

to increase access to healthy foods in full‐service supermarkets and

grocery stores. We must reevaluate this notion because studies have

shown that increasing access to healthy foods in full‐service super-

markets and grocery stores does not necessarily equate to increased

consumption of healthy foods such as fruits and vegetables

(Drewnowski, Aggarwal, Hurvitz, Monsivais, & Moudon, 2012).

Numerous studies continue to question the connection between

food access and health (Black, D'Onise, McDermott, Vally, & O'Dea,

2017). Some studies that have examined the connection between

food environment and unhealthy food consumption have shown there

is no statistical significance between the two. For instance, a study

examined the number of fast‐food outlets around schools and the

relationship between dietary practices of children and the access to

fast‐food outlets. Results of the study did not show any significant dif-

ference between the children who attended school within 200 m of

the fast‐food outlet and children who were not exposed to fast‐food

outlets (Joo, Ju, & Chang, 2015). Several cities have conducted longi-

tudinal studies, which have concluded similar outcomes. A study con-

ducted in Philadelphia, Pennsylvania examined the impact of building a

new supermarket in a low‐ income neighborhood (Chrisinger, 2016).

After the supermarkets grand opening for just a few months, a major-

ity of the neighborhood used the new supermarket for shopping.

When compared with another food desert used as a control neighbor-

hood, the new supermarket had the perception that people in that

neighborhood were eating healthier because they had access to a

clean and orderly supermarket. However, there was no evidence that

neighborhood residents consumed more fruits and vegetables from

this new supermarket and had a healthier diet. A study was conducted

in the urban city of Charleston, West Virginia where they wanted to

investigate a new food hub “greener supermarket” to see if this new

initiative would offset the negative effects of a food desert (Miller

et al., 2016). Only 21% of the residents used the greener supermarket

after opening out of convenience, whereas 77% did most of their

shopping at a supermarket 11 miles away from their home due to

price comparisons, realizing they had a 30% savings by traveling to

the distant supermarket.

Even when we build healthy “greener supermarkets” in food

deserts, this does not make low‐income residents immune to

unhealthy eating and disproportionate rates of obesity. Many con-

sumer health experts agree that supermarkets typically provide

greater variety and access to fresh produce compared with local

bodegas or corner stores (Ghirardelli, Quinn, & Foerster, 2010). How-

ever, an abundance of sugary unhealthy snacks also tend to dominate

the shelves of grocery stores. In fact, according to Khandpur, Graham,

and Roberto (2017) of the approximate 85,000 packaged foods and

beverages sold in the U.S. 73.5% contain added sugar. A study in

Los Angeles found that both supermarkets and drugstores offered

considerably greater amounts of unhealthy snacks compared with

fruits and vegetables with 50% of grocery stores and 90% of drug-

stores being filled with unhealthy snacks (Farley et al., 2009; Julia

et al., 2015).

Supermarkets have been known to aggressively advertise

unhealthy foods to consumers. This marketing strategy occurs even

in the most upscale “healthy” supermarkets. However, because

unhealthy foods tend to be lower in price, thus more affordable for

low‐income shoppers, these marketing strategies have a greater nega-

tive impact on the eating habits of low‐income shoppers. Many super-

markets can be found strategically placing unhealthy foods at the end

of the aisle, in front of the stores, and even at cash registers as a

reminder to the shopper: “don't forget your unhealthy sugary snack.”.

In one study in New Zealand, children were exposed to unhealthy

foods 27.3 times per day due to stores placing their products at eye

level for children to view on a consistent basis while walking around

the supermarket (Alley et al., 2018).

Unfortunately, a review of the literature did not find any evidence

to support the notion that an increase in access to supermarkets

increases the demand for healthier items. With health disparities on

the rise, we can no longer afford to address the food desert crisis with

traditional interventions based on out dated information. Rather than

continue to be bamboozled and think, “If we build it they will come

and eat healthy.” Why not focus on United States policies and health

initiatives, which ultimately address unhealthy dietary patterns and

eliminate food deserts?

3 | SOLUTIONS TOWARD ADDRESSING UNHEALTHY DIETARY PATTERNS

With the abundance of unhealthy dietary consumption in the United

States, initiatives that have a narrow objective, focusing on at‐risk

communities such as those living in food deserts without cars (less

than 1% of the US population) are often less effective than

implementing policies that help people in their communities make bet-

ter decisions regardless of where they live, work, play, or pray, and

2 of 7 WALLACE

what type of supermarket or corner stores are located in their neigh-

borhood. More needs to be done in rethinking our strategies in the

area of policy especially for people who live in low‐income communi-

ties because they are often hit the hardest by diet—related diseases.

We specifically, explored evidence‐based policies such as nutrition ini-

tiatives, corner store initiatives, menu labeling, food assistance pro-

grams, and taxation of unhealthy foods because these initiatives

have been shown to have more validity than other policies, and

directly target economic and racial/ethnic disparities in diet quality.

4 | NUTRITION INITIATIVES FOR CHILDREN

Schools are ideal settings for providing programs to mitigate the neg-

ative impact that America's food deserts have on the health of our

children. Schools are responsible for administering at least one‐third

of a child's food intake during the school day and school personnel

have the opportunity to model making healthier food choices

(Wojcicki & Heyman, 2006). In 2016, in South Carolina, a study

was conducted which implemented new policy changes and updated

the school nutrition standards in food options at the middle school to

see the overall impact on healthy choices. The study enrolled 859

students in grades 6 to 8. Approximately, 45% of the students were

Caucasian, 34% were African American, and 21% were Latino.

Changes at the middle school consisted of removing sodas, cupcakes,

and giant slices of pizzas and replacing these items with fresh soup,

deli sandwiches, 100% fruit juice, and baked chicken and rice. Des-

serts consisted of individual fruit cups, and fresh fruit. Giant triangu-

lar pizza slices were replaced with smaller square slices and a side

salad, and extra‐large cheeseburgers were replaced with a modest

size cheeseburger. Data indicated that among the students who par-

ticipated in the study that 46% of the students preferred eating the

healthy food choices and thought that they tasted better than the

previous years (Beets et al., 2016). This demonstrates that the nutri-

tional regulations that schools were required to follow had a major

impact on participants' food intake while in school and could be used

as a tool to correct the unhealthy eating habits associated with living

in food deserts.

5 | CORNER STORE AND COMMUNITY EDUCATIONAL INITIATIVES

If storeowners provided consumers with financial assistance, educa-

tional material on healthy eating, and gave incentives for purchasing

healthy food at the point of sale, as a society, we could alleviate the

negative impact of food deserts. A study conducted in Atlanta,

Georgia provided evidence that shoppers reported being motivated

to purchase more healthy foods when they were given in‐store cou-

pons for healthy foods. In addition, results of the study showed that

when shoppers were given the opportunity to participate in tasting

demonstrations and given nutritional facts by the store owners, they

were motivated to purchase and eat healthier foods (Moore, Pinard,

& Yaroch, 2016).

6 | MENU LABELING LAWS

Having the United States government regulate the types and amount

of information about food products would be a great start for con-

sumers to understand the health consequences of their purchases

and be an effective way for consumers to change their unhealthy

dietary patterns and make healthier choices especially low‐income

families who live in food deserts. The United States Surgeon General,

Food and Drug Administration (FDA), and the Institute of Medicine

have all required food manufactures to communicate nutritional infor-

mation to consumers about the foods they eat, especially when they

eat away from home (Rutkow, Vernick, Hodge, & Teret, 2008). Listing

calories in stores and restaurants could be used as a tool to promote

healthy eating. In fact, many public health advocates believe that pro-

viding consumers with this type of information may help people make

informed choices about the foods they purchase and eat (Gruner,

DeWeese, Lorts, Yedidia, & Ohri‐Vachaspati, 2018). A study in New

York City assessed consumer awareness of menu calorie information

at restaurants after the introduction of New York City's health code

regulation requiring all restaurants to display food‐items calories on

menus and menu boards. The study revealed that posting calorie infor-

mation on menu boards increases the number of people who see and

use this information to make healthy food choices (Dumanovsky,

Huang, Bassett, & Silver, 2010).

7 | RESTRICTION ON SUGARY DRINKS IN SCHOOL LUNCH POLICY

In 1946, the first federal nutrition assistance program known as the

National School Lunch Policy (NSLP) was implemented in schools

and currently serves over 31 million school children daily that qualify

for free or reduced lunch (Kass, Hecht, Paul, & Birnbach, 2010). The

NSLP is another way we can address unhealthy dietary patterns

because it prevents the selling of foods in schools that have minimal

nutritional value including sugary drinks. Preventing the sale of sugary

drinks on school premises is effective for reducing overall sugary drink

consumption among children especially those who live in food deserts.

Schools have been providing low‐fat milk and water to young children

during free breakfast and lunch while in school, therefore, preventing

the sale of sugary drinks. Schools play a critical role in developing and

influencing the food habits of children and have the power to both set

and encourage healthy nutrition standards especially in areas deemed

to be food deserts where parents may not be able to due to limited

access to healthy foods.

8 | WIC AND SNAP FOOD ASSISTANCE PROGRAMS

Many corner stores or bodegas that are located in food deserts can

help address unhealthy dietary habits by providing incentives for

healthy food choices through food assistance programs. In 2009, the

Supplemental Nutrition Program for Women, Infants, and Children

(WIC) implemented a policy, which required the purchase of healthier

food, including adding more fruits and vegetables (Pelletier, Schreiber,

WALLACE 3 of 7

& Laska, 2017). This policy change convinced corner storeowners to

stock their shelves with healthier foods and was associated with

increases in fresh fruit (29%), vegetables (18%), and whole grains con-

sumption (Caspi et al., 2017; Johnson, Montgomery, & Ewell, 2016).

We could continue to address unhealthy dietary patterns if the

Supplemental Nutrition Assistance Program (SNAP) used the same

model and families were incentivized to purchase healthy foods by

getting money returned to their account for every purchase of a

healthy food item. A study was conducted in Baltimore, Maryland that

examined a rebate program for SNAP participants when purchasing

healthy food. The study had a sample size of 622,793 (63.1% were

African American and 28.2% were non‐Whites Hispanics) who

received $0.35 cash back for every $1 spent on fruits, vegetables,

and nonsugary drinks (Lagisetty et al., 2017). After year one of the

study, those who received the incentive reported consuming more

fruits and vegetables and fewer sugary drinks per day. This demon-

strates that incentivizing healthy food purchases from corner stores

increase healthy food purchases and may change dietary habits for

low income residents residing in food deserts.

Even though evidence has shown that implementing such policies

has worked, we must be mindful of who is being targeted and if their

liberties are being taken away by our government. Giving incentives to

low‐income individuals for making healthy purchases at corner stores

or bodegas, sends a public policy message that poor people require

government intervention to manage their food choices, whereas peo-

ple who have higher incomes do not (Kass et al., 2010).

9 | TAXATION ON SUGARY BEVERAGES AND UNHEALTHY FOODS

Placing a higher tax on sugary beverages and unhealthy foods may

serve as an alternative to changing unhealthy dietary patterns and

eliminating food deserts. In Canada, taxes are imposed on soft drinks,

sweets, and snack foods. What they found was that this “junk food

tax” encouraged a healthier lifestyle by reducing the consumption of

unhealthy sweets and snacks and motivated manufacturers to produce

healthier alternatives (Franck, Grandi, & Eisenberg, 2013). If these

taxes were implemented the same way in the United States, not only

would we see a reduction in obesity, but also there would be a decline

in cardiovascular disease, Type 2 diabetes, and dental cavities. Cities

and counties around the US are levying taxes on sugary drinks and

unhealthy snacks and its gaining momentum. A recent study con-

ducted in Berkeley, California found that the consumption of soda in

low‐income neighborhoods declined by 21% due to soda taxes

(Gostin, 2017).

In San Francisco and Oakland, policy makers approved a 1‐penny‐

per ounce tax on sugary drinks. In the city of Philadelphia, there was a

1.5 cent‐per ounce tax, and voters in Boulder, Colorado, approved a 2

cent‐per ounce tax on sugary beverages (Gostin, 2017). By far,

Boulder, Colorado has the most innovative policy with the highest

tax rate and revenue stream designated for wellness programs, chronic

disease prevention, and access to clean drinking water and healthy

nutritious foods. According the Indian Health Services, 10% of the

Navajo Nation's residents have diabetes and another 30% are

prediabetic. In addition, the obesity rate on the reservations ranges

from 30 to 60% (Bullock, Sheff, Moore, & Manson, 2017). These rates

are partly due to the fact that the reservation is a food desert.

Despite these alarming statistics, the Navajo Nation continues to

implement innovative policies to help the many Navajo people who

reside in rural Arizona. The Navajo Division of Health conducted a

study where they designed an assessment tool to determine what

popular food items (healthy or less healthy) were particularly being

consumed by the tribunal community. Findings of the study revealed

that the availability of healthy food options were located in border‐

town supermarkets and not on the Indian reservation at the local

convenient stores. Based on these findings, the Navajo Nation imple-

mented a policy that the convenient store located on the Indian reser-

vation would be responsible for providing access to healthier foods.

This innovative policy makes sense because the Navajo residents do

not own a vehicle and resides in an area that lacks public transporta-

tion (Kumar et al., 2016).

There would also be a health benefit to taxing sugary beverages

and unhealthy snacks and that would be to place the extra generated

revenue toward helping corner stores and bodegas provide healthier

food options to its customers, which could eventually reduce the num-

ber of unhealthy dietary patterns in many communities. The idea of

taxation as positive and negative incentives is not new, in fact,

tobacco taxation was highly effective in delaying the number of

teenage smokers by making sure the taxes constituted about 50% of

the cost per pack (Goodchild, Perucic, & Nargis, 2016). According to

Maslow's hierarchy of needs, food is one of the basic necessities for

sustaining life just as water, and shelter (Greene, Dasso, Ho, &

Genaidy, 2014). It is common practice in American society to tax food.

However, there is a fine line that we need not to cross. Do we need to

be particularly careful to tax sugary beverages and unhealthy foods at

a much higher rate, thus make it prohibitive to many? If we were to

implement such a policy with these types of stipulations, we could

be infringing on people's right of freedom of choice or put a tremen-

dous burden on the elderly and the poor.

10 | DISCUSSION

This paper makes the argument that all six individual policies have the

potential to eliminate food deserts, if as a society, we focus on

unhealthily dietary patterns. For example, policies that increase educa-

tion and incentives such as the corner store initiative and the SNAP

food assistance program have shown both of these policies to be

highly effective at eliminating food deserts. There are important impli-

cations that need to be mentioned anytime implementing incentives

for healthy food choices through food assistance programs are pos-

ited. Making the choice to eat fruits and vegetables often comes with

a higher cost for the consumer because fruits and vegetables are sus-

ceptible to harsh weather conditions, often needs to be hand‐picked,

has limited storage time, and may need to be transported in tempera-

ture control trucks. The price that consumers pay for fruits and

vegetables is affected by policies throughout the entire food system,

including international trade, import/export policies, and technology

to harvest crops. Incorporating incentives into food assistance

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programs such as SNAP and giving in store‐coupons to support the

Corner store initiative could increase healthy food choices in low‐

income communities.

Menu labeling is a crucial policy that can address unhealthy die-

tary patterns and eliminate food deserts. Many people often do not

realize the high calorie count in their food. The benefit of menu

labeling is that it increases the awareness of food choices in an envi-

ronment where low‐income families are surrounded by unhealthy

food choices because they live in a food desert. This is consistent with

the research. A study in New York City that examined over 100

transactions at a Starbucks found a significant calorie reduction after

calorie labeling when compared with the period prior to calorie label-

ing was implemented (Block & Roberto, 2014).

Taxing of sugary beverages and restricting sugary drinks to chil-

dren in school are two policies that are needed to combat changes

in our food environment that constantly promotes and markets excess

sugar consumption. It's crucial that policy makers keep in mind that

manufacturers are constantly using added sugar in their products

and marketing them in low‐income communities particularly food

deserts. It's also disappointing to know that people who live in food

deserts are two times more likely to be obese because of sugar con-

sumption compared with individuals who live in more affluent areas

(Hashem & Rosborough, 2017). A tax on sugary beverages can be

viewed as progressive as it relates to the changing food environment

because it can reduce sugar consumption. In addition, a tax on sugary

beverages can provide alternatives, where children can choose no or

low added sugary beverages or chose to simply drink water. Since

2016, momentum in local communities has been building where

voters have come out to the polls in record numbers to vote for taxes

on sugary drinks in their jurisdictions. The evidence is clear that taxing

sugary beverages restricts consumption of sugary drinks, generates

more revenue for communities located in food deserts, and reduces

health disparities (Gostin, 2017).

Despite the numerous research studies that support these initia-

tives and policies on how they are effective in eliminating food

deserts, it's important to point out the relationship between culture

and food consumption. For many of us, food is a source of pleasure,

comfort, and security deeply connected to one's culture (Scott, 2017).

The University of Maryland at College Park conducted a study

with 49 participants, 25 to 74 years of age to see whether the use

of food for Jamaican immigrants could provide a link to their cultural

heritage. Results of the study showed that food is very important to

ones culture and serves as a bridge by helping immigrants find a place

of familiarity while living in the United States (Goldschmidt,

Sankavaram, & Udahogora, 2018). Food is also a symbol of pride for

communities. Many ethnicities open their own restaurants and serve

traditional dishes within their community because it operates as an

expression of their cultural identity (Gao, Dutta, & Okoror, 2016).

The same could be said for corner stores. Corner stores can provide

healthy food samples that are culturally appropriate to match the

needs of their community they are serving, whereas at the same time,

they can preserve their culture. In New York City, a study examined

how small convenient stores, known as bodegas could influence local

residents shopping behaviors if the store sold its customers culturally

appropriate healthy snacks. Researchers analyzed data from 171

corner stores and 2,118 shoppers. Results of the study showed

owners of the corner stores reporting an increase in sales of culturally

appropriate foods from 5 to 16% (Dannefer, Williams, Baronberg, &

Silver, 2012).

Now more than ever, policy makers need to build on the success

that was started by the voters in 2016. Families who live in food

deserts need to demand that their local government address

unhealthy dietary patterns by implementing culturally appropriate pol-

icies that make environmental changes that increase and promote

healthier communities.

11 | CONCLUSION

Addressing unhealthy dietary patterns and reducing or eliminating

food deserts can ultimately make society healthier, but will require

federal, state, and local policy makers to rethink our current policy sta-

tus. These policies are necessary if we plan to reduce health dispar-

ities, but also critical for reinforcing a unified message to the public

that healthy food choices are essential in order to fight mortality. If

we want to have an impact on the food desert crisis, we need to

commit ourselves and focus our efforts on unhealthy dietary patterns

in low‐income communities.

ORCID

Edward V. Wallace http://orcid.org/0000-0001-7301-5375

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AUTHOR BIOGRAPHY

Edward V. Wallace is an Associate Professor in the Department of

Africana Studies at the University of Cincinnati and the director of

the Minority Health Certificate. Dr. Wallace specializes in the

area of community health with a focus on health disparities in

vulnerable populations. The emphasis of his research is in three

distinct areas: racial and ethnic health inequality, health policy, and

minority health. Dr. Wallace received his training from the State

University of New York College at Cortland, the University of

Massachusetts at Amherst, School of Public Health, and University

of Alabama, School of Public Health.

How to cite this article: Wallace EV. Health disparities: Using

policies to rethink our strategies for eliminating the impact of

food deserts by focusing on unhealthy dietary patterns. J Pub-

lic Affairs. 2019;19:e1875. https://doi.org/10.1002/pa.1875

WALLACE 7 of 7

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