Neighborhood Characteristics and Availability of

Healthy Foods in Baltimore
Manuel Franco, MD, PhD, Ana V. Diez Roux, MD, PhD, Thomas A. Glass, PhD, Benjamín Caballero, MD, PhD,
Frederick L. Brancati, MD, MHS

Background: Differential access to healthy foods may contribute to racial and economic health
disparities. The availability of healthy foods has rarely been directly measured in a
systematic fashion. This study examines the associations among the availability of healthy
foods and racial and income neighborhood composition.
Methods: A cross-sectional study was conducted in 2006 to determine differences in the availability
of healthy foods across 159 contiguous neighborhoods (census tracts) in Baltimore City
and Baltimore County and in the 226 food stores within them. A healthy food availability
index (HFAI) was determined for each store, using a validated instrument ranging from 0
points to 27 points. Neighborhood healthy food availability was summarized by the mean
HFAI for the stores within the neighborhood. Descriptive analyses and multilevel models
were used to examine associations of store type and neighborhood characteristics with
healthy food availability.
Results: Forty-three percent of predominantly black neighborhoods and 46% of lower-income
neighborhoods were in the lowest tertile of healthy food availability versus 4% and 13%,
respectively, in predominantly white and higher-income neighborhoods (p⬍0.001). Mean
differences in HFAI comparing predominantly black neighborhoods to white ones, and
lower-income neighborhoods to higher-income neighborhoods, were ⫺7.6 and ⫺8.1,
respectively. Supermarkets in predominantly black and lower-income neighborhoods had
lower HFAI scores than supermarkets in predominantly white and higher-income neigh-
borhoods (mean differences ⫺3.7 and ⫺4.9, respectively). Regression analyses showed that
both store type and neighborhood characteristics were independently associated with the
HFAI score.
Conclusions: Predominantly black and lower-income neighborhoods have a lower availability of healthy
foods than white and higher-income neighborhoods due to the differential placement of
types of stores as well as differential offerings of healthy foods within similar stores. These
differences may contribute to racial and economic health disparities.
(Am J Prev Med 2008;35(6):561–567) © 2008 American Journal of Preventive Medicine

Introduction gested that race and income are related to healthy food
1 intake. However, the availability of these healthy foods

T
he contribution of unhealthy diets to the obe-
and its relationship to race and economic status has
sity and diabetes epidemics in the U.S.2 is well
received little research attention. Although racial and
recognized. The 2005 Dietary Guidelines for
socioeconomic disparities in diet-related conditions
Americans emphasized the large deficit in the intake of
such as diabetes and obesity have been consistently
fresh fruits and vegetables, low-fat dairy products, and
whole grain foods of the U.S. population,3 and sug- reported,4,5 little research has investigated the role of
the food environment in generating and perpetuating
these disparities.
From the Department of Epidemiology (Franco, Glass, Brancati), the Given the strong residential segregation by race and
Center for Human Nutrition (Caballero), The Johns Hopkins income in the U.S., differences in local food environ-
Bloomberg School of Public Health; the Welch Center for Preven-
tion, Epidemiology and Clinical Research, Division of General Inter- ments associated with neighborhood composition could
nal Medicine, The Johns Hopkins School of Medicine (Franco, be important contributors to racial and income differ-
Brancati), Baltimore, Maryland; and the School of Public Health,
University of Michigan (Diez Roux), Ann Arbor, Michigan
ences in diet. Prior research has documented the asso-
Address correspondence and reprint requests to: Manuel Franco, MD, ciations of neighborhood racial and socioeconomic
PhD, Department of Epidemiology, The Johns Hopkins Bloomberg characteristics with neighborhood food availability. For
School of Public Health Welch Center for Prevention and Epidemi-
ology, 2024 E. Monument Street, Suite 2-607, Baltimore MD 21205- example, the type and number of food stores present
2217. E-mail: mfranco@jhsph.edu. have been shown to vary according to the racial and

Am J Prev Med 2008;35(6) 0749-3797/08/$–see front matter 561
© 2008 American Journal of Preventive Medicine • Published by Elsevier Inc. doi:10.1016/j.amepre.2008.07.003

two were new was used and adapted to the Baltimore environment. 541104-541106). the NEMS-S was used to measure food availability in directly the availability of healthy foods. Low-sodium items were added because of their poten- racial and income composition. Neighborhood racial and income composition was calcu. rather than a Improvements were made to the original list by (1) compar- comprehensive assessment. Neighborhood income composition was categorized Minor modifications were made to the NEMS-S to adapt it to using tertiles of the census tract median household income local conditions. the healthy food predominantly black. the nutri- added to the list: eight were recently opened supermarkets tion environment measures survey in stores (NEMS-S).8 Tracts that did not fall availability index.73.18. A total of ten new stores were recently validated comprehensive instrument. and ten tracts that were industrial areas.ajpm-online. hoods of interest. or HFAI) was calculated for each store. 541104-541106). There were 21 food stores (9% of the total number located in predominantly white and higher-income of stores) in which food items were displayed behind bullet- neighborhoods. Because the bulletproof glass limits the ability of consumers to examine food items and read expiration dates As part of the multiethnic study of atherosclerosis (MESA) and nutrition labels. Following prior work. type. into either of these categories were classified as racially mixed following procedures developed as part of the NEMS-S.200 for the 33rd percentile and baked goods were excluded. grocery stores (all remain. and 42 (11%) were neighborhoods than in predominantly white and higher. In addition.. 86 (23%) had closed for business perma- available in predominantly black and lower-income nently at the time of data collection. Hot dogs. 21 food within a given type of store. 17 small city tracts. grocery stores in Baltimore City were corner stores with very hoods. proof glass and sold through a revolving window. Many of the areas compared to minority and poorer neighbor.e. Like the original NEMS-S availability Information on all food stores located in the study area score. and liquor stores).6 – 8 A limitation of these studies is that they limited food offerings. snacks.9 In the spring of 2006. census tracts in which ⬎60% of the residents were instrument were standardized by brand.9 –13 InfoUSA list fulfilled the inclusion criteria in the neighbor- and most existing studies relied on very simple mea. neighborhood study14—an ancillary study to the MESA was created for these stores. (all of them situated in Baltimore County). For neighborhoods 562 American Journal of Preventive Medicine.8: supermarkets Of the 159 census tracts in the study area. Of the 375 stores in It was hypothesized that healthy foods would be less the improved list. ing stores in SIC codes 541101. a the main thoroughfares of all the study neighborhoods to identify any omitted stores. nine tracts dedicated to parks. tial health relevance. and size. leaving nantly black and lower-income neighborhoods would 226 stores for assessment. The area included in each store. behind-glass stores. commercial businesses other than food stores (food places. frozen foods. 541103). 53 had no food (SIC codes 541101. stores. were assigned as in Table 1. either white or black were defined as predominantly white or A healthy food availability score (i. sures. using data from the Year 2000 U.9 grocery stores in the city (corner stores). fruits. Both inter-rater reliability and which 112 were in Baltimore City and 47 were in Baltimore test–retest reliability (over a mean of 9 days) for food items County.500 for the 66th percentile). A secondary hypothesis was that food warehouses. respectively. with a higher census tracts was obtained from InfoUSA in 2004. All the refusals were corner stores have poorer healthy food availability than similar stores located in predominantly black and lower-income city neigh- borhoods. Following 100% whole wheat bread.20 The instrument’s reliability was previously tested the study encompassed 159 contiguous census tracts.9 the HFAI ranges from 0 to 27 points. and conve- kets generally more common in white and wealthier nience stores (SIC codes 541102. income neighborhoods. and none was a gas Methods station. Census. Points were categorized following the Standard Industrial Classifica. vegetables. low-sodium foods. availability of eight food groups: nonfat/low-fat milk. These included 17 suburban census tracts in Baltimore cery stores on the basis of chain-name recognition or an County. store managers (9%) refused to be part of the study. (2) comparing To investigate associations of neighborhood racial and the list to Baltimore City Health Department 2006 food income composition with healthy food availability in license records. search assistants visited the 226 Baltimore stores to assess the ies for neighborhoods. respectively.10 –13 ing the list to Baltimore-area 2006 phone books. Number 6 www. very study sample.9 areas.83 and ⱖ0. stores located in predomi. with supermar. census tracts (administrative were high (␬ statistics ⱖ0. tion (SIC) codes used in previous studies7.net . food items examined).17 Neighborhoods in. A total of 365 stores in the directly across different types of neighborhoods. a special category. Food stores score indicating a greater availability of healthy foods. low-fat meat.S. Items in the prior work. trained re- neous socioeconomic characteristics)16 were used as prox. for all areas with a mean of 3500 residents of relatively homoge. distribution in the sample ($26. and low-sugar cereals. of in 85 stores located in Atlanta. lated. study15—the local food environment of the neighborhoods of Developed as part of the nutrition environment measures Baltimore MESA participants was characterized by measuring survey. Volume 35. differentiated from gro. and (3) having data collectors drive through selected areas of Baltimore City and Baltimore County. Local brands were used. These stores were all originally coded as grocery stores. generally use the presence of different types of stores as Three public markets located in the area were included in the crude proxies for healthy food availability. annual payroll of ⬎50 employees. Specialty stores such as bakeries and chocolate few studies have measured healthy food availability or candy stores were excluded.19 Convenience stores are generally 7-Eleven–type stores or food marts attached to gas stations. To date. often of a single food item. vealed local challenges in assessing these products in Balti- cluded in the study sample were heterogeneous in terms of more.income composition of neighborhoods. because pilot testing re- and $38.

multilevel models with stores as the Level-1 available (frozen or canned fruits and vegetables are not included) units. if available. if Results low-sodium canned soups 100% whole wheat 2 pts. if ratio of Analyses were conducted in 2007.001). The distribution of neighborhood adapted to Baltimore from the Nutrition Environment healthy food availability (as assessed by the mean HFAI for all Measures Survey in Stores9 stores within the neighborhood) and of types of stores (in broad categories) was compared across categories of neigh- Food groups Availability scores borhood racial and income distribution using chi-square Nonfat/low-fat 1 pt. if two intercept for each neighborhood were used to assess associa- or more varieties tions of store type and neighborhood characteristics with Chicken boneless. if ⬎50% shelf space for food stores of a similar type located in different neighbor- Fresh fruits and 0 pts. if available. vegetables/ice cream shelf space ⬎15% Low-sodium 1 pt. 1 pt.. Healthy food availability and type of stores by neighborhood racial and income composition in Baltimore neighborhoods Neighborhood Types of food stores healthy food availability tertile % # % % % behind- neighborhoods % % % # food super. Scoring system for healthy food availability. if ⬎33% shelf tests.001. In a second vegetables on increasing number of varieties set of analyses. which quantify the varieties correlation among HFAI within neighborhoods. if low-sodium tuna. if available. points being in the lowest tertile of food availability scores) was present in 43% of predominantly black neighbor- hoods and in only 4% of predominantly white neigh- with at least one food store (n⫽106). pt. borhoods (p⬍0. if not available. 1–4 pts. if lated. if store HFAI before and after adjustment for each other. The analyses reported here are neighborhoods versus 68% of predominantly white neigh- based on 226 food stores located in 106 census tracts. if ity tertiles by neighborhood racial and income compo- two or more varieties sition. 1 pt. compared to predominantly white and higher-income neighborhoods. ⬎33% shelf space. 1 pt. grams. with higher-income neighborhoods showing The primary goal of the analysis was to assess the associations greater availability than lower-income neighborhoods. point.. Neighborhood healthy food avail- availability) was present in 19% of predominantly black ability was categorized into tertiles based on the observed distribution in the sample. compared to predominantly white and high-income neighborhoods December 2008 Am J Prev Med 2008. if available. A high availability of healthy foods was calculated as the mean of the HFAI scores of all stores (defined as being in the highest tertile of healthy food within the neighborhood.Table 1. **p⬍0. 2 pts. the neighborhood HFAI borhoods (p⬍0. if two or more Intraclass correlation coefficients (ICC). were calcu- Frozen foods 1 pt.05. A low availability of healthy foods (defined as g. Differences by income composition in neighborhood healthy food availability were also sub- Statistical Analysis stantial. 1 pt. 1 pt.001). 1 pt. 2 pts. convenience grocery glass with stores low medium high stores markets stores stores stores Total 106 32 33 34 226 18 24 49 9 Neighborhood race composition Blacka 67 43** 38* 19** 139 11 16 58 15 Mixed 14 14 36 50 31 26 32 42 0 White 25 4 28 68 56 33 37 30 0 Neighborhood income Lowerb 39 46** 31* 23** 85 11 16 55 18 Medium 36 25 47 28 86 10 19 64 7 Higher 31 13 26 61 55 42 44 14 0 Administrative boundaries City 78 39** 39* 22** 177 9 19 60 12 County 28 7 21 72 49 51 43 6 0 a Neighborhoods classified as predominantly white or black when ⬎60% of residents were of that group b Income tertiles based on census tract household median income *p⬎0. if low-fat TV dinners. available. if two or more bread varieties Table 2 shows the distribution of healthy food availabil- Low-sugar cereals ⬍7 g/serving: 1 pt. based hoods were compared. skinless breast: 1 pt. using variance estimates from the multilevel models. 1 pt. using t-tests or ANOVA. Mean HFAI scores for different types of food stores and milk space. Large among neighborhood racial and income compositions and differences were also observed between city and county Table 2. pts. neighborhoods as the Level-2 units. healthy food availability. and a random Ground beef 90% lean: 1 pt.35(6) 563 .

persisted after adjustment for store type (Table 4.48) (23) 4.10) (14) Medium 6.41). both variables were strongly associated. nience stores. Discussion Supermarkets in predominantly black and lower-income neighborhoods had lower HFAI scores than those located In this sample of Baltimore City and County neighbor- in predominantly white and higher-income neighbor. making it diffi- Table 3 shows mean HFAIs by neighborhood charac. with for neighborhood characteristics (ICCs⫽0.36 (3. Number 6 www. Associations of neighbor- of stores by racial composition.76 (0.04 a Corresponds to the mean of all the stores within the neighborhood (census tract) 564 American Journal of Preventive Medicine.75) (16) Higher 13.07) (18) 6.0001).37) 18. grocery stores. Predominantly black and lower-income neighbor- borhoods. store type and neighborhood characteristics of the Table 2 also shows differences in the types of food store location. Differences hood characteristics with store HFAIs were reduced but in the types of stores by neighborhood income compo.67 (3.06) (13) — 5.48 (5.89) (81) 1. Stores located in predominantly black neighbor- composition. for models adjusted for neighborhood a mean difference between neighborhoods of lower and racial and income composition). but lower-income neighborhoods (p⬍0.001 0.70) (24) p-trend ⬍0.20 (4. Mean This correlation was somewhat reduced after adjusting neighborhood HFAI increased in a graded manner.62) (21) 3. Models 1 and 2).49 (3.998 — 0. vegetables. and there were more behind-glass stores (15%) in predominantly white or higher-income neighbor- than supermarkets (11%). Associations of neighborhood income sition: 42% of the stores in higher-income neighbor. availability by neighborhood racial and income composi- borhoods. Conve- behind-glass stores were present. and was sharply re- higher income of 8.05 (3. with county neighborhoods showing better Table 4 shows mean differences in store HFAIs by healthy food availability than city neighborhoods. tion. Model 6).50 (2.80) (47) 1. Grocery stores in predominantly hoods had significantly lower availability of healthy foods.net .00) (9) 4. and supermarkets. there were important differences in healthy food hoods (mean differences 3.09) (15) 3. sition were similar to those observed by racial compo.0001 ⬍0.47) (10) White 13. and 4.6 HFAI points (for differences in means correlated (ICC for model without covariates⫽0.04 (8.25 (2.87) (9) 4. Models 4 and 5). no hoods.31. HFAI 13.10 (2.001 0. Model 3).93) (16) — 5. The mean HFAI in predomi. p⬍0. have substantially lower mean HFAI scores than super- mately equally distributed (for differences in the types markets (Table 4. compared to composition and income were not significant. increasing neighborhood income (p-trend⬍0.9 for lower. and convenience stores were approxi.7 for white versus black neigh.001).ajpm-online.001).56) 20. than pre- Table 3.20) 22.26) (8) — 5.83) (55) — 4. compared to only 11% in when racial composition was also in the model. mean HFAI was highest in supermarkets and for Model 6⫽0.30 (8. before and after adjusting for each stores present by neighborhood racial and income other. p⬍0.02 0.11).10) 24.00 (3.34 (3.81) (22) Mixed 10.98 (8. skim milk.76 (0.54 (6. hoods and stores located in lower-income neighbor- the large majority of food stores (58%) were grocery hoods had significantly lower HFAIs than those located stores.44 (6. In white neighborhoods.1 HFAI points.10). lowest in behind-glass stores. across neighborhood race composition.85 (2. cult to estimate their independent effects (Table 4.21 Neighborhood income Lower 5. hoods. and whole wheat bread.25 (5. teristics and store type.13 (4. a mean scores for stores located within the same tract were difference of 7.48. Interactions between neighborhood racial nantly black neighborhoods was 5. The distribution of duced after adjusting for store type (ICC⫽0. white neighborhoods also had higher mean HFAIs than often lacking recommended foods such as fresh fruits and those located in predominantly black neighborhoods. some correlation persisted even after accounting tion is shown in Figure 1. respectively (Table 4. ever.62) (21) 3. Mean healthy food availability index (HFAI) by neighborhood characteristics and store type Store HFAI (SD) (n) Neighborhood HFAIa Super-markets Grocery stores Behind-glass Convenience M (SD) (41) (110) stores (21) stores (54) Neighborhood racial composition Black 5.neighborhoods.08) 21.52 (3.78 (1. with HFAIs were reduced and became nonsignificant hoods were supermarkets.17 (4. for store type and neighborhood characteristics (ICC Overall.04 in predominantly white neighborhoods.001).35 and 0. p⬍0. with respectively.78) 23.0 (3.34) (8) 5. with grocery stores and convenience stores having similar low values (Table 3). Volume 35.31 (2.versus higher-income neigh. In predominantly black neighborhoods.04 — 0. How- stores and their HFAIs by neighborhood racial composi. and behind-glass stores grocery stores.05).31) (22) p-value across all categories ⬍0.

neighborhoods.44) ⫺2. **p⫽0.85 (0.98)* NH income tertiles Higher ref ref ref ref ref ref Medium ⫺6.70) ⫺0. white neighborhoods had a higher availability of ciated with healthy food availability after adjustment for each healthy foods than did supermarkets in predominantly other.63)* ⫺16.93 (0.69) Lower ⫺7.66 (1. white ref ref ref ref ref ref Mixed ⫺1.10 *p⬍0. NH. In fact.71)** ⫺1.15 (0.64)* ICC 0.78 (0. Racial composition of study neighborhoods and healthy food availability index of permarkets has direct conse- the 226 food stores in the study quences for the availability of healthy foods. intraclass correlation coefficient for store healthy food availability index within tracts.6 – 8 By sys- tematically measuring the actual food availability in stores using a previously val- idated comprehensive in- strument. predominantly December 2008 Am J Prev Med 2008. The re- sults of these analyses are con- sistent with those reported in a comparison of two distinct neighborhoods in New York City11 and four neighbor- hoods in Atlanta. Type of store Supermarket ref ref ref ref ref ref Convenience store ⫺17.50) ⫺1.98)* ⫺18. Moreover.32 (0.93)* ⫺19.48 (0.18 (0.60 (1.72) NH race categories Pred.95)* ⫺18.23 (0. pred. regression analyses also showed several stores coded as grocery stores in predominantly that both store type and location were independently asso.00 (0. This study also found that many Table 4. Few studies have examined the differences in measured food availability by neighbor- hood characteristics.005 ICC. supermarkets in different types of neighborhoods availability within similar types of stores located in different did not have the same healthy food availability. inc.35(6) 565 . but there were also differences in food ple. Results also dominantly white and higher-income neighborhoods..11 0.76 (0.68)* ⫺17.49) ⫺2. For exam- neighborhoods. this study found that supermarkets were sig- nificantly more common in white and higher-income ar- eas than in predominantly black and lower-income neighborhoods.40 (0.81) Pred.35 0.70)* ⫺17. income.64)* ⫺16.50 (0.85 (2.80) ⫺1.31 (0.15 (0.12 0. Adjusted mean differences in food store healthy food availability by store and neighborhood characteristics Model 5: store Model 6: store Model 1: Model 2: Model 3: Model 4: store type ⴙ NH type ⴙ NH race NH race NH income store type type ⴙ NH inc.69)* ⫺17. in large part.05) ⫺1.9 As in this prior work.29 (0.50 (0. race ⴙ NH inc.10 0.68)* Grocery store ⫺17..01 (0.0001. black neighborhoods.52 (0.31 0.20 (0.68)* ⫺16. depending on their location. this study also demonstrated that this dif- ferential placement of su- Figure 1. to fewer tion in the availability of healthy foods within similar supermarkets in the predominantly black and lower-income types of stores.20 (0.61)* ⫺2. show that there was varia- These differences were attributable.68)* Behind-glass store ⫺20.89 (1. black ⫺6. neighborhood.

Other relevant policies 16. Horowitz CR. and it is unlikely that store-assessment errors cans 2005. Food environment is affected by many different 1991. Government Print- ing Office. perspective. Bonnie Wittstadt empirical information on which to base the definition and Richard Zhu. The relationship between neighborhood food avail. 1-12-2005. Colson KA. U. A second limitation is the reliance on commercial lists to identify food stores. 2000. Morenoff JD. Despite these inevitable continuing epidemics of obesity and diabetes in the U. Marks JS. Psaty BM. Am J Public Health 2005. Am J Epidemiol 2007. Wilson ML. future work in this area needs to develop better racial composition. necessary to evaluate the dietary consequences of these come neighborhoods were behind-glass stores that pro. Community-level comparisons between mended foods in minority and lower-income neighbor.85:1690 –2. and energy costs. Stroup DF. The misclassification of store types. such this study may be contributing to racial and economic stores accounted for 15% of the food stores. Drewnowski A. Diez Roux AV. Hebert PL.156:871– 81. Washington DC: U. Mokdad AH. food store managers in Baltimore. academic. Prev Med hoods.291:1238 – 45. JAMA 2001. Geocoding and monitoring of U. and the spatial accessibility of approaches to characterizing food resources in areas. et al. Waterman PD.S. Frank LD. increasing the availability of healthy foods at these 15. addition. 5. Vinicor F. whereas disease disparities. Am J ability and the dietary preferences of its residents is Prev Med 2002. Mokdad AH. Burke GL. Diez Roux AV. However. given the important limitations of commercial data. Am J Public Health 2006. Soobader MJ. Cheadle A. and policies affecting the location of various 12. that were studied. Carson healthy foods and attracting stores that offer healthy R. 10. Raghunathan T. Primary 9. relevant for food shopping. This work was supported in part by R01 describe patterns of food availability associated with HL071759 (Diez Roux. Bowman BA.95:660 –7. Number 6 www. Basch CE. Am J Prev Med and diabetes may be impaired by the lack of recom. Wechsler H. Saelens BE. Oxford: Oxford University Press.96:325–31. likely to be bidirectional. However.S. Geocoding and measuring neighborhoods socioeconomic po- may involve both encouraging supermarkets in minor. No financial disclosures were reported by the authors of mative. Chen JT. Brooke Mickle. Assessing the neighborhoods actually do have a large number of measurement properties of neighborhood scales: from psychometrics to grocery stores—most of them lacking healthy foods— ecometrics. Principal Investigator). Am J Clin Nutr 2004. Am J Public Health 1999. Baltimore data collectors: Amanda Rose- relevant for food shopping. the census tract was used as a proxy The authors would like to thank the NEMS study group at for the geographic area (or neighborhood) potentially Emory University.. Krieger N. 2005. www. eds. Associations of neighborhood characteristics changing dietary practices will be much more difficult with the location and type of food stores. the refusal rate was only 9%. JAMA 2004. Krieger N. including the price of food. Wing S. Specter SE. in the absence of supportive environments. Berkman L. Curry S. The joint efforts of public health supermarkets accounted for only 11%. Zenk SN. 17. Israel BA. the grocery store environment and individual dietary practices. Mujahid MS. The availability of low-fat milk in an inner-city Latino community: implications for nutrition types of stores. the perceptions and knowledge of store ities. 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