Improving Access to Healthy Foods: Implications for Fruit and Vegetable Consumption and Dietary Quality Restricted; Files Only

Woodruff, Rebecca (Spring 2018)

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Disparities in access to healthy foods among rural areas and in neighborhoods with predominantly low-income and racial or ethnic minority residents persist in the United States and may be an important contributor to poor dietary quality and high chronic disease prevalence among these populations. However, research investigating the relationship between access to healthy food retailers and dietary intake has been mixed, and questions remain about the effectiveness of interventions to open new retailers of healthy foods, the mechanisms through which access to healthy food retailers influences dietary behavior, and whether food environments can moderate the efficacy of health promotion interventions. This dissertation explored these questions through three studies. Study one was a systematic review examining the dietary impact of openings of new retailers of healthy foods. Findings indicated that the methodological approaches used in this literature, including study designs, sampling approaches, and outcome measures, ranged widely in rigor. Sub-analyses among the studies that used a repeated measures design indicated that opening a new retailer of healthy foods resulted in short-term improvements in fruit and vegetable consumption among adults who chose to shop at the new retailer, but more rigorous research is needed to confirm these findings. Study two explored food acquisition behaviors as mediators of the association between distance to a primary food store and fruit and vegetable intake among a large national sample of adults. Contrary to expectations, greater distance to a primary food store was weakly associated with increased fruit and vegetable consumption, and this relationship was mediated by greater home inventories of fruits and vegetables, but not shopping frequency. Study three explored to what extent three measures of access to healthy food retailers moderated the efficacy of an intervention to improve dietary quality. Results suggested that limited access to healthy food retailers was associated with poorer dietary quality among the control group, but participation in the intervention may have attenuated this relationship. Results from this dissertation help clarify the role that food retail environments play in influencing dietary behavior and highlight the need for future research focused on food acquisition behaviors as determinants of dietary behavior.

Table of Contents

CHAPTER 1. Introduction 2

Improving Dietary Intake as a Chronic Disease Prevention Strategy 2

Socioeconomic Disparities in Dietary Intake 4

Theoretical Frameworks of Food Environments 5

Disparities in Access to Healthy Food Retailers 8

Access to Healthy Food Retailers as a Determinant of Dietary Intake 9

Initiatives to Increase Access to Healthy Food Retailers 12

Research Gaps 13

Dissertation Overview 16

Figures and Tables 18

References 22

CHAPTER 2. The Dietary Impact of Introducing New Retailers of Fruits and Vegetables into a Community: Results from a Systematic Review 34

Abstract 34

Introduction 35

Methods 37

Results 39

Discussion 47

Figures and Tables 52

References 62

CHAPTER 3. Home Food Inventories and Shopping Frequency as Mediators of the Association between Access to Healthy Food Retailers and Fruit and Vegetable Consumption 68

Abstract 68

Introduction 69

Methods 72

Results 77

Discussion 81

Figures and Tables 87

References 93

CHAPTER 4. Does the Food Retail Environment Modify the Efficacy of a Behavioral Intervention to Improve Dietary Quality? 98

Abstract 98

Introduction 99

Methods 101

Results 108

Discussion 111

Figures and Tables 117

References 124

CHAPTER 5. Summary and Conclusions 129

Summary of Key Findings 130

Importance of Food Acquisition Behavior as a Cross-Cutting Theme 133

Strengths & Limitations 135

Implications for Public Health Practice 136

Directions for Future Research 140

Conclusion 144

Figures and Tables 146

References 149

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