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The Impact of Limited Food Access and Availability on Purchases and Eating Behaviors

Related to Childhood Obesity

Lauren Planas

University of Connecticut
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Cover letter:
I understand plagiarism as I have taken numerous verification tests for other courses, and did not
plagiarize my paper which Safe Assign may indicate as it has for everyone’s paper. I feel that I
improved in my mini summaries and transitions from the beginning of the paper as well as from
the second draft which has helped to make my paper more concise and flow better. I struggle
writing conclusions for papers but felt that I significantly improved what I had written for the
second draft and feel that I put my best effort in something that causes me stress and I often
struggle with. I still could have improved my transitions to make my paper flow easier and
connect studies to make the paper more concise, but feel that I did what I could best. I am
confident that I have strengthened my research skills and am proud of the paper that I am
submitting because this is the first research paper I have ever written. Thank you for all of your
help!
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Introduction:
According to the National Health and Nutrition Examination Survey 2012-2014, nearly

17% of children across the nation are obese as a result of complex interactions between social,

behavioral, economic, and environmental factors1. Rates of obesity can be highest among

children who live in areas with limited food availability, affordability, and access of nutrient

dense foods within proximity of neighborhoods and schools. For example, a recent observational

study noted that the odds of overweight/obesity were lowest among children with access to lower

priced healthy food, despite the finding that most children had low access to grocery stores

within a walkable distance2. In the discussion of this paper, the researcher generalizes their

findings to many urban centers throughout the United States to show the pattern observed in Los

Angeles, California, where there is high access to convenience stores and fast food restaurants

yet low access to healthy food outlets such as grocery stores3.

This paper will explore the hypothesis that families who live in low socio-economic

communities have limited access to healthy foods at an affordable price and are more apt to buy

high calorie, low nutrient foods due to cost constraints. Limited access to healthy foods and

physical activity behaviors increases the risk of energy overconsumption as well as obesity in

children, while parents have an influence on healthy behaviors which could contribute to or

decrease the risk of over-consumption in poor food environments. This paper will discuss

interventions necessary to promote healthy eating, improvements in access to healthy foods in

various outlets at affordable prices, and enhance efforts through the educational arm of the

Supplemental Nutrition Assistance Program to encourage healthier food choices within limited

budgets for income-challenged children and families. Overall, the connection between food

access, food availability, and childhood obesity is influenced by a number of factors that are
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often interrelated including: socioeconomic status, neighborhood environments and barriers,

school environments, and food insecurity, which can be improved through interventions at

numerous levels.

1. Food Accessibility and Availability Barriers and Correlation to Obesity

Access to food outlets that provide nutritious foods at an affordable price is a prerequisite

for a healthy diet. However, the types of food outlets, the foods available, and the cost of

healthier foods varies by neighborhoods and affects the ability of the residents to consume

healthy diets. The following studies examine food access in neighborhoods in terms of the

prevalence/density of food outlets (grocery stores, convenience stores, fast food restaurants), the

variance of cost among them, and relationships with diet quality. The studies were identified by

PubMed searching with terms of “food access,” “childhood obesity,” “availability,” “food cost,”

“obesity,” and “low socioeconomic.”

Neighborhoods with income-disadvantaged residents have a larger number of convenience

stores and fast food restaurants, which in turn associates with a high intake of sugar-sweetened

beverages, heavily processed foods, and reduced physical activity3. A cross-sectional study

revealed that access to grocery stores was limited, while access to convenience stores and fast

food restaurants were more prominent and sold larger amounts of unhealthful food than healthful

food. Assessments were collected to determine the number and type of retail food outlets in three

urban Los Angeles communities and if healthful foods were sold and at what cost.

From the analysis, fast food restaurants were the most common type of retail food outlet

(30%), followed by convenience/liquor/corner stores (22%). Convenience/ liquor/corner stores

had a higher availability of foods and beverages high in fat and sugar than fruits and vegetables;

85% of the convenience/liquor/corner stores surveyed had sold Flaming Hot Cheetos, 89% sold
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Pepsi, while only 32% sold carrots and 17% broccoli. The difference between availability of high

fat and sugar products versus fruits and vegetables was also correlated with a higher price on

fruits and vegetables. Supermarkets offered a larger variety of foods such as whole wheat bread,

carrots, apples, and milk at lower prices than smaller food stores such as the

convenience/liquor/corner stores, with equivalent items costing up to 75% more but lower in

quality.

Supermarkets were more than a mile away from the neighborhood and made up less than 2%

of the available food outlets. The distance was problematic as many of the neighborhood

residents do not have their own transportation and rely on public transportation or walking to the

store, which requires a more time and is considered unsafe because of crime in the communities.

These barriers along with the price of gas and the inconvenience of transport to a supermarket

lead some residents to shop daily and purchase small amounts of food from convenience/corner

stores closer to home. A limitation of this study is that it was limited to urban Los Angeles and

may not be generalizable to other areas3.

Similarly, an observational study found limited access to grocery stores, but greater access to

convenience stores and fast food restaurants in a residential neighborhood (Le et al, 2016).

Geocoded dated of residential addresses for 1,469 children of 10-14 years was collected and

examined to see if the proximity to or density of grocery and convenience stores and fast food

restaurants were associated with overweight/obesity in children. Nutrition Environment

Measures Survey (NEMS)-Stores and NEMS-Restaurants were utilized to quantify availability,

quality, and price of healthy food items in these food outlets.

From the analysis, it was found that within 800m walking distance from home, 76% of

children did not have access to a grocery store, but 58% had access to at least one convenience
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stores at 32% to one fast food restaurant2. However, the cost and type of food sold in these

establishments influenced what was purchased. Significantly lower odds of overweight/obesity

were associated with lower prices of healthy food items in grocery stores (OR=0.87, CI=0.77-

0.99) and fast food restaurants (OR=0.97, CI=0.95-0.99) within walking distance from home2.

The findings of these previous studies2, 3 are further supported by data from a quantitative,

cross-sectional study which found that a high density of fast food outlets was associated with

consumption of fast food and SSB, as well as lower participation in physical activity4.

Participants included 126 children (15.9% of the children were obese, 13.5% overweight, and

70.6% normal weight) along with the addition of density of food outlets, and how food

consumption and physical activity are affected by distance and density were examined. This

involved content analysis by using geographic information systems (GIS), focus group

interviews, and surveys to identify if features of neighborhood food and activity environments

are linked to eating and activity behaviors and obesity status in children.

As seen in Table 2, there was a larger density of Korean fast food, physical activity outlets,

and convenience stores than fruits/vegetable and Western fast food outlets within a 200m

distance from the closest community center. As a result of exposure to a large density of fast
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food outlets and convenience stores, fruit and vegetable intake (31.7%) was lower than fast food

(71.4%), and sugar-sweetened beverage (86.5%) consumption, which was positively associated

with increased availability of fast food outlets, and inversely associated with physical activity

(15.9%). In relation, sedentary behaviors (71.4%) were associated with reduced availability of

physical activity outlets and the increased prevalence of fast food outlets and convenience stores.

However, while an unhealthy neighborhood environment was associated unhealthy

behaviors, it was not directly linked to obesity status. Nonetheless, said behaviors increase the

risk of excessive adiposity. Limitations of this study include the 200m buffers of community

child centers which may not accurately reflect the overall neighborhood food and activity outlet

availability, as well as the small sample size may not allow for a multi-level data analysis.

Overall, the availability of eating and activity behaviors in neighborhoods was not significantly

associated with obesity status in vulnerable children, but showed the link between availability

and consumption of fast food and physical inactivity4.

As previously stated: access to food outlets that provide nutritious foods at an affordable

price supports a healthy diet. Unfortunately, individuals in low-income neighborhoods are at a

higher risk for behaviors and diseases related to obesity than those that are not. This is due to the

differences in the type and prevalence of food outlets in these neighborhoods which will be

discussed in the following section.

Neighborhood Disparities Limiting Food Availability and Accessibility

The types and density of food outlets available vary across communities of different

socioeconomic status, income, and race. Low-income neighborhoods have fewer supermarkets

than middle-income, causing transportation and affordability issues for those residing there.
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Obesity is also more common among African Americans, Latinos, and low-income populations

where there are fewer chain supermarkets4. The following sources from PubMed and CDC were

found by searching “low-socioeconomic,” “neighborhood/neighborhoods,” “obesity,” “food

access,” and “income.”

Wealthier neighborhoods have larger numbers of supermarkets than the poorest

neighborhoods according to an observational study in 4 states in the United States (Morland et al,

2002). Specifically, there are four times more supermarkets located in white neighborhoods than

black neighborhoods (prevalence ratio=4.3, 95% CI=1.5-12.5), creating a higher ratio of

supermarkets to residents in predominately white areas than predominately black neighborhoods

(1:3816 versus 1:23,582, respectively). Less wealth in neighborhoods was associated with an

increase in black residents, where fast food restaurants were found to be more prevalent5.

These findings are further supported by a multivariate analysis of food outlets and

associations with neighborhood characteristics on race, ethnicity, and SES (Powell et al, 2007).

By linking food store outlet data across 28,050 zip codes, associations were made between the

availability of chain and non-chain restaurants, grocery stores, and convenience stores to

neighborhood characteristics. Low-income neighborhoods have fewer chain supermarkets with

75% of what is available in middle-income neighborhoods. The availability in African American

neighborhoods is only 52% of that in White neighborhoods, while Hispanic neighborhoods have

32% as many chain supermarkets as non-Hispanic neighborhoods. Low-income neighborhoods

had more non-chain supermarkets were found to offer foods at higher prices due to the lack of

supermarket availability in the neighborhood6.

An examination of differences of neighborhood SES and the environment on BMI was

conducted in a cross-sectional and longitudinal study of 44,810 children, 4-18 years of age and
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different race/ethnicities in Eastern Massachusetts7. The participants were 13.3% black, 5.7

Hispanic, 9.3% Asian, and 65.2% white. BMI z-score along with the prevalence of

obesity/overweight was higher among black (95% CI: 0.40, 0.45) and Hispanic children (95%

CI: 0.34, 0.42) than white children. On average, black and Hispanic children lived in lower

median income neighborhoods closer to food establishments than white children, and the food

establishments present may not have comparable access to healthful food options as those in

higher income neighborhoods. Disparities in access and delivery of healthcare services were also

noted in low income and minority racial/ethnic populations which can be related to the BMI

disparities observed in this study7.

In summary, there was strong evidence collected from cross-sectional, longitudinal, and

observational studies. The studies had provided data on distances and density of food outlets

which affect food access and availability, cost differences between food outlets, and

neighborhood disparities which have influence on an individual’s diet quality and health status.

The availability of food in the home and school environment has a large influence on a child’s

food choices and diet quality and can either positively or negatively impact their risk for obesity

and will be further addressed in the following section.

2. Food Access & Availability in the School Environment

Negative Impact on Children’s Food Choices and Diet Quality

The school environment is very influential in shaping a child’s dietary and physical

activity behaviors. Food sold at schools and in food outlets close by give children more access to

energy dense foods which has been found to be associated with obesity. This section explores the

negative effects that the school environment has on a child’s health due to availability of
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unhealthful foods within the environment. PubMed was searched with the following terms to

find the corresponding articles: “school,” “child/childhood,” “food availability,” “obesity.”

As evidenced in an observational study, food availability at home, near home, and at school

were positively correlated with obesity8. Height, weight, and waist circumference of 684 fifth

graders were recorded and examined along with a food inventory questionnaire that was

distributed to 264 parents, 22 teachers and cafeteria workers, vendors, and stores in order to find

the association between food availability and consumption in a child’s environment with

adiposity. Of the 684 children, 28% were overweight, 26% obese, and 45% were normal weight.

The home environment was the largest contributor to availability and consumption of energy

dense foods in the children, while the school environment provided energy dense foods daily and

was positively correlated with larger consumption (p=0.0001). In summary, assessing the

availability of energy dense foods in the home and school environment improved the

understanding of food consumption in children. A limitation is that response of students and

parents was low, limiting the representation of the whole community. Also, not conducting

interviews which may have indicated why families purchased certain foods was another

limitation8.

Similarly, a cross-sectional study of 968 children, ages 3-13 years throughout six primary

schools determined that the food availability and physical activity environment in schools

influences overweight/obesity among children (Morshed et al 2016). By assessing the children’s

dietary intake, height and weight, along with questions about what is purchased at school,

researchers found that always purchasing food at school was significantly associated with

children being overweight (p=0.001). Food vendors were present on and surrounding the

property of each school, while only one school had a kiosk that contained SSB, processed, fried,
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and prepared foods. There was no relationship between percent overweight/obese and outdoor

space, however only 5-7%, 15-20 minutes, of the school day was allotted for physical activity in

a limited recreational space provided by all six schools meaning that the schools were not

meeting the recommendation of 30 minutes of physical activity. School settings expose children

to dietary and physical activity factors which influence their decisions. The large availability of

energy dense foods, limited area and time for physical activity, along with low consumption of

nutrient dense foods, puts children at risk for becoming obese. A limitation to this study in terms

of this paper is that findings from Haiti may not be comparable to major US cities, but the

influence of school settings on healthy behaviors in children is what is most notable9.

Positive Impact on Children’s Food Choices and Diet Quality

Although the food outlets available in close proximity to schools have been seen to have a

negative impact on food choices and weight in children, research supports that school regulation

and health programs positively impact children’s dietary choices and weight. The following

articles disagree with the previous, and were found by searching PubMed with the terms:

“school,” “child/childhood,” “diet,” “obesity,” and “programs.”

An observational study including 2,315 6th grade students enrolled in Project Healthy

Schools had found that school-based health programs positively influence childhood obesity

reduction and improve cardiovascular health, diet, and physical activity10. Project Healthy

Schools utilized educational lessons and activities and found through student-reported surveys:

significantly higher fruit intake (p=0.046), fewer sugary beverages (p=0.054), fewer servings of

fatty/sugary food (p=0.002), and more moderate physical activity (p=0.009). Related to

improvements in health program implementation, school environments and policies (SEP) also
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were found to have a significant impact on improving diet quality and reducing

obesity/overweight in children10.

Likewise, an observational study found that school environments and policies in four

Chinese megacities have a positive influence on unhealthy eating and overweight/obesity in

children11. Data were collected from 1,648 students (25.6% obese) along with their parents and

schools from 16 primary and middle schools in Beijing, Shanghai, Nanjing, and Xi’an to find the

association between students’ eating behaviors and overweight/obesity in relation to school

environments and policies (SEP). Nutrition-related SEP including price control, restriction of

unhealthy foods, promotion of healthy foods, guidelines for nutrition in school cafeterias (SC),

campus food stores (CFS), and school vicinity food stalls (SVFS), along with physicals for each

child were collected at four schools in each city and compared with child eating behaviors and

BMI.

From the analysis, it was found that most schools had food policies in the SC (75%), while

few had policies on CFS (6.25%) and SVFS (25%). Food prices (56.3%), nutrition guidelines

(56.3%), and PE classes (93.8%) were more likely to be regulated and set by local governments,

whereas school administrations regulated SC on unhealthy food restriction and healthy food

promotion. Policies implemented in regards for CFS and SVFS were associated with

significantly lower intake of sugary beverages (IRR=0.54), snacks (IRR=0.84), and fast food

(IRR=0.58). A lower likelihood for overweight/obesity for all students was associated with

policies on SC (OR=0.54), CFS (OR=0.74), and SVFS (OR=0.56). Only policies on SC were

found to be associated with lower overweight/obesity in girls (OR=0.48). A strength of this study

was that it was large and had looked at four schools in each of the four large cities involved in

the city, which showed variations between the regions11.


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In summary, the level of evidence was somewhat weak since mostly observational studies

were used to examine both the positive and negative impacts that the school environment has on

influencing eating behaviors and childhood obesity. Further cross-sectional studies examining

the impact of food availability and physical activity environments in schools in the United States

would be beneficial to incorporate to strengthen the argument of this topic. Both the home and

school environment have a large influence on the dietary quality and health status of children,

and can either promote or neglect good health through the availability of foods. However,

individuals with low-socioeconomic status living in low income neighborhoods have fewer

resources to purchase healthful foods, and are at a higher risk to become obese.

3. Impact of Food Insecurity on Food Purchases and Effects on Dietary Quality

A sad reality for many families is that it is unknown when and where their next meal will

come from. According to the U.S. Census Bureau, 42.2 million Americans lived in food

insecure households in 2015 (Proctor, 2016). Food insecurity refers to having limited or unsure

access to nutritionally adequate, safe, and culturally acceptable food13. Living in food insecure

households places children at higher risk for poor health and lower likelihood to meet nutrition

recommended guidelines due to lack of resources preventing them from buying healthful foods.

The following studies, found by searching PubMed with the terms “food insecure,” “food

insecurity,” “obesity,” “neighborhood,” “income,” and “low socioeconomic,” examine how low

income families are at a higher risk for food insecurity and obesity due to their low-

socioeconomic status, the access to food outlets in neighborhoods, and effect on diet quality.

Food-insecurity was found to be more prevalent in low-income households than not which

resulted in frequent purchase of unhealthful foods as evidenced in a cohort study (Bauer et al

2011). Food security (60.1%), low food security (29.5%), and very low food security (10.5%)
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were identified among families of 454 kindergarten students within 14 schools in Pine Ridge

Reservation, SD through examination of sociodemographic characteristics, home food

availability, and food frequency. Food insecurity was more prevalent in families with lower total

household income. Children from food insecure families ate ready-made foods from convenience

stores and gas stations twice as often than families with food security (p=0.002); including

higher intakes of SSB, pizza, fried chicken, and fewer servings of fruits and vegetables related to

food outlets carrying significantly less variety (p=0.003) or selling fruits and vegetables in poor

condition (p=0.03). There were few differences in children’s dietary intake by food security

status, however, food insecure families are more likely to purchase unhealthy foods more

frequently which can lead to weight gain due to their budget, inexpensiveness of high-fat,

calorically dense foods, and access to food outlets at which they are readily sold13.

Similar to the findings of the previous study, the relationship of food insecurity and obesity

through the home environment was found to be impacted by eligibility for school meals and

family influence in a cross-sectional study14. Assessing 270 children and 186 parents through

surveys and screening tools found that food home nutrition and physical activity (FNPA) is

associated with BMI and food insecurity (FI) in children. Children at risk for FI (43%) were

more likely to be overweight/obese (37%) and less likely to be enrolled in free/reduced-cost

meals when compared to normal weight children. Children not eligible for school meals were at

a significantly greater risk for FI if overweight or obese than normal weight, while children

eligible for free/reduced meals were at a significantly lower risk for FI. It was also found that

families that ate together, limited watching TV during meals and monitored intake of chips,

cookies, and candy were 69% less likely to be at risk for FI and less likely to be obese. Low-

income families deal with lifestyle challenges more often such as stress and time constraints due
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to financial constraints. This lowers the chances of the family being able to eat together (p=0.04)

and have their children enrolled in activities (p=0.04) which is associated with a lower risk for FI

because they do not have the income to provide such assets 14.

Barriers in accessing food in food-insecure individuals including transportation, price, and

availability were found in an observational study which examined the relationship between

income and food accessibility in terms of food consumption through convenience sampling and

interviews of 35 food-insecure individuals15. Low-income individuals are vulnerable to

becoming food-insecure, and often receive assistance to provide food to their household.

Participants enjoy eating fruits (97%) and vegetables (100%), however, only 23% are able to

purchase as much fruits and vegetables as they would like because they are unaffordable.

Transportation to grocery stores and food programs, such as a food pantry, was a barrier among

40% of participants since many low-income individuals do not have their own car.

While these food-insecure individuals may enjoy fruits and vegetables, being low-income

affects their ability to purchase healthful foods which are at an unaffordable price, and are not

picked over inexpensive, high caloric foods. Even with the assistance of the pantries, 17%

expressed that they receive insufficient quantities of food for their household, 20% return to

various food pantries throughout the region since they do not receive enough food at one

location, and 29% agreed that the pantry is not open long enough to fit their schedule to allow

them to obtain food. These barriers prevent food-insecure individuals from receiving healthful

foods and leave them settling for foods that they can afford in closer proximity which is more

often convenience stores and high calorie foods15.

In summary, food insecurity is faced by many low-income families which makes it unknown

when and where their next meal will come from. The large role that parents play in providing
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and shaping food behaviors of children requires action and intervention to gain the resources to

provide adequate nutrition and meals daily. The following section will explain how food

assistance programs such as SNAP help to alleviate food insecurity and provide recipients with

resources to adequately feed their family.

Individual Interventions:

To improve the diet quality and health status of children, parents must take initiative to

become educated and enroll in food assistance programs that can help alleviate food insecurity

and provide resources to obtain easier access to healthful foods. This section will look at the

benefits of enrolling in food assistance programs such as SNAP to promote a larger intake of

healthful foods to prevent obesity. The following articles were found by searching PubMed with

the terms “SNAP,” “food assistance,” “obesity,” and “diet.”

SNAP has been seen to promote behaviors that reduce the prevalence of obesity while

alleviating food insecurity and ensure adequate dietary of nutritious foods intake among

participants. A case-control study found that SNAP-Ed positively impacted fruit and vegetable

consumption and led to less frequent consumption of SSBs (Molitor et al, 2015). The 1,273

SNAP recipients had received low, moderate, or high level of intervention. As seen in Table 1,

children who received higher levels of intervention (2.07 servings/day) consumed more fruits

and vegetables when compared to low intervention (0.6 servings/day), and were also more

physically active (1.47 days/week) than participants who received low intervention (0.15

days/week). High intervention also was associated with less frequent consumption of SSBs (-

0.44 servings/week) and fast food (0.04 servings/week) than low intervention participants (0.65

servings/week, 0.07 servings/week). The education provided by SNAP-Ed was responsible for

the positive changes in fruit and vegetable consumption and physical activity, along with the
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decreaed consumption of fast food and SSBs in adults, and therefore translated into the same

results for children16.

Table 1: The relationship between SNAP-Ed interventions and Healthful Eating


Behaviors through consumption of Sugar-Sweetened Beverages and Physical
Activity of Adults, Teenagers, and Children.

Individuals who are food-insecure, receiving SNAP, and are at higher risk for chronic

disease and obesity are more often low-income and face lifestyle challenges such as time

constraints with multiple jobs and lack of transportation. This prevents individuals from having

the time to prepare homemade meals, and leads to frequent consumption of fast food or

unhealthful foods from convenience stores. SNAP participation has been related to improved

dietary quality and consumption of healthier foods along with cooking meals daily. The

supporting article was found by searching PubMed with the terms “SNAP,” “obesity,”

“intervention,” “cooking,” “income status,” and “diet quality.”

SNAP can help low-income individuals have adequate dietary intake by providing

resources to purchase more foods than they would have been able to without the assistance. A

cross-sectional study using data from 2007-2010 NHANES revealed that frequent home cooking
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was associated with healthier diets and lower risk of obesity of SNAP households (Taillie et al,

2016). SNAP recipients who cooked daily meals averaged lower intakes of solid fats and added

sugars (SoFAS) (-3%), solid fat (-1.6%), SSB (-49kcal/day), fast food (-1 meals/week), and

frozen meals (-1.9 meals/month) eligible non-SNAP recipients who had a higher intake of solid

fat (0.2%) and SSB (-4 kcal/day). A -6% lower prevalence of overweight/obesity was associated

with SNAP recipients who prepared seven home-cooked dinners a week, while non-recipients

that preparing seven home-cooked dinners daily did not have any association with

overweight/obesity (p=0.07). SNAP participants also were less likely to eat one meal per week at

fast food restaurant than non-recipients (9.3 vs. 11.6%, respectively). Overall, this study had

shown that SNAP recipients who cook daily home-cooked meals have a lower prevalence of

obesity related to decreased consumption of unhealthful foods and improved dietary outcomes as

a result of having more money to spend on food due to the programs resources17.

Receiving assistance from programs like SNAP is beneficial to provide families with

resources to assist in improving dietary quality and outcomes in low-income individuals which

was supported by strong evidence of case control and cross-sectional studies. Parents/guardians

are extremely vital in promoting proper health and nutrition in their children which can be better

improved through taking initiative and signing up for these resources if eligible. In order to

promote a healthy lifestyle for children, intervention on an individual level along with efforts

from the community are necessary to provide healthy options and support consumers to make

better choices when out to eat and while shopping.

Community Interventions:

The food environment and the type of food available influences individual eating behaviors.

As previously discussed, low-income neighborhoods have a large prevalence of convenience


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stores that sell inexpensive, high calorie foods and few fruits and vegetables influence poor

dietary quality and behaviors. These food outlets provide the opportunity to promote healthy

eating and advocate the importance of obtaining a healthy diet in these neighborhoods. This

section discusses how community food outlets have the opportunity and can influence healthy

eating behaviors in residents. The following articles were found by searching PubMed with the

terms “neighborhood,” “community,” “obesity,” “intervention,” and “convenience store.”

A community-level intervention identified that improvements in the food environment

positively influenced customer purchases and improved healthy eating in food outlets (Martinez

et al, 2015). Between two rural communities, fourteen restaurants and four food stores were

evenly split into a control group and an intervention group that utilized Waupaca Eating Smart

(WES), an intervention to improve the nutrition environment and promote healthy eating through

social marketing techniques to influence positive health behaviors, increased availability and

promotion of healthy foods, and displaying promotional materials. Pre and post-test intercept

surveys identified that restaurants adopted 7.42 of 10 WES strategies at the beginning and had

5.4 in place one month post-intervention. Similarly, grocery stores adopted 9.5 of 12 WES

activities at the beginning and had 7.5 in place one month post-intervention.

As seen in Figure 2, implementation of WES had a large influence on promoting healthy

eating in restaurants and minimal improvements on healthy purchases in stores. Nutrition

Environment Measurement Survey (NEMS) scores increased from 13.4 to 24.1 (p=0.01) and

14.9 to 16.6 (p=0.59) in the seven restaurants and two food stores participating in the

intervention, reflecting the influence a food environment has on healthy eating through

promotion and marketing of healthy food. In restaurants, this intervention trended toward higher

satisfaction with availability and promotion of fruit, vegetable, and low-calorie choices.
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Overall, implementation of WES was associated with an improvement in NEMS scores for

restaurants with an 80% increase, but no changes in the environment other than affecting food

purchases. Interventions to improve the nutrition environment in restaurants and supermarkets

through WES activities such as identification and promotion of healthier foods influenced

customer purchases and promoted healthy eating behaviors18.

Figure 2: Food environment scores measured by Nutrition Environment Survey for


Restaurants (NEMS-R) and for Stores (NEMS-S), showing the comparison of
intervention and comparison/control after implementation of WES.

The role that supermarkets and restaurants have on an individual’s diet quality are further

examined in a cluster-randomized controlled study (Foster et al, 2014) which shows the positive

influence of marketing strategies to increase purchase of healthy food items. This study

examined how the placement and product availability of milk, ready-to-eat-cereal, frozen, meals,

in-aisle beverages, and checkout cooler beverages in eight supermarkets in low-income, high

minority neighborhoods influenced the purchases of 57 participants. Four of the intervention

stores had worked to increase purchase in the five foods and beverages listed through marketing

strategies including: increased number of facings of these products, price placement at eye level,

signage, secondary placement, taste-testing, and promotion. Over the 6-month intervention

period, the sale of 1% milk improved significantly in the intervention stores when compared to

the control stores as a result of decreased availability of whole milk and taste-testing of 1% milk.

Intervention stores had significantly increased sales of the lower-calorie frozen turkey dinners
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and chicken nuggets, while control stores had a significant decrease in sales. Lastly, the sale of

water had increased significantly in the intervention stores, while all other in-aisle beverages and

ready-to-eat-cereal had no significant differences19.

In summary, randomized control studies showed the effectiveness of product placement,

promotion/marketing, and increased availability on influencing customers to purchase healthful

foods. However, further randomized controlled studies along with cohort studies should be

reviewed to strengthen the scientific evidence of these summaries. While customer purchases

were positively affected by these interventions, the price, access, and availability of food may

override the initial choice of the individual which is why policy-level interventions including

placing restrictions on what SNAP participants can purchase can further help promote the

purchase of healthful foods to promote a healthy diet.

Policy Level Interventions:

SNAP is the country’s largest food assistance program that works to alleviate food insecurity,

provide adequate dietary intake, and improve participants’ nutrition and overall health. However,

there are barriers preventing SNAP recipients from improving their diet quality, many reported

in the present paper, including heavy marketing of unhealthy foods heavily in low-income

communities, high cost of healthy foods, and lifestyle challenges faced by low-income

individuals. This section will examine interventions to restrict what SNAP participants are able

to purchase as well as implementing incentives to help improve diet quality to prevent a higher

risk of obesity. The following articles were found by searching PubMed with the terms “SNAP,”

“obesity,” “intervention,” “incentives,” and “income.”

Implementing incentives for SNAP participants to purchase more fruits and vegetables along

with restricting the SNAP eligible food list for improving participant’s diet quality has had
Planas 22

success and been favored by respondents in an observational study (Blumenthal et al, 2013). Of

the 1250 respondents that had completed a survey regarding their opinions and perceptions of

SNAP, the following includes the indicated desire to change factors of the eligible food list and

SNAP guidelines: changes to make sodas unable for purchase with SNAP benefits (78%), make

SNAP benefits consistent with the Dietary Guidelines (54%), increase the availability of healthy

food options in low-income neighborhoods (79%), and further modify the list of eligible foods

has been perceived as necessary by respondents to improve the dietary intake and health of

participants (85%)20.

Creating incentives such as adding money to the customer’s EBT card after purchasing fruits

and vegetables also was perceived as a method to improve nutritional status, and has been

implemented in Massachusetts resulting in increased fruit and vegetable consumption20. A

limitation to this study is that SNAP participants, retailers, and the general public were not

included in the study and their opinions were not accounted for. A later poll had indicated that

removing sodas and other SSB was well-supported by participants (54%), and providing

increased funding was supported by the general public (77%) 20.

The benefits of providing incentives for SNAP participants was examined in a randomized

trial design (Harnack et al, 2016), where providing incentives and restrictions supported

increased purchase and consumption of fruits and decreased consumption of SSBs. For 12

weeks, 279 low-income participants (24% overweight, 57.4% obese) who were not enrolled in

SNAP and had low (34%) or very low (46%) food security, were placed in four categories:

received a financial incentive for purchasing fruits and vegetables, had restrictions on purchases

(SSB, candies), received a financial incentive plus restrictions, or were in the control group.

SNAP participants have insufficient fruit and vegetable intake (44%) which is why placing
Planas 23

financial incentives for 30% of the purchase price was implemented in hopes that it would

increase consumption, this totaled to be about $44 over the 12 weeks.

Changes in energy intake differed between the restriction (-105kcal/day), incentive plus

restriction (-96kcal/day) and the control (80kcal/day). SSB intake also differed between the

incentive and incentive plus restriction groups (-0.3 servings/day) compared to the control (0.2

servings/day). Between the incentive and incentive plus restriction, servings of restricted foods

were less in the incentive plus restriction (-0.6 servings/day) than just incentive (-0.1

servings/day). Offering incentives was found to increase fruit consumption among SNAP

participants by 0.32 servings/day compared to those not receiving incentives. Providing incentive

plus restriction was the most effective condition to cause changes in the diet by reducing SSB

and calories/energy intake, while increasing fruit and Healthy Eating Index. A strength of this

study is that multiple dietary recalls of food and nutrient intake were collected at baseline and

follow-up21.

Conclusion

The research articles examined throughout this paper have observed how families that

live in low socio-economic communities have limited access to healthy foods at an affordable

price. Low-socioeconomic neighborhoods have a larger prevalence of convenience stores and

fast food outlets that promote the purchase and consumption of high-calorie foods. As a result of

having a low budget and the types of foods sold, these families are more likely to have increased

energy consumption of less nutritious foods and put children at risk for or further childhood

obesity.

The large and influential role that parents play in providing food for their children while

setting examples for lifelong dietary and physical activity behaviors affect what children are able
Planas 24

to and choose to eat. This is further supported in a cross-sectional study of 611 mothers and

children where it was found that higher parental demandingness and lower responsiveness was

positively associated with restrictive feeding22. Restrictive feeding strategies are often used to

limit children’s intake of unhealthy snack foods, but in this case was associated with poor dietary

outcomes as a result of increased intake of unhealthy snacks and lower intake of healthy snacks.

The opposite was true for covert strategies, suggesting that when the parent controls the

environment rather than the child, it positively manages children’s dietary intake and contributes

to the development of healthy eating habits as seen by higher healthy snack (4.75 times/day) and

lower unhealthy snack consumption (1 time/day)22. It was also found that living in a higher

socioeconomic area was associated with greater intake of healthy snacks and lower intake of

unhealthy snacks. This collaborates with the topic of neighborhood disparities on how the types

of food outlets available in low socioeconomic neighborhoods influence poor dietary intake due

to offering fewer choices with healthy foods often at a higher price when compared to higher

socioeconomic areas.

Overall, the subject of food availability and accessibility connects to parental influence

and behavior in how parents are responsible for either a positive or negative influence on food

choices and dietary intake of children. This includes the behaviors projected onto the children as

well as the options available for children to choose from as a result of socioeconomic status of

the family. Providing a covert environment where the parents manage the environment by

purchasing fewer unhealthy snacks influences positive dietary intake for children, showing the

impact that parents have on children’s food choices and dietary quality22.

With parents/guardians being a large influence on their children’s food choices and

dietary quality, ensuring that they have adequate resources to provide healthful foods for their
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family and set positive examples is necessary. Registering for SNAP as well as altering aspects

of SNAP are needed to promote a healthful diet and lifestyle in children to prevent obesity.

Interventions involving SNAP are associated with SNAP-Ed in regard to healthy eating and

thrifty spending to alleviate food insecurity and improve participants’ nutrition and overall

health.

Further research completed in a random sample survey found that SNAP-Ed intervention

including; messages on the health benefits of fruits and vegetables (F/V), how to prepare foods at

home, and healthful recipes, increased fruit and vegetable consumption of children in SNAP

eligible families23. The level of intervention impacted the degree to which there were

improvements in participants F/V, SSB, and fast food intake: high SNAP-Ed had the most

significant improvement in F/V intake in children and adults, and decreased intake of fast food in

adults in all intervention levels (low, moderate, and high). The improvement in F/V intake in

children is associated with sensory lessons at schools which made the children more comfortable

with food as a result of repeated exposures, as well as changes to snacks and meals made by

parents which translated into increased F/V by their children23. The association between SNAP-

Ed interventions and SNAP at individual and policy levels further supplements the benefits on

food purchases and dietary intake for participants by the resources given throughout the program.

Overall, childhood obesity is affected by many factors of which they do not always have

control over. Taking action at numerous levels to work to provide better access and availability

to healthy foods would positively influence eating and physical activity behaviors by limiting

unhealthful foods which have been linked to obesity. The summaries conclude that childhood

obesity is associated with factors of food availability and accessibility including socioeconomic

status, food insecurity, neighborhood disparities, and neighborhood and school environment. The
Planas 26

level of evidence is varied as there was a large prevalence of observational studies, but also

numerous cross-sectional and randomized controlled studies. Utilizing more cross-sectional and

randomized controlled studies would allow for stronger evidence to support the hypothesis. For

the future, research should focus on questions regarding changes in school lunch participation as

a result of the Healthy Hunger Kids Act 2010 to see if children purchase food more frequently

outside of the school lunch which contributes to poor dietary intake.


Planas 27

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