nutrients

Review
Increasing Access to Healthy Foods through Improving Food
Environment: A Review of Mixed Methods Intervention
Studies with Residents of Low-Income Communities
Dea Ziso, Ock K. Chun and Michael J. Puglisi *

Department of Nutritional Sciences, University of Connecticut, Storrs, CT 06269, USA; [email protected] (D.Z.);
[email protected] (O.K.C.)
* Correspondence: [email protected]; Tel.: +1-860-486-1198

Abstract: Food insecurity is a broad and serious public health issue in the United States, where
many people are reporting lack of access to healthy foods. The reduced availability of healthy,
affordable foods has led to increased consumption of energy-dense and nutrient-poor foods, resulting
in increasing the risk for many chronic diseases such as obesity, cardiovascular diseases, and type
2 diabetes mellitus. Thus, identifying promising approaches to increase access to healthy foods
through improving the food environment is of importance. The purpose of this review article is to
highlight how the food environment affects directly a person’s food choices, and how to increase
access to healthy foods through improving environmental approaches. The literature search was
focused on finding different approaches to improve food security, primarily those with an impact
on food environment. Overall, potential solutions were gathered through multilevel environmental
approaches, including nutrition education and peer education, community-based participatory
research, and policy changes in supplemental nutrition programs. A recommendation to reduce food
Citation: Ziso, D.; Chun, O.K.; insecurity is learning to create meals with a variety of seasonal fruits and vegetables purchased from
Puglisi, M.J. Increasing Access to affordable farmers’ markets.
Healthy Foods through Improving
Food Environment: A Review of Keywords: food insecurity; chronic disease; multilevel approaches; low-income; food environment
Mixed Methods Intervention Studies
with Residents of Low-Income
Communities. Nutrients 2022, 14,
2278. https://doi.org/10.3390/ 1. Introduction
nu14112278
Food insecurity comprises limited or uncertain access to nutritious and adequate
Academic Editor: Rosa Casas food intake and is widespread in the United States [1]. The United States Department of
Agriculture (USDA) reported that 10.5% of Americans were food insecure at least some
Received: 21 April 2022
of the time during 2019 [2]. Many individuals who are food insecure utilize food banks
Accepted: 27 May 2022
Published: 29 May 2022
and food pantries to procure food, but studies have shown that pantry users consume
limited amounts of fruits, vegetables, and fiber [3]. The majority of the calories for this
Publisher’s Note: MDPI stays neutral population are taken from energy-dense, nutrient-poor foods, including refined grains and
with regard to jurisdictional claims in foods high in added sugars and saturated fats, in contrast with the food-secure population,
published maps and institutional affil-
who have access to more nutrient-dense and healthier options [4]. This can result in the
iations.
consumption of empty calories, rather than insufficient calories [4]. In general, food-secure
individuals are more likely to meet the recommended dietary allowance for nutrients than
food-insecure individuals [5]. This is displayed in a study by Champagne et al. [5], in which
Copyright: © 2022 by the authors.
researchers determined the food security status through self-reported food intake, and
Licensee MDPI, Basel, Switzerland.
found that food insecurity is associated with lower-quality diets assessed by the healthy
This article is an open access article eating index (HEI) scores.
distributed under the terms and A few factors that affect poor diet quality are related to lack of access to healthy
conditions of the Creative Commons foods in the surrounding neighborhood and limited household income [3,6]. The macro-
Attribution (CC BY) license (https:// environmental sector refers to broad infrastructure (including food advertising and health
creativecommons.org/licenses/by/ systems), whereas micro-environments indicate local settings (such as workplaces and
4.0/).

Nutrients 2022, 14, 2278. https://doi.org/10.3390/nu14112278 https://www.mdpi.com/journal/nutrients

Nutrients 2022, 14, 2278 2 of 13

homes) [7]. Through improving these food environments, access to healthy food op-
tions can be increased, resulting in better diet quality and reduced chronic disease risk in
these populations. Therefore, developing effective strategies to improve the diet quality
and nutritional status of high-risk populations is important for the prevention of diet-
related chronic disease. This review paper will evaluate specific risks for chronic disease
associated with food insecurity and strategies to improve the food environment and in-
dividuals’ choices towards a healthier diet and lifestyle. The objectives will be reached
through assessing the literature on mixed-method intervention studies with residents of
low-income communities.

2. Materials and Methods

To learn more about food insecurity and the risk of chronic disease, as well as ap-
proaches to improve food access, a literature search was conducted in June 2021 using
the databases PubMed, Scopus, and Google Scholar, with a combination of keywords
“food insecurity”, “chronic disease”, “food access”, “multilevel approaches”, “low-income”,
“healthy eating”, “community”, and “policy changes”. Reading through each study, the
titles and abstracts were observed to identify which articles provided informative data that
helped towards reducing food insecurity. As summarized in Table 1, full-length articles and
book chapters in English with the US population in focus for all age ranges were selected.
There were no limits to the state or region in the US in which the studies were conducted.
The study designs conducted were randomized controlled trials, clinical trials, comparative
studies, multicenter studies, and cohort studies. Notes, comments, editorials, and review
articles were excluded from the articles with an exception of two review articles that were
complementary to the data from other major studies. Studies that had other populations
in focus, including low-income communities outside of the US, were excluded. Addition-
ally, there were studies selected from the reference lists of relevant articles. Studies that
compared the lifestyle and diet of food-secure populations vs. food-insecure populations
were included, with a specific focus on the impact of the food environment. As different
approaches to improve food security were searched for this narrative review, there was a
focus on nutrition and peer education, community-based research, policy changes, and
multilevel approaches.

Table 1. Criteria for studies included.

Parameter Criteria Exclusion

Food insecurity, chronic disease, multilevel
Search terms included N/A
approaches, low-income, food environment.
RCT, clinical trials, comparative studies,
Review articles, notes,
Criteria for study design multicenter studies, cohort studies, qualitative
comments, editorials.
studies, books.
Other populations, low-income
Criteria for subject population Low-income populations, all age ranges.
population not living in US.
Improved dietary behavior, weight status,
Criteria for outcomes improved lifestyle, educating the community N/A
on healthier choices when on a budget.

3. Food Insecurity and Risk for Diet-Related Chronic Disease

3.1. Obesity
At the individual level, rates of obesity are higher among groups with low education
and low incomes [8,9]. Current meta-analysis studies show that food insecurity increases
the risk for obesity for adults (odds ratio 1.15) in food-insecure households, especially
women odds ratio of 1.26) [10]. Paeratakul et al. [9] assessed data from the USDA Agricul-
tural Research Service Continuing Survey of Food Intakes by Individuals, and reported
that, among other factors, socioeconomic condition is one of the main factors leading
Nutrients 2022, 14, 2278 3 of 13

to greater obesity severity. The study further linked obesity rates with an increased in-
cidence of diabetes, hypertension, and high serum cholesterol, which further supports
the role of socioeconomic factors in increasing these disease risks through an increase
in obesity [9]. Individuals with food insecurity commonly use resources, such as food
pantries, for access to a variety of products. An important issue that has been shown to
lead to obesity among low-income populations is the poor nutritional quality of food and
lack of knowledge of how to prepare certain fresh produce provided by the food pantries
and other food assistance programs [5,11]. A great focus has been towards children in
low-income populations and their greater risk of obesity due to their diet patterns and
food choices [12]. Kaur et al. [12] analyzed the National Health and Nutrition Examination
Survey (NHANES) data assessing personal food insecurity through USDA’s Food Security
Survey Module to determine its relationship with obesity risk. The researchers determined
that obesity was significantly associated with levels of food insecurity among children of
ages 6 to 11 years, with an odds ratio of 1.81; 95% confidence interval (CI) 1.33 to 2.48 [12].
Food pantries are good resources from which to analyze the needs of food-insecure
populations and determine obesity rates. Studies of food pantry participants concluded
that the mean body mass index (BMI) of the pantry users was 29.5 kg/m2 , and 78.0% of the
population of obese pantry users were women [3,5,11,13]. Many people from the population
have shown an interest in regularly consuming nutritious food and fresh produce, but they
reported that these products were unaffordable [14,15].

3.2. Cardiovascular Diseases

According to the American Heart Association, the seven cardiovascular health metrics
are based on smoking, diet, physical activity, BMI, blood pressure, total cholesterol, and
fasting glucose [16]. Individuals with food insecurity face barriers meeting the ideal cardio-
vascular health metrics, including lower odds of meeting at least three metrics (p < 0.01) [17].
Data further show a greater presence of hypertension and heart disease in individuals
with lower education and income compared to others [9]. Furthermore, hypertension is
associated with greater intake of added sugar and sugar-sweetened beverages (p < 0.05) [18].
Adults from food-insecure households had a 21% higher risk of clinical hypertension than
adults from food-secure households [19]. A systemic review and meta-analysis of 36 stud-
ies indicated an association between food-insecure adults and self-reported hypertension
with an odds ratio of 1.13 [20]. Additionally, very low food security was associated with
increased risk for cardiovascular disease, and a 58% higher risk for cardiovascular disease
mortality [21–23]. Sun et al. focused on associations of adult food insecurity with all-cause
and cardiovascular disease mortality in US adults [23]. This study concluded that partici-
pants with very low food security had a higher risk of cardiovascular disease compared
with those with high food security, with an odds ratio of 1.54 (95% CI 1.04–2.26) [23].
Bazzano et al. [24] conducted the first NHANES Follow-up Study to observe fruit and
vegetable intake through a food-frequency questionnaire, and the incidence of mortality
from cardiovascular disease from medical records and death certificates. A significant
association was identified between frequency of fruit and vegetable intake and incidence
of and mortality from stroke, ischemic heart disease, and cardiovascular disease [24].
Bazzano et al. [24] further concluded that consuming three or more fruits and vegetables
per day, compared to less than one per day, was associated with a 27% lower stroke
incidence, a 42% lower stroke mortality, a 24% lower ischemic heart disease mortality, a
27% lower cardiovascular disease mortality, and a 15% lower all-cause mortality. Due
to the high cost of fruits and vegetables, lack of transportation, low quality products in
low-income areas, and other factors, individuals in these neighborhoods consume fewer
servings of fruits and vegetables than the Dietary Guidelines recommendations, leading to
an increased risk for cardiovascular disease [25]. Among nonelderly adults with household
income <200% of the federal poverty level, analysis of NHANES data by Seligman et al. [19]
(a nationally representative survey of the US population) found an association between
food insecurity and clinical evidence of hypertension and diabetes.
Nutrients 2022, 14, 2278 4 of 13

3.3. Diabetes Mellitus

As previously mentioned, poor diet quality includes low nutrient consumption and
high intake of energy dense foods. This lifestyle factor is one of the main factors leading to
diabetes mellitus. Walker et al. [13] conducted a cross-sectional analysis with data from
the NHANES survey 2005–2014 to evaluate levels of food security and its association
to diabetes. The results indicated higher risk for food insecurity, with an odds ratio for
prediabetes of 1.39 (95% CI 1.21–1.59), for undiagnosed diabetes of 1.81 (95% CI 1.37–2.38),
and for diagnosed diabetes of 1.58 (95% CI 1.29–1.93) [13]. The results are supported by a
cross-sectional study; when compared to individuals with food security, participants with
low food security were 1.35 times more likely to have prediabetes (95% CI: 1.17–1.55) [26].
Very-low-food-secure participants, compared with both low-food-secure and food-secure
participants, have been reported to have greater diabetes distress and more frequent and
severe hypoglycemic episodes [27]. Individuals with food insecurity live paycheck by
paycheck or wait for monthly assistance, which can lead to a cycle of restraining dietary
intake during hard times and overeating during food restock [28]. This process can lead
to insulin resistance and diabetes [13,28,29]. In individuals with food security the self-
management to improve diabetes is easier, but a lack of quality food makes diabetes self-
management more difficult, worsening the food-insecure individual’s health condition [27].
A meta-analysis study by Abdurahman et al. further strengthens the hypothesis for an
association between household food insecurity and increased risk of type 2 diabetes, with
an odds ratio value of 1.27 (95% CI 1.11–1.42) [30]. Based on the studies mentioned
previously, it appears that food insecurity is associated with different stages of diabetes
mellitus; however, there are some recent studies that contrast the findings and do not
suggest an association between food insecurity and clinically determined type 2 diabetes or
significant differences in fasting blood glucose and HbA1c [31]. Beltran et al. additionally
stated that food insecurity is a complex issue and it might look different depending on
factors such as social, economic, and geographic consideration [31]. The study explained
that the differences in the findings might be a result of the difference in food insecurity
concepts, where in some cases hunger and chronic starvation are the primary drives of
food insecurity [31]. In another study, starvation due to food insecurity was related to
worsening signs of insulin sensitivity in type 2 diabetes [29]. Meanwhile, food-insecure
areas in the United States are usually not associated with hunger, but mainly with intake of
lower-quality, high-calorie foods, which increase a person’s risk for type 2 diabetes [31].

4. The Impact of Food Environment on Access to Healthy Food Choices

The nutritional environment is affected not only by the number of stores in an area
but also the availability and cost of healthy food items. Reduced access to fresh produce
greatly impacts food choices for low-income populations [32]. Typically, individuals with
reliable transportation make frequent trips to supermarkets [32,33]. However, many people
in low-income neighborhoods rely greatly on food pantries due to the lack of transportation
and availability of fresh produce in their areas [33]. A research study, conducted in a
low-income neighborhood in Pomona, CA, determined that 41% of the food pantry clients
did not live within walking distance of a store with a variety of fresh produce and 13%
did not have access to any type of food store with fresh produce [33]. This problem is
widespread in many areas in the US and highlights rural adults not being able to meet
recommended nutrition guidelines due to environmental barriers and lack of community
resources [33]. In areas with food insecurity, convenience stores are more common than
supermarkets or grocery stores [32]. These stores have a very limited range of food items
and are more likely to stock less healthy versions of products (for example: low-fiber bread
vs. high-fiber bread, whole milk vs. reduced-fat milk vs. low-fat or nonfat milk) [32].
A multicenter study in Hartford, CT, combined customer shopping behavior with store
food inventory data, and concluded that when there is a greater variety of fresh products,
such as fruits and vegetables, there is an increased likelihood of these products being
purchased [34]. This research study conducted face-to-face interviews on different days
Nutrients 2022, 14, 2278 5 of 13

and at different times of the day to measure typical food shopping behaviors and determine
whether shoppers had access to and used the Supplemental Nutrition Assistance Program
(SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children
(WIC) benefits in the store [34]. They also maintained inventories, using a modified version
of the Nutrition Environment Measures Survey in Stores (which included the availability
of fresh/canned fruits and vegetables, and whole grain and reduced-fat dairy products) to
measure availability and quality of healthy food in stores [34]. Due to an increased variety
of fruits and vegetables offered, those receiving SNAP were significantly more likely to
purchase fruit (p < 0.05) and vegetables (p < 0.01), compared with those who were not
receiving SNAP [34].
When it comes to the cost of fresh products, more healthful versions of food items are
typically more expensive than the corresponding less-healthful versions, with the exception
of milk [35]. At the same time, foods with high energy density provide the most calories
at a lower cost, which contributes to people in low-income populations consuming them
over fresh, nutrient-dense products [35]. Alteration of this environment, as with the study
discussed above by Martin et al. [34], may significantly change these consumption habits.

5. Environmental Approaches to Improve Food Security and Nutritional Status:

Multilevel Intervention Studies with Residents of Low-Income Communities
Figure 1 uses the framework of the socioecological model (SEM) concept, as outlined
by the Centers for Disease Control and Prevention [36], to summarize the key multilevel
approaches discussed in this review for improving food security and nutritional status. En-
vironmental approaches and nutrition programs can improve food security more efficiently
if they work in a multilevel interaction approach [36]. This interaction starts from working
personally with the individual, to creating a support system of family, friends, and social
networks [36]. Other more significant factors that can assist this population are resources
provided through schools or workplaces, communities (considering cultural values and
norms), and policy changes from local laws to national changes [36]. Multilevel approaches
have been used to increase the fruit and vegetable intake in low-income housing communi-
ties. Table 2 summarizes the key approaches that have led to improvements in food security.
A 12-month cluster, randomized controlled trial (RCT) was conducted to demonstrate the
benefit of year-round fruit and vegetable markets at improving fruit and vegetable (F&V)
intake for low-income adults [37]. This research study featured discount fresh fruit and
vegetable markets called ‘Fresh to You’ (FTY), as well as a multicomponent, educational
intervention, which was a combination of individual, community, and policy change ap-
proaches [37]. The prices of the fruits and vegetables were kept at or below the retail prices
at local supermarkets [37]. This study also included chef-run cooking demonstrations,
taste-testing events, shared recipes, and educational boxes (including newsletters, DVDs,
reusable shopping bags, and kitchenware) and two six-week educational/motivational
campaigns, which focused on increasing intake and variety of fruits and vegetables [37].
The results indicated that more than half of the participants attended a few of the FTY
markets [37]. From baseline to 12 months, there was an increase in total fruit and vegetable
intake by 0.44 cup/day (as assessed by the National Cancer Institute’s ‘Eating at America’s
Table All Day Screener’) in the intervention group with the control group decreasing intake
by 0.08 cup/day [37]. There was also an increase in the frequency of fruits and vegetables
by 0.24 servings per day, which was assessed through the Fruit and Vegetable Habits Ques-
tionnaire Score [37]. Reading newsletters or attending campaign events was not associated
with any change in fruit and vegetable consumption, but watching DVDs was associated
with an increase in fruit and vegetable intake by 0.69 cup/day [37].
Nutrients 2022, 14, x FOR PEER REVIEW 8 of 14

Nutrients 2022, 14, 2278 6 of 13

Figure1.1.Multilevel
Figure Multilevelapproaches
approaches to
toincrease
increasehealthy
healthyfood
foodconsumption
consumption in
in low-income
low-income populations,
populations,
basedon
based onthe
theSEM
SEM[36].
[36].

5.1. Individual Nutrition

Adding culturally Education
competent and to
aspects Peer Educationapproach, with resources focused
a community
on multiethnic communities, materials provided
The main factors that have been shown to increase in the population’s native language,
fruit and vegetable consumption and
incorporation of recipes and food demonstrations from their country
in multilevel approaches are taste tests and nutrition education, including providing of origin, may result
in improvements
healthy recipes for in diet quality [38].
participants [37].Hammons
Along with et al. [38] added
healthy recipes,these cultural
some studies aspects
have
and reported greater interest for the individuals to try recipes
focused on helping improve participants’ cooking skills to make low-cost meals, which provided with fruits and
vegetables and an overall
further decreased food increase
insecurity, in daily servings ofcooking
by increasing fruits and at vegetables
home andconsumed
reducing[38]. the
The results are supported by another study that reported an increase
amount of time people ate out at restaurants, leading to increased total variety of in variety of fruits and
vegetables
vegetables (pand < 0.01 forin
fruits both), after[34,37,39,40].
the diet a six-week cooking program atnutrition
Even short-term the Community
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Bank that teaches food pantry clients plant-based recipes [39].
made people more aware concerning sodium in processed foods and nutrient and calorie- These data further indicated
adense
decrease
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the importance of physical beverages
activity,and anddesserts with nutrition
interpreting p < 0.01
a value oflevels [39].
[43].
B’more
WIC focuses on improving the health and nutritional status of pregnant that
Healthy Communities for Kids was a multilevel obesity prevention study and
sought to improve healthier food purchasing and help reduce
postpartum low-income women and children up to the age of 5 years. The participants of sweet-snack consumption
among low-income African-American youths [40]. This group worked to achieve the
these programs are faced with many barriers when shopping for the correct foods on their
objectives for two-year time period, through youth-led nutrition education in recreation
WIC food list, therefore nutrition education is a great tool to better assist this population
centers, in-store promotion, and social media programs [40]. In this multilevel approach,
[44]. Through mobile phone apps, there are educational tools to help the participants with
many areas for education were considered, including promoting healthier alternatives to
shopping management features, clinic appointments, and informational resources [44].
beverages and snacks, and sharing information for healthier cooking methods through
Shopping management features assisted the WIC participants with real-time shopping for
promoting healthier cooking ingredients, such as low-fat milk, 100% whole wheat bread,
WIC foods in the grocery store, including food benefit balance checking, barcode
and fresh/canned/frozen vegetables [40]. The multiple components involved wholesales,
scanning, and checking if the item was WIC eligible [44]. The participants shared that this
which were encouraged to stock B’more Healthy Communities for Kids-promoted healthier
app was very easy to use and convenient in helping pick the right products, while saving
food alternatives [40]. They also worked on improving supply for healthier options of foods
time [44]. Some applications also allowed participants to manage their WIC clinic visits,
and beverages in corner stores and carryout restaurants, as well as improving demand
and view their future appointments and the documents needed to be provided in the
through taste tests for healthier alternatives [40]. Posters, handouts, and educational
appointments
sessions [44]. Required
were provided. nutrition
Through theseeducation modules
sessions there were were also features,
peer-led, hands-on which could
activities
be completed from home instead of going to the clinic [44]. Throughout
where participants learned different sugar and fat contents in drinks and snacks and were a 7 month period,
Weber et al.
introduced to[44] reviewed
the traffic lightthe main features
labeling method for of abeverages
publicly available
and snacks mobile phone
[40]. For app for
additional
WIC participants and concluded that, even though all the features
resources, recipes, news, and educational activities related to healthier eating behaviors were beneficial and
useful,
were sent thethrough
most frequently
social media usedand were the [40].
texting shopping management
The text features.was
message platform Some users
focused
shared their feedback, giving the app 4–5 stars out of 5
towards caregivers with goal setting strategies and educational activities, where theystars for being time saving,
convenient,
received and an
messages overall
three great
to five times app [44]. Other
a week relatedusers would eating
to healthier have liked in addition
behavior [40]. a
nutrition/healthy section with recipes and ideas to help people
B’more Healthy Communities for Kids also worked with key city stakeholders to learn to consume healthier
choices,policies
support not justforthea WIC-approved foods [44]. and provided evidence-based information
healthier food environment
Another
to support theapproach
development to increase diet at
of policies quality forlevel
the city low-income
using a populations is individual
Geographic Information
tailoring of nutrition
System/System Science education
simulation [18]. A recent
model pilot
to help 8 week study
stakeholder assessed the effectiveness
decision-making in regard to
sugar-sweetened beverage warning labels, urban farm tax credits, mobile meals,users
and acceptability of personalized nutrition intervention for mobile food pantry [45].
etc. [40].
When comparing the treatment group with the control group,
The results showed that the overall intervention group purchased 1.4 more healthier foods a personalized nutrition
and beverages per week in relation to the comparison youth. Additionally, there was
Nutrients 2022, 14, 2278 7 of 13

a decrease in calorie intake from sweet snacks and desserts among older intervention
youths [40]. This finding was supported by other results in improving the availability of
healthier foods and beverages in small food stores in intervention zones, indicating that
food availability affects an individual’s choice [40]. Overweight and obesity are major
issues, especially in low-income communities, but community-enhanced school programs
can be effective in reducing childhood obesity in these populations [41]. Schools with
health program training and community partnerships decreased the percentage of students
classified as overweight/obese by 8.3%, compared to a 1.3% decrease in schools that were
provided only with health program training, without the community aspect [41].
In the case of emergency food aid, there are also food banks open and available
around the US. Wetherill et al. [42] conducted a study to look a strategies and innovative
programs that are focused on advancing nutrition-focused food banking in the United
States. This study included in-person or phone interviews to obtain further information
regarding personal experiences, perceptions, and practices related to nutrition-focused
food banking [42]. Overall, the study findings indicated that food banks are implementing
a variety of multi-level approaches to improve healthy food access among users [42]. This
is done through four major themes: building a healthier food inventory at the food bank;
enhancing partner agency healthy food access, storage, and distribution capacity; nutrition
education outreach; and expanding community partnerships and intervention settings for
healthy food distribution, including healthcare and schools [42].

5.1. Individual Nutrition Education and Peer Education

The main factors that have been shown to increase fruit and vegetable consumption in
multilevel approaches are taste tests and nutrition education, including providing healthy
recipes for participants [37]. Along with healthy recipes, some studies have focused
on helping improve participants’ cooking skills to make low-cost meals, which further
decreased food insecurity, by increasing cooking at home and reducing the amount of
time people ate out at restaurants, leading to increased total variety of vegetables and
fruits in the diet [34,37,39,40]. Even short-term nutrition education has made people more
aware concerning sodium in processed foods and nutrient and calorie-dense foods, the
importance of physical activity, and interpreting nutrition levels [43].
WIC focuses on improving the health and nutritional status of pregnant and postpar-
tum low-income women and children up to the age of 5 years. The participants of these
programs are faced with many barriers when shopping for the correct foods on their WIC
food list, therefore nutrition education is a great tool to better assist this population [44].
Through mobile phone apps, there are educational tools to help the participants with
shopping management features, clinic appointments, and informational resources [44].
Shopping management features assisted the WIC participants with real-time shopping
for WIC foods in the grocery store, including food benefit balance checking, barcode scan-
ning, and checking if the item was WIC eligible [44]. The participants shared that this
app was very easy to use and convenient in helping pick the right products, while saving
time [44]. Some applications also allowed participants to manage their WIC clinic visits,
and view their future appointments and the documents needed to be provided in the
appointments [44]. Required nutrition education modules were also features, which could
be completed from home instead of going to the clinic [44]. Throughout a 7 month period,
Weber et al. [44] reviewed the main features of a publicly available mobile phone app for
WIC participants and concluded that, even though all the features were beneficial and use-
ful, the most frequently used were the shopping management features. Some users shared
their feedback, giving the app 4–5 stars out of 5 stars for being time saving, convenient,
and an overall great app [44]. Other users would have liked in addition a nutrition/healthy
section with recipes and ideas to help people learn to consume healthier choices, not just
the WIC-approved foods [44].
Another approach to increase diet quality for low-income populations is individual
tailoring of nutrition education [18]. A recent pilot 8 week study assessed the effectiveness
Nutrients 2022, 14, 2278 8 of 13

and acceptability of personalized nutrition intervention for mobile food pantry users [45].
When comparing the treatment group with the control group, a personalized nutrition
education intervention was effective in improving the diet for food-insecure participants
(4.54% vs. 0.18% improvement in healthy eating index scores) [45]. Culturally tailored
nutrition education involving family time and physical activity has also been a way to
incorporate healthier food choices [46,47]. These approaches also include educational
information in the participant’s native language, including all the handouts, recipes, and
visual guides [47]. Focusing on diet based on culture, studies have also worked with tiendas,
small Latino stores, to promote greater intake of fresh produce among consumers [46].
Education programs culturally tailored to a specific group have also been shown to
be effective. Flores-Luevano et al. [48] conducted a bilingual culturally tailored, hands-
on diabetes education program among Mexican American adults with diabetes. The
sessions were interactive with demonstrations, activities to promote problem-solving, and
facilitated group dynamics through sharing personal experiences [48]. This, intertwined
with peer-education, resulted in improvements in glycated hemoglobin by −1.1% and
total cholesterol with −17.2 mg/dL at 6 months post-intervention [48]. There were also
behavioral changes, such as glucose self-monitoring improvement by 1.3 times increase a
week, increased exercise levels, and increased positive nutritional behavior by 2.23, and the
benefits were observed with attendance rates as low as 50% [48].
Marshall et al. [49] conducted a two-year follow-up study using a one-group pre-
post evaluation design that focused on school-based nutrition education and food co-op
intervention and how it can increase children’s intake of fruits and vegetables. In this study,
407 families completed baseline data, of which 262 parent-dyads agreed to participate in the
two-year follow-up study, where the parents were provided with education along with their
children [49]. This nutrition education included changes in home setting, such as increased
frequency of cooking behaviors, increased usage of nutrition facts labels in making grocery
purchasing decisions, and increased food availability of fruits and vegetables [49]. The
results of the study showed an increase in child intake of fruits by 0.18 cup/day, vegetables
by 0.14 cup/day, and fiber by 1.06 g/1000 kcal, and a significant decrease in total fat intake
by 1.55 g/1000 kcal and percent daily calories from sugary beverages by 0.52% [49]. Parents
also reported an increase in daily intake of vegetables by 0.6 cups/d and combined fruits
and vegetables (p < 0.05) [49].

5.2. Community-Based Participatory Research

Community-based participatory research is a kind of study where community mem-
bers, organizational representatives, and academic researchers are all equally involved in
the process [50]. This research method is important to collect the data on what kind of
lessons and resources will be beneficial for the population, but also to make the partici-
pants more comfortable and more open when conducting interviews with educators of
the community. This approach was used in the selected studies to modify elements in the
environment, which would result in an increase in nutrient-dense food consumption. A
number of studies have focused on improving diet quality and reducing metabolic risk
through gardening and cooking [47,48,51]. These studies organized classes tailored towards
low-income youths and consisted of lessons about gardening, where they used “hands-
on” approaches to facilitate participation in planting, growing, and harvesting organic
fruits and vegetables [47,48,51]. Additional interactive cooking and nutrition lessons were
included with the fruits and vegetables raised from the garden [47,51].
These elements worked to increase fruit and vegetable consumption and preparation
of healthy snacks and meals [47,51]. Creative food preparation with blending of new
vegetables into juices or other dishes has also been a way to introduce unfamiliar foods
to children and other family members [47,51,52]. Participants shared that their children
would be curious of the new items introduced each week and they were excited to include
them in their smoothies [47,51,52].
Nutrients 2022, 14, 2278 9 of 13

As previously mentioned, accessibility and affordability are two of the main factors
that lead to food security. Since supermarkets and convenience stores are known to have
expensive products, a way to provide access to food in low-income families is community-
supported agriculture products. Community-supported agriculture products are more
affordable and flexible in their accessibility [52]. Farm Fresh Foods for Healthy Kids
examined the perception of food access among low-income families in nine communities
participating in community-supported agriculture [52]. Participants reported improved
access to food products and benefited from flexible pick-up times and locations; however,
despite the cost being relatively low, payment remained a barrier for some [52]. A multistate
randomized intervention trial targeted obesity prevention in low-income families through
improving access to affordable, local, seasonal produce through community-supported
agriculture and support of obesity-related behavior changes through tailored education
to increase knowledge and skills, and provide increased revenue and business to support
community-supported agriculture farmers [53]. Even though the community took steps to
help low-income populations, there are still barriers that need to be faced for more effective
results of current and future studies [53]. When shopping through community-supported
agriculture, participants believed that they were saving money for produce of high quality,
compared to the grocery stores [53].
McGuirt et al. [54] examined the influence of farmers’ market pricing and accessibility
on willingness to shop at farmers’ markets, among low-income women. Percentage price
savings were presented visually as discounts at the standard amount, or there were pictures
of the amount of produce a consumer could buy at the farmers’ market compared to the
supermarket, reflecting the savings [54]. The different quantity bought with the same price
was determined by a member of the research group who went to local supermarkets to
establish the price per pound and calculate the amount to compare with the products from
the farmers’ market [54]. The results of this study showed that there was an increased
interest to shop at farmers’ markets when there was at least a 20% price saving [54,55].
Additionally, participants were more influenced by the visual representation of a greater
quantity of produce with the price savings, rather than the money saved by the reduced
price [54].

Table 2. Summary of key studies to increase access to healthy foods.

Target
Author Type of Study Sample Size Type of Approach Outcome Measure Results
Population
Fruit and vegetable
consumption measured -↑ total intake F & V by 0.44
Individual,
Gans. et al. by National Cancer c/day with the control group ↓
RCT Western adults 1587 community, policy
[37] Institute’s “Eating at by 0.08 c/day (p < 0.02).
Changes
America’s Table All -↑ F&V frequency (p = 0.01)
Day Screener”
-↑ healthier purchases by
Obese children Individual, -Purchase and 1.4 more items per week
Trude. et al. (9–15 years old) in interpersonal, consumption of compared to the control group.
RCT 401
[40] 30 areas of organizational, low-sugar foods -There was a 3.5% ↓ in kcal from
Baltimore. community, policy and beverages. sweets for older
intervention youths.
App features were classified
into categories for shopping
Review and -Reviewing app stores
Weber. et al. WIC Organizational and management, WIC required
analysis of 17 app features and their benefits
[44] participants community nutrition education modules
features to users.
and others. The app was rated
with 4–5/5 stars
-Increasing food access Availability was enhanced for
Multicenter based on availability, those who could select their
White et al. randomized Community and accessibility, own produce items.
Children 53
[52] intervention policy affordability, Flexible pick-up times
trial acceptability, and and locations.
accommodation. ↑ access to F&V.
Individual, -Examine willingness to More likely to shop at farmers’
McGuirt et al. Qualitative Women of
37 organizational, shop at market when price saving ↑ at
[54] Study child-bearing age
and policy farmers’ markets. least 20%.
↑ indicates increase, ↓ indicates reduction.
Nutrients 2022, 14, 2278 10 of 13

5.3. Policy Changes in Supplemental Nutrition Programs

To reduce energy-dense, low-nutrient food consumption, there need to be environ-
mental and policy changes that promote healthy eating. The main categories that need
to be in focus, based on research, are pricing, nutrition labeling, and access to healthier
ready-to-go foods [55–57]. Additionally, to increase food security and diet quality, policy
changes are needed in school programs that work on strengthening links to the traditional,
nutrient-dense food system in schools [58]. A significant increase in fruit and vegetable
intake has been shown with greater access to healthier ready-to-go foods [58]. Additionally,
reducing the cost of healthier snacks increases the consumption of these products [57,59].
When prices of fruits and vegetables were reduced by 50% for high school students, their
consumption increased by twofold to fourfold [55]. Low-fat snack sales increased by 93%
with a 50% reduction in their prices [59]. Studies also worked with key city stakeholders to
support policies for a healthier food environment and provided evidence-based information
to support the development of these policies [40].

6. Discussion and Conclusions

Food insecurity is a widespread problem in the US that greatly affects quality of
life, leading to greater risk for obesity, diabetes, and cardiovascular diseases. There are a
number of barriers causing food insecurity in certain areas, such as lack of transportation,
food deserts or food swamps, and lack of nutrition education. This review paper discussed
certain approaches to reduce food insecurity in low-income communities and increase
access to healthful foods, especially consumption of fruits and vegetables. Multilevel
approaches are shown to have the most distinguishable results and also take into considera-
tion a wide spectrum of reasons and factors. Multilevel approaches have included nutrition
educational material, taste-testing events, price reduction of healthy products, increased
access to healthy options, and overall policy changes. The major limitation to multilevel
approaches is that when a change is observed, there is not a way to specifically identify
which components of the intervention led to changes in food behaviors [35]. Other potential
limitations of studies thus far have included small sample sizes and sample populations
that were predominantly women, self-reporting of data, potentially leading to bias, and the
possibility that participants may not have fully represented the low-income population of
interest [38,39,53,55]. Beneficial approaches comprise community-based research, which
obtains an input from the community, where the main focus is on factors that lead to food
insecurity and how to reduce these barriers. Farmers’ markets that provide local, seasonal,
affordable produce are shown to be a way to support behavior changes and increase access
to fresh produce [12]. Nutrition education helps decrease food insecurity from a different
approach, through hands-on activities and peer-education to increase cooking skills and
help incorporate a variety of fruits and vegetables in the diet [17,37,49].
Additionally, current studies have shown a need for more research, but it is important
to point out that perception of an individual’s food environment may impact the foods they
purchase and consume [60]. For example, if they perceive the environment to be poor, they
may be less likely to buy fruits and vegetables and other healthy options [60]. Furthermore,
future research can further focus on how to effectively improve diet quality and reduce diet-
related chronic disease risk by developing and validating multi-dimensional intervention
studies tailored for target populations with special needs and barriers, and studying the
impact of the perceived food environment and social support on improving the diet quality
of a population with poor access to healthy foods.

Author Contributions: Conceptualization, D.Z., O.K.C. and M.J.P.; writing—original draft prepara-
tion, D.Z.; writing—review and editing, D.Z., O.K.C. and M.J.P. All authors have read and agreed to
the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Nutrients 2022, 14, 2278 11 of 13

Informed Consent Statement: Not applicable.

Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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