Access to Healthy Food: Beyond Proximity
Refocusing the debate on healthy food access and health outcomes in underserved communities
By Breanna Hawkins-Morrison (MPL/PhD Candidate), Daniel Rizik-Baer (MSW) and Clare Fox (MAUP) (With support
from Esther Park and Camille de la Vega)
A recent study1 by the RAND Corporation, in conjunction with researchers from the Los Angeles County
Department of Public Health2 (published on September 3, 2015) suggests that proximity to different types of
food retail does not strongly correlate with rates of obesity, fruit and vegetable or unhealthy food consumption.
The new study comes at a time when government and non-profits are increasing investments aimed at
improving the number and quality of food retail in low-income communities that are often described as food
deserts, or neighborhoods lacking sufficient grocery stores or other healthy food options.
The study and subsequent media coverage on the relationship between food retail proximity and health
outcomes calls into question the validity of the existence of food deserts and the efficacy of policies aimed at
addressing them. In our assessment, however, the study neglects to address multiple and complex factors that
shape how communities access healthy food. Simply placing a grocery store in a neighborhood or introducing
produce into a convenience store will alone not change the health of neighborhood residents. The price and
quality of food as well as how food is marketed and how people travel to food retail are all factors that impact
an individuals access to healthy food.3
This essay is our response to the questions and limitations raised in the RAND study. In our assessment, we find
that the question is not whether food deserts are critical to health, but that the term access and how we
address it must be more holistically considered to cover the many ways in which food choice is impacted and
shaped by community conditions. Our concern with this RAND study is that it reduces the issue to a matter of
proximity to retail alone. Terms like food deserts, food swamps and food apartheid are all different ways
to describe how poverty and racism have led to limited healthy food access and proliferation of unhealthy food
options for some communities. In low-income communities of color in Los Angeles, these conditions are shaped
by complex historical, political and economic factors. Because of the historically complex nature of the food
access issue, solutions for addressing nutrition-related health disparities require complex policies that work
together to ameliorate these problems. No one policy will improve health outcomes for impacted communities.
However, increasing access to healthy food, and the manner in which we do this, remains an important
endeavor toward achieving health and social equity.
Mejia N, Lightstone AS, Basurto-Davila R, Morales DM, Sturm R. Neighborhood Food Environment, Diet, and Obesity Among
Los Angeles County Adults, 2011. Prev Chronic Dis 2015;12:150078. DOI: [Link]
2
As stated in the document: The opinions expressed by authors contributing to this journal do not necessarily reflect the
opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control
and Prevention, or the authors affiliated institutions.
3
Sloane, D., Nascimento, L., Flynn, G., Lewis, L., Guinyard, J. J., Galloway-Gilliam, L. & Yancey, A. K. (2006). Assessing resource
environments to target prevention interventions in community chronic disease control. Journal of Health Care for the Poor
and Underserved, 17(2), 146-158.
200 North Spring Street, City Hall M125, Los Angeles, CA 90012
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Expanding the Concept of Healthy Food Access and Choice
We must be sensitive to variables that impact an individuals access to healthy food and their decisions to eat
or not to eat healthy food. The concepts of access and choice are socially and economically determined. If
we are to individualize choice or oversimplify the concept of access to simple geographic proximity, we limit our
understanding of why people make the decisions they make within the larger context of the world that we live
in.
A useful tool in understanding how access is more complex than simple proximity is the idea of potential vs.
realized access. 4 That is, just because something seems accessible or seems close and readily available, does not
mean that it is accessible or that access is actually realized. This way of framing access allows us to consider the
nuances that contribute to access that are not solely determined by closeness, but also by affordability, cost,
and value (or perceived value), and availability.
Proximity to Food is not the Same as Food Access
Geographic proximity to food retail may seem to equate to ease of access, and in fact, it is an important piece
to consider. However, distance alone, especially without understanding how people actually move around their
neighborhoods, is an incomplete measure. An establishment may seem close on a map but simply may not be
welcoming, or in reality one may have to walk a farther distance due to obstacles- for example: cul de sacs, lack
of pedestrian infrastructure or lack of lighting on the street, to name a few ways that perceived geographic
proximity may, in fact, not be so close.
While one may think that in a car-centric city like Los Angeles, someone who does not have a neighborhood
grocer can simply jump in the car and drive to their closest supermarket, the truth is quite different. In Los
Angeles, the overwhelming majority of households without cars are low-income (68.2% of total households
without cars are low-income), 5 and 74% of households in Los Angeles without cars are Black or Latino.6 Public
transportation ridership in Los Angeles is even more predominantly low-income and non-white. Bus riders are
90% people of color with an average annual income of $14,423 and rail riders are 82% people of color with an
average annual income of $26,250.7
Getting to a supermarket with good food options may be difficult without a car, let alone if someone is working
a full-time job, has just commuted from work on public transportation, and still needs to take care of kids,
errands and their home at the end of the day.
The study itself states that geographic proximity as a measure of access may not tell the whole story. From
the limitations section of the recent study: the buffer analysis used Euclidean distance rather than road
Vallianatos, M., Azuma, A. M., Gilliland, S., & Gottlieb, R. (2010). Food Access, Availability, and Affordability in 3 Los Angeles
Communities, Project CAFE, 2004-2006. Preventing Chronic Disease, 7(2), A27.
5
Tomer, Adie. "Transit Access and Zero-Vehicle Households." Metropolitan Policy Program. Brookings, Aug. 2011. Web. 12
Oct. 2015 See: [Link]
6
Tomer, Adie. "Transit Access and Zero-Vehicle Households." Metropolitan Policy Program. Brookings, Aug. 2011. Web. 12
Oct. 2015. See: [Link]
7
Los Angeles County Metropolitan Transit Authority. 2012. Spring 2012: Metro RAIL Customer Satisfaction Survey Results
(May 15-24, 2012). Los Angeles County Metropolitan Transit Authority. [Link]
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networks, so even a small buffer (0.25 miles or 400 meters) may include outlets that residents consider to be
outside walking distance.
Cost and Perceptions of Value Also Play an Important Role in Decision-Making and Access
to Healthy Food
The cost of food is also a key factor in how people make decisions when purchasing food. Poverty itself is the
definition of lack of access to resources. The sheer lack of adequate income means that certain goods and
services are simply inaccessible, no matter the geographic proximity. Someone may desire to purchase healthy
food, but it may not make financial sense to do so when satiating hunger is the priority8. The need to stretch
dollars as far as possible lead people to choose less healthy, more fattening, higher sodium products that
provide more volume and perceived value. Without including socio-economic status and comparing
individuals at different income levels, the study does not help to clarify the effect of income on healthy food
consumption.
Marketing and merchandising of food products influence our perception of what is affordable or what is a good
deal. The concept of the value meal is an excellent example of the marketing of unhealthy food based on a
perceived increased value at lower cost. People are influenced to purchase larger portion sizes of low-quality
calories because it seems to maximize value in the face of limited financial resources. From a nutrition and even
food security standpoint, healthier food is often a greater value than unhealthy food though from a price tag
and volume standpoint, it may seem you are getting a better deal with unhealthier items.
The Quality of the Food and the Retail Establishment Itself Matters
The environmental quality of retail establishments where food is being sold and the quality of food products
being sold also shape food access.
Businesses are categorized by NAICS (North American Industrial Classification System), which is federally
monitored and relies on businesses to self-categorize. Sometimes, this leads to a discrepancy between how
the business is categorized in a data set and what the reality is on the ground. A store may be listed as a
grocery store but does not, in reality, offer a full breadth of fresh grocery product lines. The on-the-ground
experience of that grocery store may be that it is more of a convenience or corner store.
The study notes this limitation as well: Business data listings are never complete or up-to-date. In previous
work, we compared listings and on-the-ground verification in the City of Santa Monica and found excellent
agreement for outlets belonging to chains, whether restaurants or retail, but not for small individually owned
businesses. Field studies (26,27) found reasonably good predictive values but discrepancies at small scales
Compared to more affluent neighborhoods, low-income neighborhoods have higher numbers of small,
independent stores such as convenience stores, and junior or neighborhood markets.9 In LA County, nearly
70% of food retailers are small stores with between 1 and 5 employees. In South and East LA, the percentage of
Ghosh-Dastidar, Bonnie et al, Distance to Store, Food Prices, and Obesity in Urban Food [Link] Journal of
Preventive Medicine , Volume 47 , Issue 5 , 587 - 595
9
Sturm R and Cohen DA. (2009). Zoning for Health? The Year-Old Ban on New Fast-Food Restaurants in South LA. Health
Affairs.
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small retailers with 1-5 employees is nearly 90%10. This makes it even more important to ground truth data
sets by walking the streets and listening to how residents perceive and experience a food retail establishment.
Community-Based Participatory Research is vital if researchers are to understand the reality of the
communities they study. For example, Community Health Councils a South Los Angeles-based health equity
organization- has done work on this very issue and found that many stores in low-income communities in South
Los Angeles that identified themselves as grocers did not provide equivalent healthy food offerings as one would
expect from a store described as a market or grocer.11
Food Quality: Even when stores might carry certain fresh food products, studies have shown that stores in lowincome areas sell lower-quality, spoiled produce or expired products at a higher rate than stores in more
affluent areas1213.
The limitations section notes that: categorizing food outlets by type is insufficient to reflect outlet
heterogeneity, and more detailed measures, such as ratings of food quality, could be more predictive for health
outcomes.
Decisions are Heavily Influenced by Marketing and Advertising
As discussed earlier, the influence of marketing and advertising on how we eat is no secret. We know that
billions of dollars are spent to influence our choices every day, including food choices. Previous RAND studies14
have shown that stores with higher prices tend to market healthy food more than unhealthy food. The reverse is
also true- lower price stores tend to market unhealthy food more than healthy food. To take this one step
further, it was shown that this has an impact on the healthy and unhealthy food people purchase. That is- the
marketing worked, regardless of price. Including marketing and branding as variables in this study could have
helped to support or clarify previous research on how those factors affect food consumption. If we know that
unhealthy food is more heavily marketed in low-income neighborhoods then by its very definition, place does
have an impact on the decisions people are making about food.
Consumer education is important to combat marketing by advertisers. We need to educate consumers not just
how to eat healthy food, but also how to see and minimize the impact that unhealthy food marketing has on
buying decisions, how value can be seen in ways that maximize healthy calorie consumption, and in recipes for
how to prepare healthy food easily and on a budget.
10
U.S Economic Census County Business Patterns, 2013.
Lewis, L. B., Sloane, D. C., Nascimento, L. M., Diamant, A. L., Guinyard, J. J., Yancey, A. K., & Flynn, G. (2011). African
Americans access to healthy food options in South Los Angeles restaurants. American Journal of Public Health.
12
Sloane, D. C., Diamant, A. L., Lewis, L. B., Yancey, A. K., Flynn, G., Nascimento, L. M., Mc Carthy, W. J., Guinyard, J. J.,
Cousineau, M. R. and for the REACH Coalition of the African American Building a Legacy of Health Project (2003), Improving
the Nutritional Resource Environment for Healthy Living Through Community-based Participatory Research. Journal of
General Internal Medicine, 18: 568575. doi: 10.1046/j.1525-1497.2003.21022.x
13
LaVonna Blair Lewis, David C. Sloane, Lori Miller Nascimento, Allison L. Diamant, Joyce Jones Guinyard, Antronette K.
Yancey, and Gwendolyn Flynn. African Americans Access to Healthy Food Options in South Los Angeles Restaurants.
American Journal of Public Health: April 2005, Vol. 95, No. 4, pp. 668-673.
doi: 10.2105/AJPH.2004.050260
14
Ghosh-Dastidar, Bonnie et al, Distance to Store, Food Prices, and Obesity in Urban Food Deserts. American Journal of
Preventive Medicine , Volume 47 , Issue 5 , 587 - 595
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Conclusion: Food Equity Is About More than Food Access
In our efforts to address the myriad of factors that contribute to health disparities, we must work to understand
and be empathetic to the unique challenges that underserved communities face. Health disparities in
underserved communities have developed over decades, therefore we cannot expect policies and interventions
to result in substantive behavior changes within a few years. Complex problems necessitate equally complex
solutions, the benefits of which may take time to actualize and, in this case, may even extend beyond
traditional metrics of health.
The fact that many communities do not have the option to make healthy choices is more than just a health
issue. It's an ethics and human rights issue. All too often, historically disenfranchised communities are asked to
bear the burden of proof to demonstrate that they are deserving of the same access to resources as their more
affluent counterparts. When we speak of food deserts and their impact on the health of communities, we
ought to remember that protecting the health and human rights of the most marginalized communities ought to
be a collective priority.
The Los Angeles Food Policy Council, alongside a large network of partner organizations and political leaders,
work through a broad, multi-sector approach that not only focuses on improving health outcomes, but also on
the fundamental issue of equity itself. A small sample of these efforts include:
Investing in the leadership and business capacity of the small food retailers prevalent in low-income
communities to sell healthier, better quality and more affordable food through the Healthy
Neighborhood Market Network
Support schools, senior centers, recreation centers and other public institutions to offer more
nutritious, locally-grown, sustainable and fair food through a Good Food Purchasing Policy
Encourage healthy mobile food vending of fruit, produce, water and healthy snacks through a citywide
sidewalk vending program
Increase opportunities for people to grow their own food at community gardens, urban farms, edible
parkways and medians, schools, yards and apartment buildings
Make Farmers Markets more inclusive by accepting CalFresh (formerly known as food stamps) so
that more low-income people can enjoy Californias agricultural bounty
Reducing the oversaturation of unhealthy foods in underserved communities by promoting an inclusive
healthy food culture in Los Angeles
This work aims to cultivate a culture of healthy eating that can combat the immense marketing and
advertising of unhealthy foods to vulnerable populations. Each of the initiatives have been developed based
on empirical foundations that demonstrate the potential for positive impacts on health151617181920. However,
15
Healthy Neighborhood Markets: Minkler, Meredith. "Linking science and policy through community-based participatory
research to study and address health disparities." American Journal of Public Health 100.S1 (2010): S81.
16
Good Food Procurement: Raulio, S., Roos, E., & Prttl, R. (2010). School and workplace meals promote healthy food
habits. Public health nutrition, 13(6A), 987-992.
17
Unhealthy Food Limitations: Morland, Kimberly, Steve Wing, and Ana Diez Roux. "The contextual effect of the local food
environment on residents' diets: the atherosclerosis risk in communities study." American journal of public health 92.11
(2002): 1761-1768.
18
Healthy Mobile Foods: Morales, A., & Kettles, G. W. (2009). Healthy food outside: farmers' markets, taco trucks, and
sidewalk fruit vendors. Journal of Contemporary Health Law and Policy, 20(20), 2010-02.
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the diverse coalitions that lead efforts to advance these policies have also been effective in building social
capital, collective efficacy, civic engagement, and cross-cultural, intergenerational bonds throughout
underserved communities as well. The benefits of these outcomes are more difficult to measure, but have
been shown to connect to improved quality of life, which is an important outcome that should not be
overlooked.
All in all, health and equity are deeply intertwined with the economic, social and environmental vitality of our
society. While there are numerous groups working on improving food and health equity more broadly, our work
is far from over. More needs to be done to overcome the long, tenuous process of effecting large-scale systemic
changes. We also need to remember that the health-related outcomes of this work may take time to develop.
For these reasons, we invite colleagues and allies to employ equity as a compass, motivator and benchmark as
we consider the complexities of our challenges and the solutions we strive for.
About the Los Angeles Food Policy Council
The Los Angeles Food Policy Council (LAFPC) is a collective impact initiative that strives to create a food system in Los Angeles where food
is healthy, fair, affordable and sustainable for all Angelenos. Through policy creation and cooperative relationships, our goals are to
reduce hunger, improve public health, increase equity in our communities, create good jobs, stimulate local economic activity, and foster
environmental stewardship. In particular, the LAFPC aims to connect environmental sustainability and local agriculture with efforts to
expand access to healthy food in historically disenfranchised communities. The LAFPC brings together hundreds of individuals and
organizations throughout Los Angeles that recognize the need for multi-faceted strategies to fix our currently broken food system. We
collaborate in Working Groups that attempt to address the wide range of factors that affect our food system and facilitate dialogue
across previously siloed sectors, departments, organizations and individuals. To learn more about LAFPC and our model for change please
visit [Link].
19
Urban Agriculture: Brown, K. H., & Jameton, A. L. (2000). Public health implications of urban agriculture. Journal of public
health policy, 20-39.
20
EBT at Farmers Markets: Kropf, M. L., Holben, D. H., Holcomb, J. P., & Anderson, H. (2007). Food security status and
produce intake and behaviors of Special Supplemental Nutrition Program for Women, Infants, and Children and Farmers
Market Nutrition Program participants. Journal of the American Dietetic Association, 107(11), 1903-1908
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