The Grocery Gap: Who Has Healthy Food and Why It Matters

PolicyLink is a national research and action institute
advancing economic and social equity

by Lifting Up What Works®.
The Food Trust, founded in 1992, is a nonprofit

organization working to ensure that everyone has
access to affordable, nutritious food.
Design by: Leslie Yang
COVER PHOTOS COURTESY OF (from left to right, top to bottom): Zejica; Lorie Slater; image100 Photography;
Richard Beebe.
PHOTOS COURTESY OF: p.4: David Gomez Photography; p.6: Lorie Slater; p.10: Victor Melniciuc; p.12:
Bart Sadowski; p.24: Plush Studios/Blend.
PolicyLink The Food Trust
Sarah Treuhaft
PolicyLink
Allison Karpyn
The Food Trust
Acknowledgments
PolicyLink and The Food Trust are grateful to the
funders who supported the development and

publication of this report, including the Convergence
Partnership and the Kresge Foundation.

The research for this study was conducted with
indispensable assistance from Diana Fischmann
(former intern, The Food Trust), who initially
collected, reviewed, and summarized many
of the studies, and Allison Hagey (PolicyLink)
who adeptly assisted with the data analysis and
manuscript development. Many thanks to Jennefer

Keller, Jon Jeter, and Leslie Yang (PolicyLink), and
Lance Loethen (The Reinvestment Fund) for their
assistance. Our gratitude also extends to Judith
Bell and Rebecca Flournoy (PolicyLink), John
Weidman (The Food Trust), and Ira Goldstein (The
Reinvestment Fund) who provided helpful guidance
and feedback throughout the research process.
2
Contents
5 Preface
7 Executive Summary
11 Introduction
13 Findings
21 Implications for Policy
23 Methods
25 References
32 Notes
3
Improving access to healthy food is a

critical component of an agenda to build
an equitable and sustainable food system.
4
Preface
For decades, low-income communities of color have Centers for Disease Control and Prevention, adult
suffered as grocery stores and fresh, affordable obesity rates are 51 percent higher for African
food disappeared from their neighborhoods. Americans than whites, and 21 percent higher
Advocates have long drawn attention to this critical for Latinos. Black and Latino children are more
issue and crafted policy solutions, but access to likely to become obese than white children. The
healthy food is just now entering the national policy lack of healthy food retail also hinders community
debate. While the problem is obvious to impacted economic development in neighborhoods that
communities, good policy must also be based on need private investment, activity hubs, and jobs.
solid data about the issue and its consequences.
Thankfully, the tide is beginning to turn. Researchers
Unfortunately, it often takes years for the research and policymakers are coming to consensus that
to catch up with pressing needs in historically this is a critical issue. And they are recognizing that
underserved communities. Sometimes information is communities have developed innovative, sustainable
not available. Other times, evidence is accumulating solutions that can work in other locales and at larger
but it is buried in journals not widely read by scales. In December 2009, 39 members of Congress
policymakers. Or it is produced by practitioners and from both political parties issued a resolution in the
advocates for local action campaigns and not accepted House of Representatives recognizing the need for
by researchers or shared with policymakers or the national policy to address limited access to healthy
broader field. Too often, research focusing on low- food in underserved communities. The President’s
income people and communities of color, informed 2011 budget calls for more than $400 million to
by their experiences, or conducted in partnership establish a national Healthy Food Financing Initiative,
with them, is perceived as a political strategy, and this initiative is a key component of the First
rather than as a legitimate search to understand Lady’s Let’s Move campaign to reduce childhood
problems and inform strategies for change. obesity. Legislation to create a Healthy Food
Financing Initiative is expected to be introduced in
PolicyLink and The Food Trust conducted this both the House and the Senate in Spring 2010.
inquiry to summarize the existing evidence base,
carefully reviewing more than 132 studies. We This report presents powerful data. It confirms
found that a large and consistent body of evidence that as a nation we must answer the appeals of
supports what residents have long observed: many community activists seeking access to healthy food
low-income communities, communities of color, for their families and their neighborhoods. We
and sparsely populated rural areas do not have hope that it provides policymakers, advocates,
sufficient opportunities to buy healthy, affordable philanthropists, and others with information,
food. The consequences are also clear: decreased evidence, and analysis that can inform their efforts
access to healthy food means people in low-income to eliminate “food deserts” from neighborhoods
communities suffer more from diet-related diseases and communities across the country.
like obesity and diabetes than those in higher-
income neighborhoods with easy access to healthy
food, particularly fresh fruits and vegetables.
Inequitable access to healthy food is a major

Angela Glover Blackwell Yael Lehmann
contributor to health disparities. According to the
Founder and CEO Executive Director
5
In hundreds of neighborhoods
across the country, nutritious,
affordable, and high quality
food is out of reach—
particularly low-income
neighborhoods, communities
of color, and rural areas.
6
Executive Summary
An apple a day? the past 20 years. This bibliography incorporates a
total of 132 studies: Sixty-one published in peer-
F or millions of Americans—especially people reviewed journals and primarily conducted by

living in low-income communities of color— university-based researchers and 71 conducted
finding a fresh apple is not so easy. Full-service by practitioners or policy researchers, sometimes
grocery stores, farmers’ markets, and other vendors in collaboration with academic researchers, and
that sell fresh fruits, vegetables, and other healthy self-published (also known as “grey literature”).
foods cannot be found in their neighborhoods. The studies include three nationwide analyses
What can be found, often in great abundance, of food store availability and neighborhood,
are convenience stores and fast food restaurants city, county, regional, statewide, and multistate
that mainly sell cheap, high-fat, high-sugar, analyses covering 22 states across the country.
processed foods and offer few healthy options.
Without access to healthy foods, a nutritious Findings

diet and good health are out of reach. And
without grocery stores and other fresh 1. Accessing healthy food is a challenge
food retailers, communities are missing the
for many Americans—particularly those
commercial hubs that make neighborhoods
livable, and help local economies thrive.
living in low-income neighborhoods,
communities of color, and rural areas. In
For decades, community activists have organized hundreds of neighborhoods across the country,
around the lack of access to healthy foods as nutritious, affordable, and high quality food
an economic, health, and social justice issue. As is largely missing. Studies that measure food
concerns grow over healthcare and the country’s store availability and availability of healthy foods
worsening obesity epidemic, “food deserts” — areas in nearby stores find major disparities in food
where there is little or no access to healthy and access by race and income and for low-density,
affordable food—have catapulted to the forefront rural areas.
of public policy discussions. Policymakers at • Lack of supermarkets. A 2009 study by
the local, state, and national level have begun the U.S. Department of Agriculture found
recognizing the role that access to healthy food that 23.5 million people lack access to a
plays in promoting healthy local economies, supermarket within a mile of their home.
healthy neighborhoods, and healthy people. A recent multistate study found that low-
income census tracts had half as many
This report, a summary of our current knowledge supermarkets as wealthy tracts. Another
about food deserts and their impacts on multistate study found that eight percent
communities, provides evidence to inform this of African Americans live in a tract with a
policymaking. supermarket, compared to 31 percent of
whites. And a nationwide analysis found
To assess the current evidence base in this there are 418 rural “food desert” counties
dynamic and fast-growing field of research, we where all residents live more than 10 miles
compiled the most comprehensive bibliography from a supermarket or supercenter—
to date of studies examining food access and its this is 20 percent of rural counties.
implications conducted in the United States over
7
• Lack of healthy, high quality foods • In rural Mississippi, adults living in “food
in nearby food stores. In Detroit and desert” counties lacking large supermarkets
New Haven, produce quality is lower are 23 percent less likely to consume the
in low-income communities of color recommended fruits and vegetables than
compared to more affluent or racially those in counties that have supermarkets,
mixed neighborhoods. In Albany, New controlling for age, sex, race, and
York, 80 percent of nonwhite residents education.
cannot find low-fat milk or high-fiber
bread in their neighborhoods. And in 3. Access to healthy food is associated
Baltimore, 46 percent of lower-income with lower risk for obesity and other
neighborhoods have limited access to diet-related chronic diseases. Researchers
healthy food (based on a healthy food find that residents who live near supermarkets
availability survey) compared to 13 percent or in areas where food markets selling
of higher-income neighborhoods. fresh produce (supermarkets, grocery stores,
farmers’ markets, etc.) outnumber food stores
• Predominance of convenience/corner/
that generally do not (such as corner stores)
liquor stores. Nationally, low-income zip
have lower rates of diet-related diseases than
codes have 30 percent more convenience
their counterparts in neighborhoods lacking
stores, which tend to lack healthy
food access.
items, than middle-income zip codes.
• A multistate study found that people
• Lack of transportation access to stores. with access to only supermarkets or
Residents in many urban areas (including to supermarkets and grocery stores
Seattle, Central and South Los Angeles, and have the lowest rates of obesity and
East Austin, Texas) have few transportation overweight and those without access to
options to reach supermarkets. Inadequate supermarkets have the highest rates.
transportation can be a major challenge for
rural residents, given the long distances to • In California and New York City, residents
stores. In Mississippi—which has the highest living in areas with higher densities of fresh
obesity rate of any state—over 70 percent food markets, compared to convenience
of food stamp eligible households travel stores and fast food restaurants, have
more than 30 miles to reach a supermarket. lower rates of obesity. In California,
obesity and diabetes rates are 20 percent
2. Better access corresponds with higher for those living in the least healthy
healthier eating. Studies find that residents “food environments,” controlling for
with greater access to supermarkets or a greater household income, race/ethnicity, age,
abundance of healthy foods in neighborhood gender, and physical activity levels.
food stores consume more fresh produce and
• Using statistical modeling techniques that
other healthful items.
control for a variety of factors, researchers
• For every additional supermarket in estimate that adding a new grocery store to
a census tract, produce consumption a high poverty neighborhood in Indianapolis
increases 32 percent for African would lead to a three pound weight
Americans and 11 percent for whites, decrease among residents, while eliminating
according to a multistate study. a fast food restaurant in a neighborhood
with a high density of fast food would
• A survey of produce availability in New lead to a one pound weight decrease.
Orleans’ small neighborhood stores found
that for each additional meter of shelf • In Chicago and Detroit, residents who
space devoted to fresh vegetables, residents live farther from grocery stores than
eat an additional 0.35 servings per day. from convenience stores and fast food
8
restaurants have significantly higher rates of supported agriculture programs, and

premature death from diabetes. mobile vendors (and ensuring public
benefits can be used at these venues);
4. New and improved healthy food retail
• Increasing the stock of fruits, vegetables,
in underserved communities creates
and other healthy foods at neighborhood
jobs and helps to revitalize low-income corner stores or small groceries;
neighborhoods. Though the economic
impacts of food retailers are understudied, • Growing food locally through backyard
we know that grocery stores contribute to and community gardens and larger-
community economic development. Analysis scale urban agriculture; and
of a successful statewide public-private
initiative to bring new or revitalized grocery • Improving transportation to grocery
stores to underserved neighborhoods in stores and farmers’ markets.
Pennsylvania provides positive evidence that
fresh food markets can create jobs, bolster local Improving access to healthy food is a critical
economies, and revitalize neighborhoods. The component of an agenda to build an equitable
effort has created or retained 4,860 jobs in and sustainable food system. It is time for
78 underserved urban and rural communities a nationwide focus to ensure that healthy
throughout the state. Analyses of stores food choices are available to all, building
supported by the effort find they lead to on these local efforts and innovations.
increased economic activity in surrounding
communities. Smart public policies and programs should support
communities in their efforts to develop, implement,
and test strategies that increase healthy food
Implications for Policy access. Government agencies at the local, state,
and federal level should prioritize the issue of
inequitable food access in low-income, underserved
The evidence is clear that many communities—
areas. Programs and policies that are working
predominantly low-income, urban communities
should be expanded and new programs should
of color and rural areas—lack adequate access to
be developed to bring more grocery stores and
healthy food, and the evidence also suggests that
other fresh food retail outlets to neighborhoods
the lack of access negatively impacts the health
without access to healthy foods. Transportation
of residents and neighborhoods. These findings
barriers to fresh food outlets should be addressed.
indicate that policy interventions to increase
Whenever possible, policies to address food
access to healthy food in “food deserts” will
deserts should link with comprehensive efforts to
help people eat a healthy diet, while contributing
build strong regional food and farm systems.
to community economic development.
Residents of low-income communities and
For many years, impacted communities and
communities of color in urban and rural areas
their advocates have been implementing
have suffered for too long from a lack of
a variety of strategies to increase access to
access to healthy food. With local and state
fresh, wholesome foods, including:
programs showing enormous promise, now is
the time for policymakers to enact policies that
• Attracting or developing grocery
will catalyze the replication of local and state
stores and supermarkets;
innovations and bring them to a national scale.
• Developing other retail outlets such
as farmers’ markets, public markets,
cooperatives, farmstands, community-
9
The presence of stores selling

healthy, affordable food makes
it possible to eat “five a day”
and consume a healthful diet.
10
Introduction
I n hundreds of neighborhoods across the country,

nutritious, affordable, and high quality food
is out of reach. Residents of many urban low-
and in need of new or revitalized neighborhood-
serving retailers and job opportunities. Grocery
stores and supermarkets are also economic
income communities of color walk outside their anchors in a neighborhood—supplying local jobs
doors to find no grocery stores, farmers’ markets, and creating foot traffic for additional businesses.
or other sources of fresh food. Instead they are Smaller food retailers and farmers’ markets can
bombarded by fast food and convenience stores also bolster the local economy and contribute to
selling high-fat, high-sugar, processed foods. a healthy neighborhood business environment.
Rural residents often face a different type of
challenge—a lack of any nearby food options. Although the lack of access to healthy foods
has preoccupied residents of low-income urban
This has been a persistent problem for communities. neighborhoods and rural areas for decades, and
Beginning in the 1960s and 1970s, white, middle- many advocates have fought long and hard to bring
class families left urban centers for homes in in or develop new fresh food retailers, until recently
the suburbs, and supermarkets fled with them. the issue was largely confined to the occasional
Once they left the city, grocers adapted their local win or news story. But that is all changing.
operations to suit their new environs, building “Food deserts”—areas with low access to healthy
ever-larger stores and developing chain-wide foods—have become a major topic of interest
contracts with large suppliers and distributors among public health advocates and the media, as
to stock the stores with foods demanded by a well as a dynamic and fast-growing field of research.
fairly homogeneous suburban population. Over With the recognition of the obesity (and childhood
the past several decades, the structure of the obesity) crises and the increasing understanding
grocery industry has changed dramatically, with of how the neighborhood environment influences
significant consolidation and growth in discount health, solving the food desert problem is now
stores and supercenters and specialty/natural food rising to the forefront of policy discussions.
retailers.1 At the same time, alternative sources
of fresh foods such as farmers’ markets, produce This report provides data to inform that debate.
stands, and community-supported agriculture Across the country, dozens of studies have
programs have proliferated, though predominantly examined the availability of nutritious, affordable
in middle-class or affluent communities. foods in communities and/or the relationship
between food access and health. These include
While some continue to be well-served, many studies authored by university-based researchers,
have been left out. Without fresh food retailers, health departments, community groups, and
these communities miss out on the economic and nonprofit policy and research organizations. A
health benefits they bring to neighborhoods. The large number of studies, particularly local studies
presence of stores selling healthy, affordable food about geographic access to healthy food, are
makes it possible to eat “five a day” and consume conducted by practitioners who seek to understand
a healthful diet. This is particularly important for the situation locally in order to take action. This
low-income people of color given the vast disparities “grey literature” often provides important data
in health that exist in areas including obesity, but is rarely included in academic reviews.
diabetes, and other diet-related diseases. The same
communities are often economically distressed
11
To assess the current evidence base, we gathered statewide, and multistate analyses covering 22
the studies conducted in the United States over the states throughout the country. The bibliography
past 20 years to create the most comprehensive also includes three review studies.3, 4, 5 Sixty-one
bibliography on this topic to date.2 We found of the studies were published in peer-reviewed
a total of 132 studies that examined access to journals and generally conducted by academic
healthy food and its impacts. They include three researchers, and 71 were self-published and
nationwide analyses of food store availability generally conducted by practitioners. (See pages
and neighborhood, city, county, regional, 23-24 for a full description of our methodology.)
Studies find that residents

with greater access to
supermarkets or a greater
abundance of healthy foods
in neighborhood food stores
consume more fresh produce
and other healthful items.
12
Findings
1. Accessing healthy food is a of food outlets such as convenience stores and
smaller grocery stores. Several of these studies look
challenge for many Americans— at the distribution of different types of food stores,
particularly those living in such as supermarkets, smaller grocery stores, and
low-income neighborhoods, “fringe retailers” such as convenience and corner
communities of color, and stores across different community types. They find
that lower-income communities and communities of
rural areas color have fewer supermarkets, more convenience
stores, and smaller grocery stores than wealthier
Researchers have measured geographic access and predominantly white communities.
to healthy foods in many different ways, and
at nearly every imaginable scale: from national Eighty-nine national and local studies document
samples to detailed assessments of specific uneven geographic access to supermarkets
neighborhoods. Only one study has sought to in urban areas according to income, race, or
calculate the extent of the problem nationally. both7-87 and nine had mixed results.88-96
The U.S. Department of Agriculture’s 2009 “food
desert” study examined access to supermarkets and Nationwide study findings include:
determined that 23.5 million people cannot access
a supermarket within one mile of their home. • Low-income zip codes have 25 percent
fewer chain supermarkets and 1.3
Most studies (a total of 113) examine whether times as many convenience stores
supermarkets or healthy foods are equitably compared to middle-income zip codes.
distributed across communities according to Predominantly black zip codes have about
socioeconomic status, racial composition, or half the number of chain supermarkets
level of urbanization (population density).6 compared to predominantly white
Their findings are remarkably consistent: people zip codes, and predominantly Latino
living in low-income neighborhoods, minority areas have only a third as many.46
neighborhoods, and rural communities face
much greater challenges finding healthy food, • Low-income neighborhoods have half
especially those who lack good transportation as many supermarkets as the wealthiest
options to reach full-service grocery stores. neighborhoods and four times as many
Ninety-seven of these studies found inequitable smaller grocery stores, according to an
access to healthy foods, 14 had some mixed assessment of 685 urban and rural census
results, and two studies did not find inequities. tracts in three states. The same study
found four times as many supermarkets
Disparities in supermarket access in in predominantly white neighborhoods
compared to predominantly black ones.38
urban areas by race and income
Another multistate study found that
eight percent of African Americans
Many researchers use supermarkets as a proxy for
live in a tract with a supermarket
food access because they provide the most reliable
compared to 31 percent of whites.42
access to a wide variety of nutritious and affordable
produce and other foods compared to other types
13
Local studies demonstrate similar trends: Disparities in access to healthy

food at neighborhood stores in
• In Los Angeles there are 2.3 times as many urban areas by race and income
supermarkets per household in low-poverty
areas compared to high-poverty areas. Other studies gather much more detailed data,
Predominantly white areas have 3.2 times conducting in-store surveys to assess the availability,
as many supermarkets as black areas and variety, quality, and price of particular healthy items
1.7 times as many as Latino areas.49 or grocery “market baskets.” Such surveys offer
a more precise look at healthy food availability in
• Among affluent neighborhoods in
neighborhoods, but they are labor-intensive so
Atlanta, those that are predominantly
generally focus on smaller geographic areas.
white have better grocery store access
than those that are predominantly
Among these studies, 21 found that food stores
black, indicating that race may be a
in lower-income neighborhoods and communities
factor independent of income.30
of color are less likely to stock healthy foods,
• In West Louisville, Kentucky, a low-income offer lower quality items, and have higher
African American community that suffers prices compared to stores in higher-income or
from high rates of diabetes, there is one predominantly white communities,13, 15, 17, 18, 20-23,
supermarket for every 25,000 residents,
28, 31, 33, 35, 52, 68, 69, 96-99, 103, 105, 106
and seven found
compared to the county average of one mixed results (for example, lower quality but
supermarket for every 12,500 residents.17 similar prices and selection)9, 81, 88, 89, 100, 102 or no
difference.101 In addition, a study based on focus
• In Washington, DC, the city’s lowest- groups with residents in East Baltimore (a low-
income wards (Wards 7 and 8) have one income community of color) found that they were
supermarket for every 70,000 people reliant on small neighborhood stores that charged
while two of the three highest-income extremely high prices and lacked a good variety
wards (Wards 2 and 3) have one for and selection of healthy foods.103 Findings include:
every 11,881 people.20 One in five of
the city’s food stamp recipients lives in a • Stores carrying fruits and vegetables are
neighborhood without a grocery store.37 unevenly distributed among different types
of communities in upstate New York: a
• In California and in New York City, low- minority neighborhood in Albany has
income neighborhoods have fewer the least access (4.6 stores per 10,000
purveyors of healthy foods (supermarkets, residents), followed by a rural community
produce stands) compared to outlets that (7.8), a small town (9.8), and a racially
primarily sell unhealthy foods (convenience mixed neighborhood in Albany (11.4).32
stores, fast food restaurants).14, 47 Low- The same researchers find that eight in
income neighborhoods in California 10 of Albany’s nonwhite residents live
have 20 percent fewer healthy food in a neighborhood that lacks any stores
sources than higher-income ones.14 selling low-fat milk or high-fiber bread.33
• In unincorporated communities (colonias) • Stores located in low-income and very
located along the U.S.-Mexico border low-income zip codes in Los Angeles
in Texas, residents in neighborhoods and Sacramento are less likely to stock
with higher levels of deprivation healthy foods than stores in higher-income
(measured by income, transportation, areas.34 Three in 10 food stores in a high-
lack of infrastructure, etc.) travel farther poverty, predominantly African American
to reach the nearest supermarket or community in Los Angeles lacked fruits and
grocery store and have lower access vegetables while nearly all of the stores in
to a variety of food stores.51 a contrast area that was low poverty and
predominantly white sold fresh produce.52
14
Share of Baltimore Neighborhood Food Stores with Low Availability of Healthy Food,
by Neighborhood Race and Income, 2006
• Produce quality is lower in a predominantly around schools because of the link between access
black, low-income community in Detroit to convenience stores and adolescent health.121 Two
compared to an adjacent suburban studies looked at convenience stores in proximity
community that is racially mixed and to schools and found that schools with more low-
middle-income.81 Produce quality is income or nonwhite students or in urban areas,104
also lower in New Haven, Connecticut’s and schools located in low-income neighborhoods
low-income communities compared or communities of color107 are more likely to
to more affluent neighborhoods.9 have at least one convenience store nearby.
• In Baltimore (see chart above), a healthy Rural food deserts

food availability survey of 226 supermarkets,
grocery stores, convenience stores, and While the majority of food desert studies focus
behind-glass stores in 106 census tracts on urban communities, 21 studies examined rural
found that 43 percent of predominantly communities. Twenty of them found significant
black neighborhoods and 46 percent of food access challenges in rural communities21,
lower-income neighborhoods were in the 29, 32, 33, 36, 43, 46, 50, 51, 70, 75, 95, 108-114, 116
and one (that
bottom third of availability, compared to looked at Springfield, Oregon) did not find urban-
four percent of predominantly white and 13 rural disparities.54 The major issues in rural areas
percent of higher-income neighborhoods. are different than those in urban areas given the
The supermarkets in predominantly black low population density, longer distances between
and lower-income neighborhoods scored retailers, and rapid rise of supercenters and their
lower for healthy food availability as well.23 impact on other food retailers. Key findings include:

Disparities in food store access around • Controlling for population density, rural
schools by race and income areas have fewer food retailers of any type
compared to urban areas, and only 14
In addition to the residential environment, researchers percent the number of chain supermarkets.46
are beginning to examine the “food environment” (See chart, next page) Another nationwide
15
Availability of Food Stores in Rural Areas by Store Type, 2000
analysis found that there are 418 2. Better access to healthy food
rural “food desert” counties where all
residents live 10 miles or more from the
corresponds with healthier eating
nearest supermarket or supercenter—20
percent of all rural counties.43 Consistent with the conclusions of a recent review
study,4 we found strong and consistent evidence
• In the Mississippi Delta, over 70 percent indicating a positive relationship between access
of households eligible to receive to healthy food and eating behaviors. Without
food stamp benefits needed to travel nearby access to healthy ingredients, families
more than 30 miles to reach a large have a harder time meeting recommended dietary
grocery store or supermarket.36 guidelines for good health such as eating fruits
and vegetables and lowering fat intake. In a
• In New Mexico, rural residents have survey of diabetic adults in New York’s East Harlem
access to fewer grocery stores than urban neighborhood, 40 percent said that they did
residents, pay more for comparable items, not follow the recommended dietary guidelines
and have less selection. The same market because the necessary foods were less available and
basket of groceries costs $85 for rural more expensive in their neighborhood stores.31
residents and $55 for urban residents.113
Of 14 studies that examine food access and
Transportation access consumption of healthy foods, all but one of them
found a correlation between greater access and
Lack of transportation to supermarkets is a major better eating behaviors. All of the studies in this
barrier for residents in many communities.115 category were conducted by academic researchers
Assessments of Lexington (KY), Seattle (WA), Central and published in peer-reviewed journals.118
and South Los Angeles (CA), East Austin (TX), and
Trinity County (CA) highlighted transportation Access to supermarkets
challenges.11, 12, 22, 69, 116 Rural residents have higher
vehicle ownership generally, but those who lack Eight studies analyzed access to nearby super-
reliable access to personal vehicles are particularly markets or large grocery stores that sell a wide
isolated given the longer distances to stores and variety of healthy foods in relation to consumption
lack of public transportation options.12, 51, 114, 116, 117 of fruits and vegetables, specific healthy foods (such
as low-fat milk or high-fiber bread), or a healthy diet
(measured by an index of diet quality). Almost all
16
Access to Supermarkets and Consumption of Fruits and Vegetables by Race, 2002
of these studies control for individual characteristics likely to have a healthy diet than those
such as race and income and still find a relationship with the most supermarkets near their
between access and healthy eating. Six of the homes, according to a study that used
studies found associations between supermarket data from North Carolina, Baltimore, and
access and healthy eating among adults42, 79, 91, New York City. A healthy diet was defined
109, 119, 120
and one had mixed results.78 Only one using two different measures: the Alternate
study examined access to food stores and eating Healthy Eating Index, which measures
behaviors of adolescents (specifically, boys aged consumption of foods related to low risk of
10 to 14); this study did not find a relationship chronic disease, and a measure looking at
between supermarket access and fruit and consumption of fats and processed meats.91
vegetable consumption but did find that proximity
of convenience stores (where young people who • Proximity to a supermarket is associated
do not drive are more likely to shop) was associated with increased fruit consumption among
with reduced fruit and vegetable intake.121 food stamp recipients (based on a
nationally representative sample). Similar
Some of the findings include: patterns were also seen with vegetable
consumption, though associations
• African Americans living in a census tract were not statistically significant.119
with a supermarket are more likely to meet
• In rural Mississippi, adults living in “food
dietary guidelines for fruits and vegetables,
desert” counties (defined as those lacking
and for every additional supermarket
large supermarkets) are 23 percent less
in a tract, produce consumption rose
likely to consume the recommended
32 percent. Among whites, each
fruits and vegetables than those in
additional supermarket corresponded
counties that are not food deserts.109
with an 11 percent increase in produce
consumption (see chart above).42 This • In Detroit’s East Side neighborhood, African
study used a large sample: 10,230 American women with lower incomes are
adults living in 208 urban, suburban, less likely to shop at supermarkets (which
and rural census tracts in four states. are all located outside the neighborhood)
and eat fruits and vegetables than
• Adults with no supermarkets within a mile
those with higher incomes.79
of their homes are 25 to 46 percent less
17
Access to fresh produce and other 3. Access to healthy food is

healthful foods in nearby stores associated with diet-related
Several recent studies go beyond using disease
supermarkets as proxies for healthy food access
and conduct in-store surveys to more accurately In addition to making it possible—and even
measure the availability of healthy food items in more likely—for residents to eat healthy diets,
nearby stores.13, 21, 91, 122, 123 Others use resident the availability of healthy food in communities
surveys to measure access to nutritious and is related to a host of diet-related diseases
quality foods and eating behaviors.5, 124 Of the six including obesity and overweight, diabetes, and
studies in this category, all of them found that cardiovascular disease. Seventeen studies examined
increased availability of produce or of specific the relationship between healthy food access
healthy foods (such as low-fat milk as a percentage and diet-related health outcomes; approximately
of all milk) is associated with the increased half were conducted by academics and half were
consumption of those foods. Findings include: conducted by policy researchers. Twelve found
a positive relationship,14, 24, 25, 27, 34, 45, 47, 72, 73, 125,
• In New Orleans, proximity to stores 126, 128
three studies had mixed results,127, 129, 145
stocking more fresh produce is and two studies had contrary findings.78, 104
associated with higher vegetable
consumption. Each additional meter of Access to supermarkets
shelf space devoted to fresh vegetables
is associated with an additional 0.35 Five studies found that proximity to supermarkets
servings of vegetables per day.13 corresponds with a lower body mass index (BMI),
or rates of obesity, diabetes, or diet-related death
• For participants in a community- among adults,27, 71-73, 125 and one found the same
based health promotion program in correlation among adolescents.45 Only two studies
Colorado, greater shelf space allocated focused on children. One found that supermarket
to fresh produce corresponded access was associated with lower BMI among
with greater increases in fruit and children in lower-density counties in Indianapolis
vegetable consumption.122 (but not in higher-density ones).127 The other tracked
• The proportion of low-fat milk in stores kindergarteners over four years and found that,
is positively and directly related to its controlling for individual characteristics, higher
consumption according to a New York fruit and vegetable prices in their city or metro
state study21 and a study that examined corresponded with weight gain, but the density of
areas of California and Hawaii.123 restaurants, convenience stores, or grocery stores
around their schools did not make a difference.145
• One study asked residents to rank
their access to healthy food and then • Adults living in neighborhoods with
examined their rankings in relation to supermarkets or with supermarkets and
their diets. Residents living in areas ranked grocery stores have the lowest rates of
by themselves or others as having the obesity (21 percent) and overweight
worst food environments were 22 to (60–62 percent) and those living in
35 percent less likely to eat a healthy neighborhoods with no supermarkets
diet than those living in areas ranked as and access to only convenience stores,
having the best food environments.91 smaller grocery stores, or both had the
highest rates (32–40 percent obesity;
73–78 percent overweight), according to
a study of more than 10,000 adults.125
• The lack of supermarket access

corresponds with higher rates of diet-
related death in Philadelphia.27
18
The Economic Impacts of Fresh Food Retailers
Direct Economic Impacts: Indirect Economic Impacts:

• Job opportunities • Revitalized neighborhood housing markets
• Local tax revenues • Asset-building for low-income homeowners (via appreciating real estate assets)
• Workforce training and development
• New businesses surrounding the store
• Additional spending in the local economy generated by the store and the new jobs it
creates (the “multiplier effect”)
• In Los Angeles, a longer distance fast food dense neighborhood (six or more
traveled to reach a grocery store was fast food restaurants per square kilometer)
associated with higher BMI. Those translates into a one pound decrease.126
who traveled more than 1.75 miles to
a supermarket weighed 0.8 BMI units • A 2009 study of Chicago’s food deserts
more (4.8 pounds for a 5’5” person).34 found that as the distance to the nearest
grocer increases relative to the distance to
• A national study of more than 70,000 the nearest fringe food outlet, the Years of
teens also found that increased availability Potential Life Loss (YPLL) due to diseases
of chain supermarkets was associated such as cancer, cardiovascular disease,
with lower rates of overweight.45 diabetes, and liver disease increases. This
relationship is significant in African
Food outlet mix American communities, but less clear for
white and Hispanic communities.25
Several studies14, 24, 25, 47, 126 have found that
the mix of food stores available to residents is
associated with diet-related health outcomes: 4. New and improved healthy
• Californians and New Yorkers living in
food retail in underserved
areas with higher densities of fresh food communities creates jobs and
markets compared to convenience stores helps to revitalize low-income
and fast food restaurants have lower neighborhoods
rates of obesity. In California, obesity and
diabetes rates were 20 percent higher
for those living in the least healthy “food Beyond the benefits to individual health described
environments,” controlling for individual above, fresh food markets contribute to the overall
factors.14 In New York City, increasing health of neighborhoods and communities.
“BMI-healthy” food stores in New York
neighborhoods corresponded with Grocery stores are known by economic development
lower obesity rates (though decreasing practitioners to be high-volume “anchors” that
“BMI-unhealthy” stores did not).47 generate foot traffic and attract complementary
stores and services like banks, pharmacies, video
• In Indianapolis, BMI values correspond rentals, and restaurants.131 Yet compared to the
with access to supermarkets and fast study of food access and its health impacts, the
food restaurants. Researchers estimate study of economic impacts related to food retail
that adding a new grocery store to a development is an area of relatively limited research.
high-poverty neighborhood translates
into a three pound weight decrease, and Several methods have been developed to estimate
eliminating a fast food restaurant from a the demand for food retail in underserved
19
The Pennsylvania Fresh Food Financing Initiative has

helped develop supermarkets and other fresh food
outlets in 78 underserved urban and rural areas,
increasing access to healthy food for nearly 500,000
residents and creating or retaining 4,860 jobs.
communities. Studies that use local data Studies of the Pennsylvania Fresh Food Financing
sources find that these neighborhoods have the Initiative (FFFI), a statewide public-private effort
potential to support thousands of square feet that has helped develop 78 supermarkets and
in additional grocery retail space.56-67, 134 One other fresh food outlets in underserved urban
study estimated $8.7 billion dollars in annual and rural areas, also demonstrate the positive
grocery leakage in inner-city neighborhoods.135 impacts of healthy food retailing. In addition
to increasing access to healthy food for nearly
Some have also investigated the impact of new 500,000 residents, the effort resulted in:
supermarkets on nearby real estate values. When
new food retailers enter areas that were previously • Job creation. The initiative created or
under-retailed, they can bring viability to urban retained 4,860 jobs throughout the state. A
neighborhoods’ commercial real estate markets, recent case study of selected supermarkets
and can change perceptions that economically in the Philadelphia region found that the
distressed urban areas are undesirable places to vast majority of jobs created through the
operate businesses.133 An assessment of the impact initiative (75 percent) were filled by local
of new supermarkets on neighborhood housing residents living within three miles of their
values in Philadelphia found that the values of workplace.138 A new store assisted by
homes located within one-quarter to one-half the initiative that is part of the regional
mile of the new supermarkets increase by four to ShopRite chain created 258 jobs and more
seven percent (an average of $1,500) after the than half were filled by local residents.139
stores open, mitigating the downward trend in real When you add in the additional jobs that
estate values. In addition, the effect was larger in are created through a new store’s multiplier
neighborhoods with weaker housing markets.130 effect, the total number of jobs becomes
much higher: one grocery store that the
Recent analyses of efforts to bring new grocery effort helped launch is estimated to have
stores into underserved communities find that these created 660 jobs directly and indirectly.140
businesses are viable (even thriving), offer a good
selection of nutritious and affordable foods, and • Economic development. New and
contribute greatly to local economic development. improved grocery stores can catalyze
An examination of the first full-service supermarket commercial revitalization in a community.
to locate in New York City’s Harlem neighborhood An analysis of the economic impacts of five
(thanks in part to a $2.5 million loan from the city new stores that opened with FFFI assistance
to cover construction costs), four years after its found that, for four of the stores, total
opening, found that the store allocated the same employment surrounding the supermarket
amount of space to a similar variety of fresh fruits increased at a faster rate than citywide
and vegetables, fish, and meat as typical suburban trends. This suggests a positive effect on
supermarkets, at similar prices.136 The store has been overall economic activity resulting from the
credited with catalyzing the revitalization of the introduction of a new supermarket.138
neighborhood.137
20
Implications for Policy
E xisting research provides clear evidence that

food deserts exist in numerous low-income
communities and communities of color across the
Communities are using a variety of strategies to
increase access to healthy foods, and their
efforts provide several lessons for policymakers
country, and that they have significant negative at the local, state, and federal level.143
impacts on health, social equity, and local economic
development. The balance of the research strongly Until more systemic solutions are instituted,
suggests that making affordable, healthy foods transportation barriers to fresh food markets need
more available to underserved residents will lead to to be removed. Community groups and planners
their making healthier choices about what to eat should evaluate existing transportation routes and
and, ultimately, better health, while contributing improve coordination of bus routes, bus stops, and
to economic and neighborhood revitalization. schedules or add vanpools or shuttles to maximize
transit access to grocery stores and farmers’ markets.
While there is general agreement in the Longer-term transportation and land use planning
literature about the lack of access to healthy should promote the co-location of food retail,
foods and increasing evidence about its transit access, and affordable homes. Communities
consequences, fewer researchers have focused and retailers can launch programs such as mobile
on the question of what are the most effective markets, grocery shuttles, and grocery van-
solutions. This search has largely been taken up delivery to improve access to healthy food.
by impacted communities and their advocates
and supporters. Across the country, they are: Community groups, residents, researchers, and
government agencies should work together to
• Attracting or developing grocery identify areas that lack access to healthy food and to
stores and supermarkets; understand local economic conditions and regional
food systems. Areas lacking access should be
• Developing other retail outlets such prioritized, strategies for action need to identified,
as farmers’ markets, public markets, and then advocates need to demand the resources,
cooperatives, farmstands, community- programs, and policies to solve the access problem.
supported agriculture programs, and Once underway, efforts should be monitored to
mobile vendors (and ensuring public examine progress over time, and advocates should
benefits can be used at these venues); seek the expansion of successful approaches.
• Increasing the stock of fruits, vegetables,
Cities have many policy tools they can use to
and other healthy foods at neighborhood
incentivize and promote healthy food retail
corner stores or small groceries;
including land use planning, zoning, economic
• Growing food locally through backyard development and redevelopment, and nutrition
and community gardens and larger- assistance. A recent analysis of retailers’ location
scale urban agriculture; and decisions found that the land availability, market
demand (and data demonstrating that demand),
• Improving transportation to grocery construction and operations costs, and approval/
stores and farmers’ markets. zoning requirements all pose barriers to locating
in underserved urban areas.141 Cities can help
21
What Type of Food Access Will Make a Difference?

One question the research begins to address is whether supermarkets are the only solution to the “grocery gap” in
low-income communities.
The majority of studies use supermarkets (typically defined by a sales volume of more than $2 million or more than
50 employees) as a proxy for access to healthy foods. This makes sense because most Americans do the bulk of their
grocery shopping at these stores (and increasingly at larger supercenters)142 and supermarkets more consistently
offer a good variety and selection of affordable and nutritious foods compared to other types of food retailers.36, 44
But more and more studies are using in-store surveys to examine the availability of particular healthy items or healthy
“market baskets” and their consumption. These studies find the same relationship between access and diet as studies
that look at supermarkets.
This suggests that health could be improved through many different food access strategies.
overcome these barriers by providing publicly the development, renovation, and expansion
owned land for food retailers, helping with land of retail outlets offering fresh healthy food
assembly, and identifying and marketing sites for (such as grocery stores, farmers’ markets, and
grocery store development. Several cities have cooperatives) should be developed.144 The success
conducted internal assessments to understand of the Pennsylvania Fresh Food Financing Initiative
how their agencies and departments can foster demonstrates that public investments can leverage
healthy food retail in underserved neighborhoods. significant private investment and dramatically
improve healthy food access. Policy replication
In New York City, the departments of health, efforts have been successful in Illinois, New York,
planning, housing, economic development, and and New Orleans, and numerous replication
the Mayor’s office all played a role in developing efforts are underway in states across the country.
and implementing several innovative programs Given the national scope of the problem, this
including: Green Carts, to help produce vendors successful state policy should be brought to
locate in underserved neighborhoods with high a national scale so this innovative financing
rates of obesity and diabetes; Healthy Bodegas, to mechanism can be available to all communities.
improve healthy offerings in corner stores; Health
Bucks, to promote produce purchasing at farmers’ Successful policies and programs need to be
markets; and FRESH, to provide zoning and financial replicated and brought to a greater scale to
incentives to promote grocery store development, increase healthy food access. A problem with
upgrading, and expansion in underserved areas. such broad and negative impacts on health,
economy, and equity warrants a focus at all
At the state and national level, fresh food levels—community, state, and national. Now is
financing initiatives—based on Pennsylvania’s the time for bold, nationwide efforts to ensure
successful program (described on page 20)—that that healthy food choices are available to all.
create public-private partnerships to support
22
Methods
B etween May and July 2009, PolicyLink and

The Food Trust created a comprehensive
bibliography of studies related to food access
In order to be included, each study needed
to meet the following criteria:
and/or food access and health across the • Related directly or indirectly to identifying
United States. Unlike previous review studies, disparities in access to food retailers
which typically only include published work, we or healthy food, and the relationship
sought to include “grey literature,” or studies, between food retail and health;
reports, and analyses that are not published in
peer-reviewed journals. Public health agencies, • Either included original research on
community-based organizations, and policy these topics or reviewed other studies;
groups frequently conduct primary data analyses
• Conducted in the United States (while there
of retail food access to inform their activities,
have been studies conducted outside of
but generally do not take the additional steps to
the United States, the persistent trend of
submit their studies to journals for publication.
residential segregation by race/ethnicity and
income in this country makes extrapolation
We used the following search methods
from these studies of limited value); and
to compile the bibliography:
• Published during or after 1995 (although
• Sent requests for information to relevant we included a few important studies that
listservs, e.g., COMFOOD, the National were conducted between 1990 and 1994).
Neighborhood Indicators Partnership
(NNIP), American Evaluation Association One hundred and thirty-two studies were ultimately
(EVALTALK), and agency email lists; included in the database, of 168 articles initially
gathered through the search methods above. We
• Wrote to 80 food policy councils across
included studies that use random and nonrandom
the country that are listed on the North
sampling methods and quantitative and qualitative
American Food Policy Council website
techniques (such as resident interviews). We also
and the Community Food Security
included studies that examine single communities of
Coalition Food Policy Council Database;
interest (alone or in comparison to other areas). We
• Contacted several foundations and excluded newsletters, policy statements, and studies
leaders working in the food access field; that focused on methods and measurements. In
one case we found two policy papers, one shorter
• Searched PubMed and other library than the other, based on the same study and data;
databases related to the fields of they were counted as one study in the database.
planning, community development, and
geography to identify formally published Of the studies selected for the database, 61 were
work related to urban and rural food published in peer-reviewed journals, and 71 fell
access and health implications; and into the grey literature category. We did not
systematically review the evidence quality (e.g.,
• Reviewed reference lists of included studies. sample size, strength of methods used) of each
23
study for this review, but note that to date, the

studies that examine the health impacts of access
to healthy food have primarily used cross-sectional
research designs (examining survey data) and there
have been few longitudinal or intervention studies.
We also noted some systematic differences

between the content of the peer-reviewed studies
compared to those conducted by practitioners.
None of the practitioner studies examined the
relationship between food access and eating
behaviors, likely due to the difficulty of accessing
data on eating behaviors for small geographies or
individuals. Only one of the peer-reviewed studies
examined the economic impacts of grocery stores.
24
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39
Headquarters: One Penn Center, Suite 900
1438 Webster Street 1617 John F. Kennedy Blvd.
Suite 303 Philadelphia, PA 19103
Oakland, CA 94612 t 215 575-0444
t 510 663-2333 f 215 575-0466
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www.thefoodtrust.org
Communications:
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PolicyLink is a national research and action institute

advancing economic and social equity

The Food Trust, founded in 1992, is a nonprofit

Design by: Leslie Yang

21 Implications for Policy

Improving access to healthy food is a

Inequitable access to healthy food is a major

F or millions of Americans—especially people reviewed journals and primarily conducted by

Without access to healthy foods, a nutritious Findings

restaurants have significantly higher rates of supported agriculture programs, and

The presence of stores selling

I n hundreds of neighborhoods across the country,

Studies find that residents

Local studies demonstrate similar trends: Disparities in access to healthy

• In Baltimore (see chart above), a healthy Rural food deserts

Availability of Food Stores in Rural Areas by Store Type, 2000

Access to Supermarkets and Consumption of Fruits and Vegetables by Race, 2002

Access to fresh produce and other 3. Access to healthy food is

• The lack of supermarket access

The Economic Impacts of Fresh Food Retailers

Direct Economic Impacts: Indirect Economic Impacts:

The Pennsylvania Fresh Food Financing Initiative has

Implications for Policy

E xisting research provides clear evidence that

What Type of Food Access Will Make a Difference?

B etween May and July 2009, PolicyLink and

study for this review, but note that to date, the

We also noted some systematic differences

Supply: Community Food Assessment. A 27

Erdmann, C., and Bertoni, A. “Neighborhood

serves as a barrier to business development. See 140

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