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GOVERNMENT, LAW, ANO PUBLIC HEALTH PRACTICE

Neighborhood Disparities in Access to Healthy Foods and Their Effects on Environmental Justice Angela Hilmers, MD, MS, David C. Hilmers, MD, MPH, and Jayna Dave, PhD

Environmental justice is concerned with an equitable distribution of environmen- tal burdens. These burdens comprise immediate health hazards as well as subtle in- equities, such as limited ac- cess to healthy foods.

We reviewed the literature on neighborhood disparities in access to fast-food out- lets and convenience stores. Low-income neighborhoods offered greater access to food sources that promote un- healthy eating. The distribu- tion of fast-food outlets and convenience stores differed by the racial/ethnic character- istics of the neighborhood.

Further research is needed to address the limitations of current studies, identify effective policy actions to achieve environmental jus- tice, and evaluate interven- tion strategies to promote lifelong healthy eating ha- bits, optimum health, and vibrant communities. {Am J Public Health. 2012;102: 1644-1654. doi:10.2105/AJPH. 2012.300865)

ENVIRONMENTAL JUSTICE HAS

been defined as

fair treatment and meaningful in- volvement of all people regardless of race, ethnidty, income, national origin, or educational level in the development, implementation, and enforcement of

environmental laws, regulations, and poUdes.'*"

Fair treatment signifies that "no population, due to policy or eco- nomic disempowerment, is forced to bear a disproportionate expo- sure to and burden of harmful environmental conditions." " P " The concept of environmental justice, which has its roots in the fight against toxic landfills in eco- nomically distressed areas, can be similarly applied to the inequitable distribution of unhealthy food sources across socioeconomic and ethnic strata.' The neighborhood environment can help promote and sustain beneficial lifestyle patterns or can contribute to the development of unhealthy behav- iors, resulting in chronic health problems among residents.^"'* The higher prevalence of obesity among low-income and minority populations has been related to their limited access to healthy foodŝ "'® and to a higher density of fast-food outlets and conve- nience stores where they live.*''̂ " '̂ These environmental harriers to healthy living represent a signifi- cant challenge to ethnic minorities and underserved populations and violate the principle of fair treatment

Several studies have investi- gated disparities in the distribution of neighborhood vegetati the proximity of residences to playgrounds,^'' and the

accessibility of supermarkets and grocery stores,̂ '''̂ ® but fewer have examined access to fast-food outlets cind convenience stores as a function of neighhorhood racial and socioeconomic demographics. To our knowledge, our review is the first to expand the focus of environmental justice fi-om envi- ronmental hazards and toxic ex- posures to issues of the food en- vironment by examining research on socáoeconomic, ethnic, and ra- cial disparities in neighborhood access to fast-food outlets and convenience stores.

METHODS

We reviewed studies of differ- ences in accessibility of fast-food outlets and convenience stores by the socioeconomic and radal/ ethnic characteristics of neighbor- hoods. With the assistance of an experienced health science librarian, we conducted searches in the MEDLINE, PubMed, PsycINFO, EBSCO Academic Search Premier, and Scopus databases. Key words were "neigh- borhood deprivation," "food environment," "food sources," "fast- food restaurants," "convenience stores," "bodegas," "disparity," "in- equality," "minorities," "racial/ ethnic segregation," and "sodoeco- nomic segregation." We induded only original, peer-reviewed studies published in English

between 2000 and 2011. Com- ments, editorials, dissertations, conference proceedings, newslet- ters, and policy statements were excluded. We also excluded studies that focused on methods and measurements, did not ex- amine socioeconomic or racial/ ethnic characteristics of the neighborhood, or used schools as a proxy for neighborhood environment.

Our search identified 501 unique citations; after detailed inspection, we selected 24. The primary reasons for exclu- sion were irrelevant outcomes or comparisons (n = 316), fo- cus on dietary behavior (n = 96), and methodology studies (n = 65). We defined fast-food outlets as

take-away or take-out providers, often with a 'drive-thru' service which allows customers to order and pick up food from their cars; but most also have a seating area in which customers can eat the food on the premises (http:// www.merriam-webster.com).

Examples of fast-food outlets were fast-food restaurant chains, take-away or carry-out establish- ments, and small local fast-food businesses. We defined conve- nience stores as

retail stores that sell a combina- tion of gasoline, fast foods, soft drinks, dairy products, beer, dg- arettes, publications, grocery items, snacks, and nonfood items

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RESULTS

Of the 24 studies identified (Table 1), 14 were conducted in the United States^**"*; the re- mainder took place in Canada, England, Scotland, Australia, and New Zealand.^^"^' Most studies were cross-sectional,̂ ®"̂ ® and 3 had an ecological design.''^"^' Two studies used nationally rep- resentative data.^'^''^ The small geographic areas chosen as the units of analysis were a census

a census block * a zip code or postal

' a community or '''* '̂* '̂"'* a ter-

ritorial authority,*^ or a data zone.''̂ ''*3.49.50 Factors that in- fluenced the choice of units of analysis were the country or area where the study was conducted and the study design.

Techniques for identifying fast-food outlet and convenience store locations varied. Most studies used public health agency

and area-based geocoding tech-

conducted walking surveys in

a subsample of their units of anal- y^i^ 28.29,33.34,38 s o ^ e studies

used walking surveys to confirm

locations, to assess the availabiKty

of healthy menu options,^®-^^'"

and to perform food inventories

in selected fast-food outlets and

convenience stores."''*'̂ ® Only 8

circular buffers,^^ ranging

from a 0.2- to a 5-miIe radius

from each unit of analysis to

define the residents' neighbor- hood food environment

Among the neighborhood characteristics mentioned in the studies were race and eth- nidty,28-«.47 income,28-5' ed- ucational level,"'"-''^'^*'^'^'*« employment status,'''̂ '*® com- mercialization,''° alcohol outlet density,"'® presence of interstate or major state

and car ownership. Two studies assessed disparities among homogeneous demo- graphic areas with predomi- nantly African American^* or Hispanic"^^ communities.

Accessibility of Fast-Food Outlets

Eighteen studies investigated income disparities and exposure to fast-food out- lets 28,31,32,34-36,38,39,41,42,44-51

Fourteen found a relationship between neighborhood depriva- tion and fast-food outlet den- gjj^ 28,31,32,36,38,41,42,44,45,47-51

Morland et al. examined 216 census tracts in Maryland, North Carolina, Mississippi, and Minnesota and reported a higher prevalence of fast-food restau- rants among low-income neighborhoods.*' Hurvitz et al. examined 373 census tracts in King County, Washington, and found that the density of fast- food restaurants was inversely associated with the neighbor- hood household income."" Poorer neighborhoods in South Los Angeles, California, had a greater proportion of fast-food restaurants than did neighbor- hoods in wealthier West Los Angeles.̂ '' At the national level.

September 2012, Vol 102, No. 9 | American Journal of Public Health Hiimers et al. | Peer Reviewed | Government, Law, and Public Health Practice | 1649

GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

a comprehensive study of 21 976 US zip codes with 259 182 full- service restaurants and 69 219 feist-food restaurants found that these establishments were more highly concentrated in low- and middle-income neigh- borhoods than in high-income neighborhoods.^®

In New Zealand, a national study of 74 territorial authorities, comprising 37 760 neighbor- hoods, found that access to multi- national fast-food restaurants and small local fast-food businesses was greater in poor than in wealthier neighborhoods.*^ In Melbourne, the second largest dty in Australia, people living in areas with the lowest weekly incomes ($169-$ 199) had 2.5 times the exposure to fast-food restaurants as residents of areas with the highest weekly incomes ($400- $899).^' Results fi-om studies in the United Kingdom and Canada were mixed. Two studies in the United Kingdom found that poor neighborhoods were more likely than wealthier neighborhoods to have a high density of fast-food restaurants.''^-^" However, a study in Glasgow found that fast-food restaurant chains were more likely to be concentrated in more afflu- ent neighborhoods."*^ In Canada, studies in Nova Scotia and Edmonton found a significant as- sociation between socioeconomic deprivation and higher prevalence and accessibility of fast-food res-

taurants,'44,47,48 butastiidyof862 census tracts in Montreal found no association between density of all types of fast-food outlets and neighborhood income level.''®

Nine studies in the United States (and none in other countries)

examined neighborfiood racial/eth- nic disparities and exposure to fast-food outlets.^»'̂ ''̂ ^-^«'̂ «- '̂ Studies in Los Angeles,''* New York City,''̂ and New Orleans, Louisiana,̂ ^ found that unhealthy foods were more heavily promoted in African American communities. In South Los Angeles, neighbor- hoods with a higher proportion of African American residents had fewer healthy food choices and more fast-food restaurants than did West Los Angeles, an area of the city with a lower percentage of African Americans.'̂ ® A study of 5370 census blocks distributed across the 5 boroughs of New York City fotmd a higher density of fast- food restaurant chains and inde- pendent local fast-food busi- nesses in predominantly African American areas than in majority White locales.''^ In predomi- nantly African American areas, exposure to fast food was similar in more and less affluent neigh- borhoods, suggesting that radal correlates of fast-food density were more significant than socio- economic correlates.^^ Similar findings were reported in a study of 165 census tracts in New Orleans, where predomi- nantly African American neigh- borhoods had 2.4 fast-food res- taurants per square mile, and predominantly White neighbor- hoods had 1.5. In this study, the proportion of African American residents was also found to be a more powerful predictor of fast-food restaurant density than was medicin house- hold income."'®

A study of 448 block groups in New York found that African American block groups had fewer

opportunities to obtain healthy foods and greater access to fast- food restaurants than did other ethnic block groups.̂ ® Inequities in the availability of national and local fast-food restaurants within a single-minority commtmity were reported in a study of 165 census block groups in a low-income neighborhood of East Harlem, New York, where predominantly Hispanic census blocks had a higher proportion of fast-food restaurants than did radally mixed census blocks.''* In a study of 216 census tracts in Mississippi, North Carolina, Maryland, and Minnesota, fast-food restaurants were twice as common in radally mixed neighborhoods as in pre- dominantly African American neighborhoods.*'

By contrast, a study in King County, Washington,''' and a national study^® detected no assodations between a greater prevalence of fast-food restaurants and the proportion of non-White residents. In King County, how- ever, the census tracts examined had little ethnic variability: about 85% of the population was White.^'

Accessibility of Convenience Stores

Eight studies investigated neighborhood disparities in the density of convenience stores.28-30,32-34,41,43 Differences

by neighborhood income and race/ethnidty were found in urban and rural areas of the United States.̂ ®'"'"' A comparative study of the urban food environments of Kansas City, Missouri, and Hono- lulu, Hawaii, found that conve- nience stores were more prevalent

in the parts of these dties that were the most deprived and had the highest concentration of ethnic mi- norities.̂ ® A study of 6 rural counties in Texas found that poor neighborhoods with higher pro- portions of minorities had greater access to convenience stores.'''' Simüar findings were reported in a study of 197 census blocks in Texas, where increased neighbor- hood deprivation was assodated with greater access to convenience stores."'̂

A study in New York City ex- amined healthy and unhealthy food environments in ethnic neighborhoods to develop a food desert index. African American neighborhoods had more bodegas classified as less healthy because of their large stock of foods of low nutritional value than did Hispanic and White neighborhoods.^® In East Harlem, African American neighborhoods were less likely to have convenience stores than were radally mixed neighbor- hoods, and predominately His- panic neighborhoods were more likely to have convenience stores.^*

One group looked at Jackson City, Mississippi; Fors3fth County, North Carolina; Washington County, Maryland; and 7 sub- urbs of Minneapolis, Minnesota, and found a higher proportion of convenience stores without gas stations in minority and radally mixed than in White neighbor- hoods.*' In addition, more con- venience stores were located in poor than in wealthier neighbor- hoods.*' A study among Hispanic communities in Nueces County, Texas, reported a greater avail- ability of convenience stores in

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COVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

Hispanic than in non-Hispanic White neighborhoods. Compari- sons between lower- and higher- income areas within the same Hispanic neighborhoods found no significant associations."''' One international study found a greater prevalence of convenience stores in the most deprived neighbor- hoods of Glasgow than in the least deprived neighborhoods.*"'

DISCUSSION

The principle of environmental justice charges sodety and gov- ernment with the responsibility to provide equal access to healthy food options for all citizens. Our review foimd socioeconomic, ethnic, and racial disparities in neighborhood access to fast-food outlets and convenience stores and demonstrated that much remains to be done before envirorunental justice is achieved. Nei^borhoods where economically disadvantaged and minority populations reside were more likely to have abundant sources of foods that promote un- healthy eating. Previous reviews have shown that limited access to supermarkets and grocery stores in low-income nei^borhoods may represent a significant barrier to the consumption of healthy foods.̂ "' Excessive exposure to tmhealthy food sources and limited access to healthier options may explain the high prevalence of obesity ob- served in these communities. Such assodations have been described not only in the United States,̂ *"^^ but also in the United Kingdom,̂ ''" '̂

'̂ ^ Sweden,*** ' and Canada,®^

where residing in a low-income or deprived area was independently

assodated with prevalence of obe- sity and with poor-quality diets.

Accessibility is a key determi- nant of consumption^®" '̂ and can act as a barrier to or a fadlitator for healthy eating,^^ as well as a component of environmental justice. Accessibility of healthful food sources may lower the risk of overweight and obesity by facili- tating healthier diets,^^ and easy access to nutritionally inappropri- ate food sources may contribute to excessive and harmful weight gain.'̂ ^ In general, fast-food outlets and convenience stores offer high- calode foods,̂ * leading to higher total caloric intakes for their cus- tomers.'̂ -̂̂ ® Fast-food outlets are known for their convenient and affordable energy-dense foods.̂ ^ Convenience stores provide mostiy prepared, high-calorie foods and a limited choice of fresh but expensive produce.®'̂ '̂̂ ® Fast- food outlet patrons have been shown to consume large portion sizes and to significantly underes- timate the caloric content of the foods they eat, particularly for calorie-rich foods.̂ ®

Policy initiatives such as calorie labeling in fast-food restaurants are intended to help consumers make informed menu choices.*" However, assessments of the ef- fectiveness of these regulations have yielded inconsistent results. In New York City, a study com- paring purchasing patterns before and after the regulation was implemented reported that fast- food consumers living in low-in- come neighborhoods were less likely to use the calorie informa- tion.®' Furthermore, the use of the calorie information by low-income customers was not assodated

with the purchase of meals with lower caloric content®' Another New York City study found no dear reduction in mean energy content of lunchtime purchases for all menu items in the full sample of fast-food chains examined. How- ever, the regulation appeared to exert a positive effect on energy intake in 3 of the sample's 13 fast-food chains.®^ In King County, Washington, a study of a Mexican fast-food chain found no change in mean calories pur- chased after calorie labeling was implemented.®^ A study in Pierce County, Washington, evaluating labeling in a small convenience sample of full-service restaurants showed that customers who used the calorie information reduced their orders by an average of 75 calories.®*

Despite these inconsistent re- sults, calorie-labeling initiatives may encourage fast-food outiets to improve their menu offerings and promote lower-calorie items. More studies are needed to assess the potential impad of repeated exposure to such regulations on long-term consumer purchas- ing paftems and their impact on en"vironmental justice.

Other initiatives, such as pub- lic-private partnerships to intro- duce supermarkets to under- served areas, offer promise. For example, the Pennsylvania Fresh Food Financing Initiative found that adding a supermarket to an underserved area increased availability of healthy foods in the community.®^

The emergence of so-called urban food deserts—areas with limited access to healthful food sources and high levels of radal

segregation and income inequality- mandates public health interven- tion. Improved transportation in low-income neighborhoods, thus improving access to healthful foods; mobile markets to bring fresh produce into communities; and direct incentives for food re- tailers to locate near low-income communities, such as zoning al- lowances, tax holidays, or tax rebates, are among proposed strat- egies for a more equitable distri- bution of healthful food sources.®® Increased access to supermarkets, increased availabuity of healthy food choices, policy initiatives to encourage healthier menu offer- ings in fast-food outlets, and nutri- tion education in the community may work synergjstically to reduce the risk of obesity and improve dietary quality in these popula- tions. However, the differences in results across racial/ethnic, socioeconomic, and national boundaries reported by the stud- ies we reviewed demonstrate that no one-size-flts-all solution exists for the problem of envi- ronmental justice. Each situation has its own regional flavor and requires flexible strategies at the national and local level to effect positive change.

Limitations

Our database search did not indude sodological abstracts or the science and sodal science d- tation indices of the Web of Sd- ence. Nevertheless, the multiple databases we used encompassed the sodological literature, making the likelihood of missed articles small. Our definition of environ- mental justice included "meaning- ful involvement of all people.""P"

September 2012, Vol 102, No. 9 | American Journal of Public Health Hiimers et ai. \ Peer Reviewed | Government, Law, and Public Health Practice | 1651

GOVERNMENT, LAW, AND PUBLIC HEALTH PRACTICE

Despite its importance, addressing this integral component of envi- ronmental justice was beyond the scope of this article. We strongly encourage further research into how community involvement may be strengthened.

Conclusions about cause and effect could not be established because most of the studies in our review were cross sectional. Therefore, other environmental and genetic causes of obesity and poor dietary quality in these populations cannot be ruled out as confounders. Not all studies employed buffering techniques, which are the most accurate methods available for defining impact areas.®^ This may explain the disparate results observed in some international studies that relied on secondary data to describe the food environment.

Description of the food envi- ronment involves the identifica- tion of specific types of outiets and their location; it has therefore been recommended that a field validation be conducted or that multiple data sources be used to increase the quality of the re- sults.®® No studies conducted out- side the United States followed these recommendations. Some studies were Hmited to large fast- food chains. Other fast-food sources, such as small comer stores (e.g., bodegas and Asian food markets) were not consid- ered in many of the studies, which could have caused underestima- tion of convenience stores, which are overrepresented in low-income and minority neighborhoods.®®

In some cases, the lack of stan- dardized methodology hindered

direct comparison of results. For example, in 2 studies of the food environments in Hispanic and African American neighborhoods in New York City, use of buffering techniques in one but not the other may explain their differing findings.^®'^* Fast-food or total dietary intake, and home avail- ability of energy-dense foods, were not objectively assessed, limiting our abuity to determine whether the physical presence of fast-food outlets and conve- nience stores could be translated into an increased consumption of energy-dense foods. Neverthe- less, current evidence suggests that easily accessible fast-food outlets and convenience stores may result in greater constimp- tion of unhealthy foods and higher energy intake.®''

Studies on store food quality have demonstrated the impact of in-store availability and price of energy-dense snack foods on pur- chase and constimption choices.®' Prospective studies that objec- tively measure the dietary intake of healthy foods in relationship to proximity to fast-food outlets and convenience stores; reliable, stan- dardized methods for measuring density of and proximity to fast- food sources; and inclusion of small comer stores in similar studies are all needed.

Conciusions

The impact of neighborhood design on residents' health has become a focus of research in- terest^^ Results from these stud- ies have led the environmental justice movement to expand its concerns beyond the unequal distribution of environmental

hazards to issues of public health, such as obesity.®^ Low-income and radal/ethnic minority populations have substantial environmental challenges to overcome to make healthy dietary choices and to maintain a healthy body weight^^

The disproportionate distribu- tion of food sources that contrib- utes to the development of tin- healthy behaviors among these communities and the consequent disease burden deeply affect not only individuals and families, but also sodety as a whole. Envi- ronmental justice wñl be achieved, says the Environmental Protection Agency,

when everyone enjoys the same degree of protection from envi- rormiental and health hazards and equal access to the dedsion- making process to have a healthy environment in which to live, learn, and work.^''

This prindple of fairness and equity needs to be reflected in neighborhood environments that facilitate healthy food choices for all sodetal strata. This should indude public-private partner- ships to increase access to healthy foods in underserved areas and the partidpation and ac- countability of the commtmity in formulating public policy and en- vironmental decisions. Nutrition education, induding learning to understand food and menu labels, could help residents of low-in- come communities to make healthier choices. These innova- tions could help reduce neighbor- hood inequalities, enhance envi- ronmental justice, and promote lifelong healthy eating habits, optimtim health, and vibrant communities. •

About the Authors Angela Hilmers andfayna Dave are with the Children's Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, TX. David C. Hilmers is with the Departments of Pediatrics and Internal Medicine, Baylor College of Medicine.

Correspondence should be sent to Angela Hilmers, MD, 2846 Bellefontaine St., Houston, TX 77025 (e-mail: hilmers® bcm.edu). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints " link.

This article was accepted April 16, 2012.

Contrihutors A. Hilmers originated the study, drafted the first version of the article, and co- ordinated all revisions. All authors con- ceptualized ideas, interpreted findings, and critically reviewed and approved the final version of the article.

Acknowledgments We are thankful to Karen W. Cullen for her timely and insightful comments on an earlier version of this article. We are indebted to Helena VonVille from the University of Texas School of Public Health Library for her invaluable assis- tance in conducting the systematic review.

Human Participant Protection This study was a review of the literature, and institutional review board approval was not needed.

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