The Role of Food Environments and Food Security on Healthy Eating Restricted; Files Only

Abstract

It is widely accepted that disparities in diet are due in part to the inequitable access of

food in the United States. However, evidence on associations between food environments and

diet is inconclusive, potentially due to the lack of specification of pathways that connect food

environments to diet and the limited attention paid to the impact of food insecurity. To better

understand potential leverage points to creating a more equitable food system, this dissertation

explored pathways between food environments and diet through three aims.

This research used a Nutrition Equity Framework and a well-known conceptual model,

the Model of Community Nutrition Environments, to investigate the following aims. The first

aim qualitatively compared differences in food environment-related experiences, challenges, and

strategies of 31 low-income adults by food security status using constructs from the Model of

Community Nutrition Environments. The second aim used baseline data from a home

environment-based intervention to assess overall model fit and direct effects of variables in the

Model of Community Nutrition Environments on 510 low-income adults’ fruit and vegetable

intakes by food security status. The third aim interrogated 49 food industry insiders’ views and

biases of customers and the influence of such views on in-store marketing decisions impacting

the healthfulness of the retail food environment.

We found both qualitative and quantitative variation in the Model of Community

Nutrition Environments for food secure versus food insecure low-income adults. For instance,

food insecure adults expressed unique challenges with transportation to grocery stores and food

affordability. Similarly, food environment-related variables explained less variation in fruit and

vegetable intakes of food insecure relative to food secure adults. We also found that food

industry insiders’ favorable and unfavorable views of customers do indeed influence in-store

marketing decisions, including the availability and affordability of healthy foods.

These results contribute to research on the impact of food environments on diet and

underscore the importance of food insecurity in such research. Further, there is clear need to

address both economic and structural drivers of food access to improve disparities in food

environments.

Table of Contents

Chapter 1: Introduction…………………………………………………………………………... 1

Introduction………………………………………………………………………………. 2

Literature review…………………………………………………………………….…… 4

References………………………………………………………………………………. 58

Chapter 2: A Qualitative Analysis of a Multilevel Food Environment Conceptual Model Among

Food Secure and Food Insecure Low-Income Adults…………………………………….……... 81

Abstract…………………………………………………………………………………. 82

Introduction………………………………………………………………………………84

Methods…………………………………………………………………………………. 86

Results…………………………………………………………………………………... 91

Discussion………………………………………………………………………………101

Future Directions……………………………………………………………….…....… 104

References………………………………………………………………………………109

Chapter 3: A Two-Group Path Analysis of a Multilevel Food Environment Conceptual Model by

Food Security Status: Home Food Environment Variables Predicted HEI-2015 Component Scores

for Total Vegetables Among Those with Food Security………………………………………. 112

Abstract…………………………………………………………………………………113

Introduction……………………………………………………………………………. 115

Methods………………………………………………………………………………....117

Results…………………………………………………………………………………. 123

Discussion………………………………………………………………………………124

Future Directions……………………………………………………………………….128

References………………………………………………………………………………137

Chapter 4: Making Money in Small Food Retail: A Tale of Two Customer Profiles….….…….141

Abstract…………………………………………………………………………………142

Introduction……………………………………………………………………………. 144

Methods…………………………………………………………………………………145

Results…………………………………………………………………………………. 149

Discussion………………………………………………………………………………161

References………………………………………………………………………………168

Chapter 5: Overall Discussion and Conclusions………………………………………………. 172

Summary of findings……………………………………………………………………173

Discussion………………………………………………………………………………174

Strengths…………………………………………….….….….……………………...... 179

Limitations………………………………………………………………………....….. 180

Implications for research and practice…………………………………………………. 182

References………………………………………………………………………………184

Appendices……………………………………………………………………………………...188

About this Dissertation

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School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health Health Sciences, Nutrition
Stichwort	Food Environments Food Security Public Health Nutrition Healthy Eating
Committee Chair / Thesis Advisor	Michelle Kegler, Emory University Megan Winkler, Emory University
Committee Members	Terry Hartman, Emory University Regine Haardoerfer, Emory University Alexandra Morshed, Emory University

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