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SEPTEMBER / OCTOBER 2012 :: 73(5)
Social Determinants of Health

This issue's policy forum focuses on key social determinants of health. Authors explore how health is linked with education, poverty, and housing, and discuss the role of neighborhoods and health disparities in shaping individual health status. Complementary sidebar articles describe effective and promising interventions occurring throughout the state to address these social determinants of health. Original articles examine the state of racial/ethnic diversity in North Carolina's health workforce and review dental visits to an emergency department in the state.


Accessing Nutritious Food in Low-Income Neighborhoods

Alice S. Ammerman

N C Med J. 2012;73(5):384-385.PDF | TABLE OF CONTENTS

“Food deserts” are described in a 2009 Institute of Medicine report as “neighborhoods and communities that have limited access to affordable and nutritious foods” [1]. However, some have argued that, given the obesity epidemic, a more appropriate geographic term might be “food swamps,” defined as “areas in which large relative amounts of energy-dense snack foods inundate healthy food options” [2]. Although results of recent studies have raised questions about whether simply living close to a food desert or a food swamp can by itself result in poor dietary intake, it is clear that one’s neighborhood environment can have a profound impact on food intake and health [3].

Interest in locally grown food, initially found chiefly in higher income neighborhoods and at upscale farmer’s markets, is increasing. As a result, a wide variety of things are being done to make healthier food more accessible and more affordable, and to teach people how to grow and prepare it. Benefits have accrued both to consumers and to the surrounding community in terms of better health and increased economic opportunities.

We are seeing the biggest resurgence in backyard gardening since World War II, when people were encouraged to become more self-sufficient in food production by planting “Victory Gardens.” Cooperative Extension agents and community organizations are helping individuals to relearn the art and science of gardening—sometimes in pots or on rooftops, if yard space is limited. Urban gardening is booming, even in blighted areas like inner-city Detroit, where many vacant and overgrown lots have been transformed into productive urban farms and gardens. In addition to producing much-needed healthy food in neighborhoods with high rates of chronic disease, urban gardens have been shown to increase community collaboration and to build social capital.

Community gardens may be tended collectively or in assigned plots, and educational programs about composting and pest control are common. Most garden programs emphasize sustainable practices and limit the use of pesticides and fertilizers. Some gardens in more affluent communities include donation programs, inviting participants to “plant a row for the hungry.” School gardens have also become increasingly popular, particularly for their educational value.

Another important mechanism for increasing food access in communities is through farmer’s markets and variations on that theme. Because lack of access to transportation is often a limiting factor in low-income neighborhoods, bringing the food to the community can increase the likelihood of purchase and consumption. Although the higher cost of food in many markets located near affluent areas has been a barrier, the participation of low-income consumers has been facilitated by making it possible for recipients of the Supplemental Nutrition Assistance Program (formerly known as food stamps) to buy food using Electronic Benefits Transfer (EBT) [4]. Special vouchers for senior citizens and for participants in the WIC program for women, infants, and children have also made farmer’s market food more accessible.

In addition, a number of creative distribution approaches are being tested to increase access. One program paired inner-city youth with rural farmers, with the youths serving as food vendors in their inner-city neighborhoods. The farmers and youth shared in the profits and had much greater reach than a stationary market. Mini-mobile markets also bring food directly to neighborhoods, just as fish vendors in Europe and ice cream trucks in the United States do.

Community Supported Agriculture (CSA) is an increasingly popular model. Consumers purchase a “share” in a farm at the beginning of the growing season and then receive a weekly box of seasonal fruits and vegetables, and sometimes meat, seafood, eggs, or cheese as well. Because this approach typically requires upfront payment, it has been less feasible for fixed-income families. However, in a model currently under development in the Triangle area, a large, for-profit CSA with more than 6,000 customers (The Produce Box) has paired with a nonprofit organization (Community Nutrition Partnership) to leverage the aggregation and distribution system of the CSA, with the help of donations from CSA customers, to deliver weekly, fresh, affordable food boxes to low-income people through churches, day-care centers, and YMCAs.

Farm-to-institution programs have diversified from the original Farm-to-School efforts as a way of increasing market opportunities for farmers while also improving access to nutritious foods for consumers and providing educational opportunities. School classes visit farms, and local chefs visit schools to demonstrate cooking techniques. Worksites may purchase local food for their cafeterias while underwriting CSA membership as an employee benefit. Other efforts link small farms with small stores to provide produce now available through the WIC program.

In order to make use of seasonal fresh produce, cooking skills are essential, but these are becoming a lost art. Although food programs on television are watched by many, they don’t provide the basic skills needed to create a healthy meal from available affordable food. Therefore, many community-based organizations and agencies are sponsoring cooking classes, cooking demonstrations, and taste tests. Certified community kitchens and “value-added processing facilities” in many communities provide the equipment necessary for home canning, light prepping of vegetables for farm-to-institution programs, and opportunities for “food entrepreneurs” to create and market healthy food options for their communities.

Financial support. A.S.A receives funding from Cooperative Agreement No. 5U48DP001944 of the Centers for Disease Control and Prevention.

Potential conflicts of interest. A.S.A. has no relevant conflicts of interest.

1. Whitacre PT, Tsai P, Mulligan J, rapporteurs; Food and Nutrition Board, Board on Agriculture and Natural Resources, Board on Population Health and Public Health Practice; Institute of Medicine and National Research Council of the National Academies. The Public Health Effects of Food Deserts: Workshop Summary. Washington, DC: The National Academies Press; 2009.

2. Rose D, Bodor JN, Swalm CN, Rice JC, Farley TA, Hutchinson PL. Deserts in New Orleans? Illustrations of urban food access and implications for policy. Paper presented at: Understanding the Economic Concepts and Characteristics of Food Access, a conference jointly sponsored by the University of Michigan National Poverty Center and the Economic Research Service of the US Department of Agriculture: January 23, 2009. Accessed July 18, 2012.

3. Boone-Heinonen J, Gordon-Larsen P, Kiefe CI, Shikany JM, Lewis CE, Popkin BM. Fast food restaurants and food stores: longitudinal associations with diet in young to middle-aged adults: the CARDIA study. Arch Intern Med. 2011;171(13):1162-1170.

4. McCormack LA, Laska MN, Larson NI, Story M. Review of the nutritional implications of farmers’ markets and community gardens: a call for evaluation and research efforts. J Am Diet Assoc 2010;110(3):399-408.

Alice S. Ammerman, DrPH, RD director, Center for Health Promotion and Disease Prevention (CDC Prevention Research Center) and professor, Department of Nutrition, Gillings School of Global Public Health and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Alice S. Ammerman, UNC-Chapel Hill, CB 7426, 1700 Martin Luther King Jr Blvd, Rm 239, Chapel Hill, NC 27599 (