The Local Food Environment and Diet. A Systematic Review

Health & Place 18 (2012) 1172–1187
Contents lists available at SciVerse ScienceDirect
Health & Place

journal homepage: www.elsevier.com/locate/healthplace
Review Essay
The local food environment and diet: A systematic review

Caitlin E. Caspi a,b,n, Glorian Sorensen a,b, S.V. Subramanian a, Ichiro Kawachi a
a
Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02114, USA
b
Center for Community-Based Research, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA
a r t i c l e i n f o a b s t r a c t
Article history: Despite growing attention to the problem of obesogenic environments, there has not been a
Received 14 March 2012 comprehensive review evaluating the food environment–diet relationship. This study aims to evaluate
Received in revised form this relationship in the current literature, focusing specifically on the method of exposure assessment
17 May 2012
(GIS, survey, or store audit). This study also explores 5 dimensions of ‘‘food access’’ (availability,
Accepted 21 May 2012
accessibility, affordability, accommodation, acceptability) using a conceptual definition proposed by
Available online 31 May 2012
Penchansky and Thomas (1981). Articles were retrieved through a systematic keyword search in Web
Keywords: of Science and supplemented by the reference lists of included studies. Thirty-eight studies were
Food environment reviewed and categorized by the exposure assessment method and the conceptual dimensions of access
Diet
it captured. GIS-based measures were the most common measures, but were less consistently
Measurement
associated with diet than other measures. Few studies examined dimensions of affordability,
GIS
Survey accommodation, and acceptability. Because GIS-based measures on their own may not capture
Neighborhood important non-geographic dimensions of access, a set of recommendations for future researchers is
outlined.
& 2012 Elsevier Ltd. All rights reserved.
1. Introduction through which ‘‘obesogenic’’ settings operate – namely, the food

environment–diet relationship.
The body of literature on the local food environment and its Studies exploring the food environment–diet relationship have
effects on health has been growing, particularly in response to used a wide variety of methodologies to measure the degree of
evidence of ‘‘food deserts’’ pocketing the US urban landscape food access for study participants. In the past two decades, the
(Michimi and Wimberly, 2010; Zenk et al., 2005). Yet, to date, increased use of Geographic Information Systems (GIS) technol-
there has not been a comprehensive review of the relationship ogy has resulted in an outpouring of exposure assessment
between the local food environment and dietary outcomes. techniques (McKinnon et al., 2009). These measures commonly
Previous food environment review articles have generally fallen use store density (using buffer distances), or proximity to the
into two categories. First, review articles have focused their nearest food store to operationalize food access (Charreire et al.,
discussion on disparities in access to healthy foods, including 2010), although finding appropriate and consistent criteria for
the existence of food deserts and neighborhood characteristics defining geographic boundaries has proved challenging (Charreire
associated with food deserts (Larson et al., 2009; Walker et al., et al., 2010). Another common objective method for assessing
2010). Other articles exploring the effects of food deserts have food access is store audits, in which researchers visit stores and
touched upon diet while focusing primarily on obesity as an estimate the shelf-space occupied by certain foods in each store,
outcome (Black and Macinko, 2008; Casagrande et al., 2009; Ford or assess product variety or food prices within stores. Validated
and Dzewaltowski, 2008; Holsten, 2009; Lovasi et al., 2009). For store audit measures, such as the Nutrition Environment Measure
the most part, these reviews present comprehensive and theore- Survey (NEMS), have often been used to evaluate such store
tically sound discussions of the environmental determinants features (Glanz et al., 2007), although such measures have been
of obesity. Yet there has been relatively little discussion specifi- used infrequently in studies linking food environments to health
cally devoted to what is conceivably the primary mechanism outcomes.
Still others studies have relied on respondent-based perceived
measures to capture the food environment, including perceived
n
availability and accessibility of food or food stores. Though
Corresponding author at: Department of Society, Human Development and
Health, Kresge 7th Floor, Harvard School of Public Health, 677 Huntington Avenue,
uncommon, a few studies have used both a perceived and an
Boston, MA 02114, USA. Tel.: þ 1 203 215 9645; fax: þ1 617 432 3123. objective measure in their study – for example, the availability of
E-mail address: caitlincaspi@gmail.com (C.E. Caspi). healthy food in the neighborhood and store density. In general,
1353-8292/$ - see front matter & 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthplace.2012.05.006
C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187 1173
the proportion of studies using perceived measures of the food or the number of places to buy produce. The dimension of
environment is small compared with those that use GIS-based accessibility may be more inherently geographic, as it refers to
methods; by 2007, GIS-based measures of the food environment the location of the food supply and ease of getting to that location.
outnumbered interview/questionnaire measures 57 to 10 Travel time and distance are key measures of accessibility.
(McKinnon et al., 2009), and the use of GIS measures is only Affordability refers to food prices and people’s perceptions of
likely to increase if current trends continue (Charreire et al., worth relative to the cost, and is often measured by store audits
2010). Undoubtedly, because of extensive variation in the oper- of specific foods, or regional price indices. Acceptability refers to
ationalization of the local food environment, many measurement people’s attitudes about attributes of their local food environ-
challenges remain unaddressed (Lytle, 2009) (Fig. 1). ment, and whether or not the given supply of products meets
Despite major measurement inconsistencies, previous review their personal standards. As an attitudinal variable, it may be
articles have yet to examine comprehensively how the food ideally measured by surveying participants; however, there have
environment–diet study results have differed according to the been a few creative attempts to estimate food acceptability by
method of exposure assessment. One previous review article more objective means – for instance, by having store auditors
sorted results by exposure assessment type, but examined only assign food quality scores to produce. Accommodation, or how
the fast food environment (Fraser et al., 2010). A recent set of two well local food sources accept and adapt to local residents’ needs,
reviews sought to overview different indicators of the food is the final dimension of access. It is largely open to exploration in
environment, but one included only GIS-based measures the current literature but could, for example, refer to store hours
(Charreire et al., 2010); the other examined only non-geographic and types of payment accepted.
measures and stopped short of linking the different exposure The primary aim of this paper is to evaluate the existing body
measures to actual dietary outcomes (Kelly et al., 2011). of literature on the relationship between the local food environ-
A theoretical framework for conceptualizing the local food ment and diet, with particular attention placed on the method of
environment: Beyond the strictly methodological task of selecting characterizing of the food environment. The secondary aim of this
the best exposure assessment technique lays a more theoretical study is to explore the variety of conceptual definitions of ‘‘food
question concerning the very definition of food access. Fre- access’’ within this body of literature. The relationship between
quently, food environment conceptualizations have been divided food environments and diet will be diced according to different
into the community food environment and the consumer food quantitative assessments of the food environment, as well as the
environment (Glanz et al., 2005), drawing a useful distinction different dimensions of access that could underlie each measure.
between the distribution of food sources within a community and Finally, this paper will identify understudied dimensions of ‘‘food
what consumers encounter while inside their local retailers. access’’, and make recommendations for future directions for the
Several previous articles have also begun to explore even more optimal study and improvement of food environments.
subtle conceptualizations of the food environment (Charreire
et al., 2010; McKinnon et al., 2009), including the different
dimensions of access that food environment measures have 2. Methods
actually tapped into. Although a complete list of such dimensions
has never been compiled, it has been suggested (Charreire et al., This paper is a review of 38 papers on the food environment
2010) that one way of conceptualizing food access dimensions is and diet. Articles were retrieved through a systematic keyword
by adapting a model of access proposed by Penchansky and search in Web of Science and supplemented via a ‘‘snowball
Thomas, who outlined 5 dimensions relevant in the healthcare method’’ in which references from relevant articles were
setting (Penchansky and Thomas, 1981). These dimensions reviewed and selected if they met inclusion criteria. Keyword
include availability, accessibility, affordability, acceptability, and searches included words pertaining to diet (dietn, fruitn and
accommodation. vegetablen, nutritionn, consumption, intake) and at least one other
The first three are the most obviously familiar in the existing term pertaining to access (accessn, availability, affordability,
body of literature. Availability refers to the adequacy of the supply acceptability, accommodation), environment (neighborhood,
of healthy food; examples in the food environment might include neighbourhood, environment, community, urban, local, dis-
the presence of certain types of restaurants near people’s homes, advantagen), or food source (food desertn, food outletn, food storen,
1. What should we measure? (e.g., access, quality, utilization)

2. What are the different dimensions of “food access”? (e.g., geographic a ccessibility of stores,
selection of produce, affordability)
3. What kind of assessment techniques are appropriate for capturing each dimension of access?
(e.g., store audits, GIS, surveys)
4. What, if anything, do residents’ perceptions of their food environment add to the measurement of
food access?
5. What is the “gold standard” for each access dimension, and how should we establish the validity
of proposed measures? (e.g., convergent validity of GIS-based measures against store audits)
6. How do we integrate both “good” and “bad” features of food retail so that it accurately reflects the
environment of residents? (e.g., neighborhoods that have an abundance of supermarkets as well
as fast food outlets)
7. How might the best measure food environments require adaptation by geographic region? (e.g.,
urban versus rural, U.S. environments versus non-U.S. environments)
8. Which measures of access have been adequately studied and which are most ripe for attention?
9. Which features of the food environment are most important for health? (i.e., how do various
measures of the food environment affect dietary patterns?)
10. What features of the food environment might be most amenable to interventions to improve food
access?
Fig. 1. Unanswered challenges in the measurement of food environments.

1174 C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187
Table 1
Studies examining the relationship between the food environment and diet.
Author (Year) Outcomes Location Cohort/Population
Beydoun et al. (2011) Specific nutrients, incl. fruit and vegetable consumption; Healthy US (nation) CSFII, children
Eating Index (HEI) and Alternate Mediterranean Diet index
(aMED)
Beydoun et al. (2008) Specific nutrients, fruit and vegetable consumption, Healthy US (nation) CSFII, adults
Eating Index (HEI), and fast food consumption
Bodor et al. (2008) Fruit and vegetable consumption New Orleans, LA Adults
Caldwell et al. (2009) Change in fruit and vegetable consumption from baseline to Colorado Youth and adults
follow up
Cheadle et al. (1991) Red meat, low fat milk, and non-white bread consumption; US (CA and HI) CHPGP, adults
calories from fat
Cummins et al. (2005) Fruit and vegetable consumption Greater Glascow Springburn Intervention, adults
Fisher and Strogatz, 1999 Percent of households in zip code that consumed low-fat milk NY state Adults reporting on households
Franco et al. (2009) Diet pattern 1: Fats and Processed Meats (FPM); Diet pattern 2: Baltimore, MD MESA (Baltimore only), adults
Whole Grains and Fruits (WGF)
Gustafson et al. (2011) Fruit and vegetable consumption North Carolina (6 Women, 40–64
counties)
Inglis et al. (2008) Fruit and vegetable consumption; fast food consumption Australia SESAW, low-SEP women
Izumi et al. (2011) Dark green or orange vegetables consumption Detroit, MI HEP, adults
Jago et al. (2007) Fruit and 100% fruit juice consumption; high-fat and low-fat Greater Houston, TX Boy scouts
vegetable consumption
Jeffery et al. (2006) Fast food consumption Minnesota Adults
Jennings et al. (2011) Food group consumption patterns UK SPEEDY, children 9–10
Laraia et al. (2004) Diet Quality Index NC state PIN, adult women
Leung et al. (2010) Total energy San Francisco, CA CYGNET, young girls
Michimi and Wimberly (2010) Fruit and vegetable consumption US (nation) BRFSS, adults
Moore et al. (2008) Alternate Healthy Eating Index (AHEI) and Fats and Processed US (3 sites) MESA Neighborhood study, adults
Meats (FPM)
Moore et al. (2009) Fast food consumption; Alternate Healthy Eating Index (AHEI) US (3 sites) MESA Neighborhood study, adults
and Fats and Processed Meats (FPMs)
Morland et al. (2002) Fruit and vegetable consumption; specific nutrients US (4 sites) ARIC, adults
Murakami et al. (2009) Food intake in one of 5 food groups Japan Japan Dietetic Students Study for
Nutrition and Biomarkers, female
students
Osypuk et al. (2009) Fats and Processed Meat (FPM) consumption US (6 sites) MESA, adults
Paquet et al. (2010) Fast food consumption Montreal, Canada Montreal Neighborhood Survey of
Lifestyle and Health, adults
Pearce et al. (2009) Fruit and vegetable consumption New Zealand (nation) NZHS, adults
Pearce et al. (2008) Fruit and vegetable consumption New Zealand (nation) NZHS, adults
Pearson et al. (2005) Fruit and vegetable consumption UK Adults
Powell and Han (2011) Consumption of specific food groups, including fruits and US (nation) Child Development Supplement of the
vegetables Panel Study of Income Dynamics
Powell et al. (2009) Fruit and vegetable consumption US (nation) NLSY97, young adults
Rose and Richards (2004) Fruit and vegetable consumption US (nation) Food stamp participants (NFSPS)
Sharkey et al. (2010) Fruit and vegetable consumption Brazos Valley, TX BVHA, older adults
Thornton et al. (2010) Fruit and vegetable consumption Australia SESAW, low- SEP women
Thornton et al. (2009) Fast food consumption Australia VicLANES, adults
Timperio et al. (2008) Fruit and vegetable consumption Melbourne, Australia Children 5–6 and 10–12
Turrell and Giskes (2008) Fast food consumption Brisbane, Australia Adults
Williams et al. (2010) Fruit and vegetable consumption Australia SESAW, low-SEP women
Wrigley et al. (2003) Fruit and vegetable consumption UK Leeds food desert study, adults
Zenk et al. (2005) Fruit and vegetable consumption Detroit, MI ESVHWP, adults
Zenk et al. (2009) Fruit and vegetable consumption Detroit, MI HEP, adults
grocery storen, supermarketn, convenience storen, fast food, res- of the same cohort were included if the exposure or outcome
taurantn, takeaway, corner storen). Because this review focuses on reported was different in the two papers. Results report only on
food environments surrounding residences, exclusion search the relationships between the food environment and dietary
terms included schooln and worksiten. The search included arti- outcomes.
cles published through March 2011.
Articles were excluded for formal review if they were non-
empirical, if they did not use a dietary outcome, if they did not 3. Results
report directly on the relationship between the food environment
and diet, or if there were fewer than 100 participants. In total, 38 studies met inclusion criteria and were included in
In total, 380 abstracts were reviewed, of which 22 met the full this review (Table 1). Most studies examined an adult population,
inclusion criteria for this study. In addition, 16 articles cited in but seven (Beydoun et al., 2008, 2011; Caldwell et al., 2009; Jago
reference lists of relevant articles or brought to the attention of et al., 2007; Leung et al., 2010; Powell and Han, 2011; Timperio
the authors in the process of writing the review were included. In et al., 2008) included children or adolescents. Studies overwhel-
cases where there were multiple studies reporting on the same mingly used a cross-sectional design, but three were natural
results, only one paper was included (e.g., Murakami et al. (2009) experiments or interventions that compared pre- and post-test
was selected and another similar article from the subsequent year dietary measures (Caldwell et al., 2009; Cummins et al., 2005;
was excluded (Murakami et al., 2010)), although multiple studies Wrigley et al., 2003).
Overview of exposure assessment methods: The greatest healthier diets, while the construct of shelf-space devoted to
variability in the set of included studies was the method of foods showed an association in only one of two studies which it
exposure assessment. Table 2 sorts these studies by assessment was measured.
technique. More than two-thirds of the studies reviewed relied on
at least some kind of geographic data to measure of exposure 3.2. Accessibility
(n¼ 26). These GIS-based measures captured the geographic
relationship between residents’ homes and an array of food store Measures representing food accessibility demonstrated a
types, including supermarkets, convenience stores, fast food out- remarkably inconsistent relationship with dietary outcomes. Of
lets, and other types of stores. Twelve studies used participant- the 13 studies that examined distance to a food store in relation
reported measures to assess a variety of dimension of food access, to diet, seven revealed null associations. Two of the remaining six
including perceived availability, perceived accessibility of food, studies showed associations in mixed directions. For instance,
perceived food store affordability, and perceived quality and Timperio et al. (2008) found higher vegetable consumption
selection of local foods. These measures of food access were among those who lived a farther from a fast food outlet, but also
commonly single-item indicators, but some studies used short among those who lived farther from a supermarket. One of the
scales which demonstrated moderate to high levels of reliability four studies which showed an association between store distance
(Cronbach’s a range 0.51–0.90) (Moore et al., 2008; Osypuk et al., and fruit and vegetable intake used a particularly sophisticated
2009; Rose and Richards, 2004). Nine studies used a store audit method of assessing distance which included actual produce
measure – including the presence, price, and quality of fresh content at the stores (Sharkey et al., 2010).
produce – to assess the relationship between store content and Survey questions pertaining to store accessibility also showed
diet. Store audit measures were sometimes combined with GIS- no significant relationship with dietary outcomes in 4 of 6 studies;
based methodologies – for example, to assess the number of in one of the remaining studies, store access was operationalized
stores selling certain foods near participants’ homes (Gustafson as a multi-faceted combination of variables, including car access,
et al., 2011). Store audit measures were different in every study where participants shopped, and travel time (Rose and Richards,
and only occasionally (Cheadle et al., 1991; Franco et al., 2009) 2004).
use a measure with reported reliability.
Dimensions of access: Table 2 presents the dimensions of access 3.3. Affordability
captured by each exposure assessment methodology. Most survey
questions related to food access looked at residents’ perceptions Affordability cannot be assessed by GIS-based measures, but
of healthy food availability and store accessibility, although a was measured by three other methodologies: (1) an index of food
handful of studies crossed into the domains of affordability, and prices in the area in which participants lived, (2) participants’
acceptability (including quality and selection of produce). Store perceptions of produce affordability, and (3) store auditors’
audits captured much of the spectrum of access dimensions – accounts of food prices. Lower regional food prices were asso-
particularly affordability – but only one store audit study con- ciated with at least one measure of dietary health in every study
tained any kind of measure of accommodation. GIS-based mea- in which it was measured (n¼ 4), while the perceived produce
sures assessed only constructs related to the availability and affordability measure was inconsistently associated with diet. In
accessibility dimensions. Table 2 also depicts the degree to which one study, participants who reported that fruit cost too much
these different dimensions of access were found to be associated unexpectedly consumed more fruit than those who reported that
with dietary outcomes. it did not cost too much (Inglis et al., 2008). Likewise, food audit
affordability measures were resoundingly not predictive of heal-
3.1. Availability thier diets – in fact, two store audit studies showed that more
expensive produce prices were associated with healthier diets.
Overall, measures which tapped in to the availability dimen-
sion showed fairly consistent positive associations with a healthy 3.4. Acceptability and accommodation
diet. Studies that used measures of perceived food availability
were particularly consistent in showing a relationship with diet- Only a handful of studies examined acceptability and accom-
ary outcomes (6/7 studies). No standardized measure of healthy modation; these studies generally showed a significant relation-
food availability exists; rather, each study measured this con- ship between constructs such as food quality and hours open for
struct according to a unique set of items – for example, agreement local stores and fruit and vegetable consumption.
that ‘‘a large selection of low-fat foods is available in my Overview of dietary outcome assessment methods: Studies
neighborhood’’ (Moore et al., 2008; Osypuk et al., 2009). used a range of assessment techniques (Table 3) to calculate an
Studies that used GIS-based methods to look at store presence array of dietary outcomes, including fruit and vegetable intake,
or store density were mixed. These availability measures were by fast food consumption, diet quality indices, as well as specific
far the most common way to measure the food environment; they foods, food groups, and nutrients. The use of validated semi-
were used in 20 studies, 13 of which showed a significant quantitative Food Frequency Questionnaires (FFQs) was common
association between geographic availability and dietary out- (n ¼11 studies). By and large, FFQs were the method of assess-
comes. Notably, there was a wide range of buffer distances used, ment of choice for those studies using a diet quality index as the
ranging from 100 m (Bodor et al., 2008) to 2 miles (Jeffery et al., outcome. These indices were generally well-established measures
2006). Three studies did not use a buffer distance from residents’ derived either from USDA guidelines (Laraia et al., 2004; Moore
houses, but instead looked at the presence of stores within a et al., 2008, 2009; Morland et al., 2002) or principal components
census tract (Gustafson et al., 2011; Morland et al., 2002) or block analysis (Franco et al., 2009; Moore et al., 2008, 2009; Osypuk
group (Laraia et al., 2004), and several recent national studies et al., 2009) and validated by association with health outcomes
used store density within a defined geographic area per 100,000 (Nettleton et al., 2006).
people as the geographic measure of interest (Michimi and The most common dietary assessment technique was the use
Wimberly, 2010; Powell and Han, 2011; Powell et al., 2009). of custom brief instruments assessing consumption patterns of
The handful of studies that used store audit metrics of product specific foods – either fruit and vegetable intake or fast food
availability and variety generally showed a relationship with (n ¼16 studies). While questions were often worded similarly to
1176
Table 2
Studies assessing the food environment and diet by exposure assessment technique, access dimension, construct, and results.
Exposure assessment Access dimension Construct At least one positive association (p o0.05) Only null associations with dietary Results opposite from expected
with dietary outcome outcome
Survey Availability Perceived healthy food availability Inglis et al. (2008), Moore et al. (2008, Gustafson et al. (2011)
2009), Osypuk et al. (2009), Sharkey et al.
(2010), Williams et al. (2010)
Accessibility Perceived access to healthy food Caldwell et al. (2009)a, Rose and Richards Inglis et al. (2008), Gustafson et al.
(2004) (2011), Pearson et al. (2005),
Williams et al. (2010)
Affordability Cost, affordability Williams et al. (2010), Zenk et al. (2005) Sharkey et al. (2010) Inglis et al. (2008)b
Acceptability Quality, selection Inglis et al. (2008), Sharkey et al. Zenk et al. (2009)
(2010),Zenk et al. (2005)
C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187

Store audit Availability Shelf-space Bodor et al. (2008) Caldwell et al. (2009)a
Product-availability Cheadle et al. (1991), Fisher and Strogatz, Gustafson et al. (2011)
1999,Franco et al. (2009), Thornton et al.
(2010)
Variety Caldwell et al. (2009)a Bodor et al. (2008)
Affordability Price Pearson et al. (2005), Zenk et al. Caldwell et al. (2009)b, Thornton et al.
(2009) (2010)b
a
Acceptability Quality Caldwell et al. (2009) Zenk et al. (2009)
Accommodation Hours open Thornton et al. (2010)
GIS Availability Store presence Gustafson et al. (2011), Jennings et al. Bodor et al. (2008), Williams et al. Leung et al. (2010)b
(2011),Morland et al. (2002), Timperio (2010)
et al. (2008)
Store density Izumi et al. (2011), Moore et al. (2008, Jeffery et al. (2006), Laraia et al.
2009), Murakami et al. (2009), Powell et al. (2004), Paquet et al. (2010),
(2009), Powell and Han (2011), Thornton Thornton et al. (2009), Turrell and
et al. (2010), Timperio et al. (2008), Zenk Giskes (2008), Williams et al.
et al. (2009) (2010)
Variety Thornton et al. (2009)
Accessibility Distance Laraia et al. (2004), Michimi and Wimberly Bodor et al. (2008), Gustafson et al. Jago et al. (2007)n, Timperio et al.
(2010), Sharkey et al. (2010), Thornton (2011), Pearce et al. (2009), Pearson (2008)n
et al. (2010) et al. (2005), Thornton et al. (2009),
Turrell and Giskes (2008), Williams
et al. (2010)
Travel time Pearce et al. (2008)
Other Availability Informant report Moore et al. (2008, 2009)

Opening of a new store Wrigley et al. (2003)a Cummins et al. (2005)a
Affordability Regional food price index Beydoun et al. (2008), Powell et al. (2009), Beydoun et al. (2011)n
Powell and Han (2011)
a
Natural experiment or intervention study.
b
Significant results only in opposite direction from expected.
n
Mixed results (significant results in both directions).
Table 3
Dietary assessment technique by environmental exposure technique.
Survey Store audit GIS Other
Food frequency questionnaire Moore et al. (2008, 2009), Franco et al. (2009), Zenk Izumi et al. (2011), Jago et al. Moore et al. (2008, 2009)
Osypuk et al. (2009), Zenk et al. (2009) (2007), Laraia et al. (2004), Moore
et al. (2009) et al. (2008, 2009), Morland et al.
(2002), Murakami et al. (2009),
Timperio et al. (2008), Zenk et al.
(2009)
24-hour recall Bodor et al. (2008) Bodor et al. (2008), Leung et al. Beydoun et al. (2011),
(2010) Beydoun et al. (2008)
Brief, customized screener (e.g., ‘‘In a Gustafson et al. (2011), Inglis Gustafson et al. (2011), Gustafson et al. (2011), Jeffery Cummins et al. (2005),
typical day, how many servings of et al. (2008), Moore et al. Pearson et al. (2005), et al. (2006), Moore et al. (2009), Moore et al. (2009), Powell
fruit do you consume?’’ or ‘‘How (2009), Pearson et al. (2005), Thornton et al. (2010) Paquet et al. (2010), Pearce et al. and Han (2011), Powell
many times per week do you eat Sharkey et al. (2010), (2009), Pearson et al. (2005), et al. (2009)
meals from fast food Williams et al. (2010) Powell and Han (2011), Powell
restaurants?’’) et al. (2009), Sharkey et al. (2010),
Thornton et al. (2010), Thornton
et al. (2009), Turrell and Giskes
(2008), Williams et al. (2010)
Food diary Jennings et al. (2011), Michimi Wrigley et al. (2003)

and Wimberly (2010)
BRFSS Caldwell et al. (2009), Zenk Caldwell et al. (2009)

et al. (2005)
Other Rose and Richards (2004) Cheadle et al. (1991), Fisher

and Strogatz (1999)
the FFQ, they asked about food groups rather than specific foods. consumed, on average, 86 more grams per day of fruit (approxi-
Examples of this type of assessments included, ‘‘How many times mately half a serving) than those who reported poorer access
in the last 7 days have you eaten meals at fast food restaurant- (Rose and Richards, 2004). Results for GIS-based measures were
s?’’(Inglis et al., 2008) or ‘‘How many servings of fruit do you occasionally statistically significant but not clinically meaningful;
usually eat each day?’’(Thornton et al., 2010). for instance, in one study, a difference of one mile in distance to a
The Behavioral Risk Factor Surveillance System (BRFSS) Ques- supermarket was statistically significant, but only associated with
tionnaire for fruit and vegetable intake was a validated assess- a 0.02 difference in fruit and vegetable servings per day (Sharkey
ment tool used in three studies. This measure was related to other et al., 2010), and in another study, the effect size for distance to
brief instruments, but asks a set of 6 questions related to the the nearest food store on fruit and vegetable consumption was
consumption of certain foods and food groups (fruit juice, other not measurable (b ¼0.00), but still statistically significant (Jago
fruit, green salad, potatoes, carrots, and other vegetables). Other et al., 2007). Most store audit measures – including food prices,
less common methods of dietary assessment were the 24 h recall variety, shelf-space and price – were not found to be associated
(n¼ 4 studies) and food diaries (n¼2 studies). with fruit and vegetable intake, but availability of specific
Table 3 presents the frequency of each dietary assessment produce items and hours open at greengrocers were two notable
method by the type of neighborhood exposure technique. By far exceptions (Thornton et al., 2010).
the most common studies were those that used GIS-based Beyond fruit and vegetable intake, eight studies examined fast
neighborhood assessments to examine diet with a brief instru- food consumption, seven studies used a diet quality index as an
ment or FFQ. There was substantial variability in the outcome outcome, and five looked at either food group consumption
assessment for survey-based studies, as well as those that used patterns (e.g., nonmeat protein) or consumption of specific foods
store audits and food prices. The oldest studies were most likely (e.g., low-fat milk). Four studies used specific nutrients (e.g.,
to use unusual dietary assessment methods – for instance, asking saturated fat) or total energy as an outcome. The vast majority
participants about whether they had a specific food at home of studies within each category of outcomes showed some
(Fisher and Strogatz, 1999). evidence of an association with food environment features.
Results by dietary outcome: Fruit and vegetable intake (n ¼26) Notably, the evidence was the weakest for studies of fast food
was by far the most common outcome measure. In general, consumption, where 4 out of 8 were positive (Table 5).
results from these studies (Tables 4a and 4b) are consistent with Overview of results by country: Twenty-four studies were US-
the trends in the findings described above. Twelve of the 18 based, of which 6 were national studies of the US; the others
studies using GIS measures and five of the eight studies using examined selected US regions. Eight studies were based in
cross-sectional survey measures showed at least one significant Australia or New Zealand, four in the United Kingdom, and 1 each
positive association. While it is difficult to compare the magni- from Canada and Japan. Studies outside the US, Australia and New
tude of effects across studies given the variety of measurement Zealand demonstrated inconsistent evidence of an association
strategies, those studies that used survey measures of the food between the food environment and dietary behavior. The Cana-
environment consistently reported small but meaningful differ- dian and Japanese study showed null results, whereas in the UK
ences in fruit and vegetable consumption. For example, one study results were mixed. Both of the natural experiments which
showed that those who reported shopping at a supermarket explored the effects of opening a new supermarket were conducted
consumed, on average, 1.22 more servings per day of fruits and in the UK (Table 4b). One natural experiment study showed no
vegetables then those who did not, and in another study (Zenk change in fruit and vegetable consumption between the interven-
et al., 2005), those who reported easy supermarket access tion an control group (Cummins et al., 2005), and in the other, fruit
Table 4a
Cross-sectional studies using fruit and vegetable intake as an outcome.
Author (Year) n Specific exposure reported Outcome Key findings
GIS measure Perceived measure Store audit or other

measure
Beydoun et al. 7331 Price index: Fast food price fruit grams per day No statistically
(2008) index (FFPI); fruit and (g/d), vegetable (g/d) significant
vegetable price index (FVPI) relationship with
price index
measures
Beydoun et al. 6759 children; Price index: Fast food price fruit and FVPI for children:
(2010) 1679 adolescents index (FFPI); fruit and vegetables (g/d) b 40, po 0.05
vegetable price index (FVPI) Other price index
relationships not
statistically
significant
Bodor et al. 102 GIS: Distance (km) to nearest fruit servings per No statistically Fresh vegetable
(2007) small food store and day (s/d), significant shelf space: b 4 0,
supermarket; presence of vegetable (s/d) relationships with GIS p ¼ 0.025
small food store (within 100m) measure Other store audit
or supermarket (within measure
1000m) of residence; Store relationships not
audit: shelf space and variety of statistically
fruit/vegetables significant
Gustafson et al. 186 GIS: Presence of food stores fruit and Presence of a No statistically significant No statistically
(2011) within census tract, access vegetable (s/d) supercentre and perceived access measures significant store
(distance o 5 miles) from convenience store audit measures
home; Participant report: Foods (combo): b o 0, p ¼
store access o5 miles or 410 0.04
min), neighborhood and store Other relationships
availablity of heealthy foods; with GIS measures
Store audit: Food srore not statistically
availability of healthy foods significant
Inglis et al. 1328 for Participant report: Perceived High fruit High quality fresh
(2008) fruits; 1376 availability, perceived consumption (at produce available:
for accessibility, and perceived least 2 s/d) versus Fruit: OR¼ 1.40 (1.08
vegetables affordability (tested as low; high vegetable to 1.83)
mediators) consumption (at Veg: OR¼ 1.65 (1.24
least 3 s/d) versus to 2.19)
low Plenty of healthy
options to eat out:
Fruit: OR¼1.37
(1.06 to 1.76)
Veg: OR¼ 1.34 (1.05
to 1.71)
Other relationships with
perceived measures not
statistically significant
Izumi et al. 919 GIS: Number of stores within Consumption of dark No store carrying at
(2011) 800m of census block centroid green or orange least 5 varieties of
with 5 or more dark green or vegetables (s/d) vegetables,
orange vegetables (compared to
2 stores): b o 0,
p ¼0.047
One store
(compared to 2) not
statistically
significant
Jennings et al. 1669 GIS:Presence of BMI-healthy % difference in intake No statistically
(2011) and BMI-unhealthy stores with of fruit and significant
800 m of participants’ vegetables (g/d) relationship with GIS
residences measures
Jago et al. 210 GIS: Distance to nearest food Fruit and juice, high- Distance to small
(2007) store fat vegetable, low-fat food store:
vegetable Fruit and juice:
b 4 0, p¼ 0.008
High-fat veg:
b 4 0 , p o0.001
Distance to fast
food outlet:
High-fat veg:
b o 0, p o 0.001
Other relationhips
with GIS measures
not statistically
significant
Table 4a (continued )
Michimi et al. 568,584; 267,697 GIS: Distance to supermarket Fruit and vegetables, Distance to
(2010) 4 ¼5 and o 5 supermarket in
servings metro area: OR¼ 0.95
(0.92 to 0.99)
Non-metro distance
not statistically
significant
Morland et al. 2392 blacks; GIS: Presence of a supermarket, Fruit and vegetables, Presence of
(2002) 8231 whites grocery store, full service or fast consuming at least supermarket among
food restaurant within the 2 s/d fruit and 3 s/d blacks: RR ¼ 1.54
census tract of a participant veg (1.11 to 2.12)
Other relationships
with GIS measures
not statistically
significant
Murakami 990 GIS: Quartile categories for Fruit and No statistically

et al. (2009) neighborhood availability of vegetables (g/d) significant
fruit and vegetables within relationships with GIS
0.5 mile radius of residences measure
Pearce et al. 12,529 GIS: Street network distance to Fruit, at least 2 s/d, No statistically
(2009) fast food outlets (multi-national and vegetables, at significant
and locally operated) from least 3 s/d relationships with GIS
population-weighted centroid measure
of mesh block group
Pearce et al. 12,529 GIS: Travel time to the nearest Fruit, at least 2 s/d, Best access to
(2008) supermarket and convenience and vegetables, at convenience stores:
store along the road network least 3 s/d Veg: OR¼ 0.75
(0.60 to 0.93)
Better access to
convenience
stores:
Veg: OR¼ 0.80
(0.64 to 0.99)
No statistically
significant
relationships with
other GIS measures
Pearson et al. 426 for fruit; 420 GIS: Distance to a supermarket Fruit and No statistically No statistically significant No statistically
(2005) for vegetable (km); Participant reported: vegetable (s/d) significant relationships with significant
Difficulties shopping; Store relationships with GIS perceived measure relationships with
audit: Price of fruits and measure store audit measure
vegetables at supermarkets
where participants shopped
Powell and 1134 Price index: Price of food items Number of days per Supermarket/ No statistically
Han (2011) in nearest city to participants week respondents grocery store significant price
home; GIS: number of food consumed fruit and density: index measure
stores per 100,000 residents per vegetables Veg: b 4 0,
10 square miles p ¼0.05
Other relationships
with GIS measures
not statistically
significant
Powell et al. 3739 Price index Price of fruit and fruit (s/d), No. of non-fast food Price of fruit and
(2009) vegetables in county of vegetable (s/d), count restaurants: vegetables
resident; GIS: number of food model RR ¼ 1.013, p o 0.05 RR ¼ 0.678, p o 0.01
stores in the county of residents No. of fast food
per 100,000 residents restaurants:
RR ¼ 0.951, p o0.05
Other relationships
with GIS measures
not statistically
significant
Rose an 963 Participant-report: Distance to a Household fruit and Difference for
Richards supermarket, round trip travel vegetable supermarket shoppers:
(2004) time and supermarket access consumption (g/ Fruit: b 40
adult male/ day) (7 to 157)
Distance to store 45
miles:
Fruit: b o 0
(117 to -7)
Easy supermarket
access:
Fruit: b 40
(7 to 164)

Sharkey et al. 582 GIS: Network distance to fruit and Supermarket: b o 0, Few grocery stores:
(2010) nearest store from home: vegetables (s/d) p ¼0.002 b o 0, p ¼ 0.000
Survey: availability, variety, and Any store with fresh/ Fruit/vegetable variety:
affordability of food stores, processed fruit: b o 0, p ¼0.043
variety, freshness, and price of b o 0, p ¼0.005
fruits and vegetables in stores Any store with fresh/ Other perceived measures
processed veg: b o0, not statistically significant
p ¼0.004
Other relationships
with GIS measures not
Thornton 1082 GIS: Road network distance High fruit and Supermarkets: For supermarkets:
et al. (2010) from the nearest food store; vegetable Store density, veg: Veg availability:
count of each of these stores consumption (at b 4 0, po 0.001 b o 0, p ¼ 0.032
within 3 km of home; Store least 2 s/d) versus Proximity, veg Fruit price: b 40,
audits: mean cost difference of low trend po 0.001 p ¼0.009 a
fruits and vegetables between Veg price: b 4 0,
stores; opening hours p ¼0.002a
Greengrocers Greengrocers:
Store density, veg: Fruit availability:
b 4 0, po 0.001 b 4 0, p ¼ 0.038
Proximity, veg Veg availability:
trend: p o 0.001 b 4 0, p o0.001
Other relationships Fruit price: b 40,
with GIS measures not p ¼0.026a
Veg price: b 4 0,
p o 0.001a
Opening hours:
Fruit: b 40,
p ¼0.034
Other relationships
with store audit
measures not
statistically
significant
Timperio et al. 775 for fruit; 784 GIS: Distance to closest food High fruit Convenience stores:
(2008) for vegetable store, number of food stores consumption (at At least 1 store
within 800m, and presence of at least 2 s/d) versus within 800 m:
least 1 food store within 800m low; high vegetable Veg: OR ¼ 0.75
consumption (at (0.57 to 0.99)
least 3 s/d) versus Number within
low 800 m:
Fruit: OR¼ 0.84
(0.73 to 0.98)
Veg: OR¼ 0.84
(0.74 to 0.95)
Other relationships
with GIS measures
not statistically
significant
Williams et al. 243 for fruit; 225 Participant report: Cost of fruit High fruit intake (at GIS results not Cost of fruit:
(2010) for vegetable and vegetables, whether food least 2 s/d) versus statistically significant Fruit: OR¼ 0.63 (0.45
stores were within walking low; high vegetable in bivariate models. to 0.86)
distance of home, and perceived intake (at least 3 s/d) Results not reported in Availability of healthy
availability of healthy food; GIS: versus low fully adjusted models. food options:
# of supermarkets and fruit and Fruit : OR¼ 1.14
vegetables stores within 2km (1.04 to 1.25)
road network distance; distance Veg: OR¼ 1.10 (1.01
to nearest supermarket or fruit to 1.21)
and vegetable store Perceived access to
healthy food options not
in bivariate models;
results not reported in
fully adjusted models
Zenk et al. 266 Participant-reported: Type of Fruit and Shopping at

(2005) store in which respondents vegetable (combined) supermarket: b 40, p
purchased their food; selection intake (s/d) o 0.001
and quality of fresh produce; Shopping at a specialty
affordability of fresh produce store: b 40, p o0.05
Selection/quality: b 4
0, p o0.05

Zenk et al. 919 GIS: No. of food stores in the Fruit and vegetable Large grocery store: No statistically
(2009) 0.5 mile buffer around census intake (s/d) b 4 0, p¼ 0.002 significant
block centroid; Store Audit: Other relationships relationships with
distance to nearest with GIS measures store audit measure
supermarket; availability of not statistically
produce; variety, quality and significant
affordability of produce;
Participant reported: Satisfaction
with variety, quality, cost and
affordability of fresh produce
a
Association in the opposite direction from expected.
and vegetable consumption was increased among residents who Although fruit and vegetable intake was the most commonly
switched stores, lived closest to the new store, and had the lowest studied outcome, a variety of dietary outcomes showed evidence
consumption at baseline, although there was no overall increase in of a meaningful association with food environment features,
fruit and vegetable consumption (Wrigley et al., 2003). consistent with the notion that poor food environments may
have cross-cutting effects on dietary behaviors. The evidence for
fast food outlets and fast food consumption was the weakest,
perhaps due to a relative ubiquity of fast food outlets compared to
4. Discussion other food sources. Another possibility is that factors such as
individual preference govern fast food-seeking behavior even
Overview: This review of 38 studies of the food environment more than either perceived or objective availability of fast food
found moderate evidence in support of the causal hypothesis that outlets. Perceived access to ‘‘healthy places to eat out’’ was
neighborhood food environments influence dietary health. Yet, associated with less likelihood of consuming fast food in one
even though the number of studies on the subject is substantial, study (Inglis et al., 2008), supporting the idea that improving non-
overall reproducibility was lacking because of the absence of an fast food options for eating out may be a promising approach.
‘‘industry standard’’ for measuring local food access. It has been suggested in previous literature that countries
Perceived measures of availability were consistently related to outside the US, Australia, and New Zealand do not show the same
multiple healthy dietary outcomes. On the other hand, GIS-based kind of patterns in the existence of food deserts, (Cummins and
measures of accessibility (primarily operationalized as distance to Macintyre, 2002) perhaps because ‘‘food deserts’’ may take a
various food stores) were overwhelmingly unrelated to dietary different form in places without the economic segregation that
outcomes. GIS-based availability measures – such as store pre- commonly occurred in US-based downtown areas in the second
sence and density – were somewhat more promising, although half of the 20th century (Walker et al., 2010). But beyond the
results were mixed; in general, the vast array of store types question of the existence of food deserts in the international
studied made it difficult to discern which, if any, true associations setting, the body of literature assessing the relationship between
exist. Survey-based perceived measures of store accessibility the food environment and diet is currently too small to make an
were comparably weak and inconsistently operationalized. adequate comparison between studies in the US and outside the
Unexpectedly, more than one store audit study showed an US Only a total of six studies from outside the US and Australia/
association between higher fruit and vegetable costs and higher Zealand met criteria for inclusion in this review.
consumption (Caldwell et al., 2009; Thornton et al., 2010). In reviewing the overall results of this study, it is also
However, neither of these studies controlled for area-level depri- worthwhile to acknowledge that, in general, studies that show a
vation, which could conceivably be related to both store prices positive relationship may be more likely to be published than
and individual fruit and vegetable intake. It is also possible that in those with null results. Because of this publication bias, almost all
these studies, the quality of the produce in the more expensive of the studies included in this review contained at least one
stores was substantially higher and, consequently, consumption significant positive relationship; it is, therefore, impossible to
of these more appealing foods was higher. Perceived affordability assess the true proportion of studies in which a positive associa-
measures have turned up mixed results, perhaps because some- tion is found between a food environment feature and a dietary
one who buys very little produce might under-report prices outcome. Nevertheless, nearly all of the studies tested multiple
because they do not have a good sense of what they cost. food access constructs and multiple outcomes; dicing the findings
Measures of affordability based on regional price indices offer by exposure and outcome, as was done in this review, helps to
some promise of assistance in future studies. discern which categories of associations may be the most robust.
Dietary outcomes and assessment measures varied substan- Comparisons between GIS-based and perceived measures:
tially across studies. Yet it appears that studies with and without Studies which relied on GIS-based measures were substantially
demonstrable validity of the outcome measure were equally more common than those using other measures, yet these studies
dispersed between those that used GIS, survey methods, store – particularly distance-based studies – less consistently revealed
audits, and other techniques. The very oldest studies use instru- a significant relationship between food environment features and
ments that could be deemed outlier instruments, (Cheadle et al., dietary outcomes than other measures. One chief explanation for
1991; Fisher and Strogatz, 1999; Rose and Richards, 2004) but by this pattern is that GIS-based measures on their own simply
and large, outcome assessment has been standardized in more cannot capture non-geographic dimensions of access that are key
recent studies. Overall, there was no comprehensible correlation factors in the food environment–diet relationship. These factors
between the quality of assessment method for the exposure and include produce affordability, food choice and acceptability, and
for the outcome. store accommodation to local residents, all of which can be
1182
Table 4b
Studies using a before-and-after design to assess change in fruit and vegetable intake.
Key findings
Author (Year) n Study design Exposure FV outcome Exposure measured by survey Exposure measured by store audit
or other
Caldwell et al. (2009) 130 Broad intervention to achieve Healthy Participant reported: Ease or Change in fruit and vegetable Perceived access to fresh produce: Square meters of fresh fruits and
People 2010 objectives; Before-after design; difficulty in getting fresh consumption (servings per b 40, p ¼0.011 veg:
no control group. Results estimate the produce; Store audit: shelf week), measured at the b 40, p ¼ 0.0137
association of each exposure with change in space, cost, variety, and beginning and end of the Variety of fruit and fresh fruits

fruit and vegetable consumption from quality intervention and veg:
intervention baseline to intervention end b 40, p ¼ 0.007
No. of stores in community:
b 40, p ¼ 0.0013
Produce freshness:
b 40, p ¼ 0.045
Minimum price of produce
basket:
b 40, p ¼ 0.0022a
Minimum price of fresh
produce:
b 40, p ¼ 0.0187a
Cummins et al. (2005) 412 Before–after natural experiment for Presence of a new Fruit and vegetable Participants with new stores not
residents who lived with 1 km of a new supermarket within 1 km of consumption (portions per statistically significant
supermarket; control site 5 km away. residence day)
Results estimate difference in change in FV
between groups.
Wrigley et al. (2003) 598 Before–after natural experiment; no control Switching stores, distance to Fruit and vegetable Switched from budget store to new Distance to the new store
group. Results estimate the before–after new store consumption, (s/d) Store, FV change: b 40, p o0.05 o ¼500 m:
change in FV consumption. Switched to new store not statistically FV change: b 40, p o 0.05
significant
a
Association in the opposite direction from expected.
Table 5
Studies using fast food consumption as an outcome.
Key findings
Author (Year) n Specific exposure reported FF outcome GIS result Perceived result Other result
Beydoun et al. (2011) 8438 Price index: Fast food price index (FFPI); fruit Number of fast food items Children:
and vegetable price index (FVPI) consumed in the last 24 h FFPI: b o0, po 0.05;
No other statistically
significant relationship with
price index
Beydoun et al. (2008) 6759 Price index: Fast food price index (FFPI); fruit Number of fast food items No statistically significant
and vegetable price index (FVPI) consumed in the last 24 h relationships with price index
Inglis et al. (2008) 1580 Participant report: Perceived availability, Consumption of fast food at Healthy options to eat out:
perceived, accessibility, and perceived least once per week OR ¼0.70 (0.52 to 0.94)

affordability (tested as mediators) No other statistically significant
relationship with perceived measures
Jeffery et al. (2006) 911 GIS: Number of fast food outlets within Frequency of eating at fast No statistically significant
2 miles of resident’s home food restaurants, relationships with GIS measures
dichotomized (not specified
further)
Moore et al. (2009) 5633 GIS: Fast food store density in square mile Consumption of fast food at No statistically significant Participant report of fast food Informant report of fast
around residents house Participant report: least once in the last week relationship with GIS measures access: food access:
Access to fast food; Informant report: Access OR ¼1.61 (1.51 to 1.72) OR¼ 1.27 (0.17 to 1.39)
to fast food (aggregate neighborhood scores)
Paquet et al. (2010) 415 GIS: Number of fast food outlets within 500m Consumption of fast food at No statistically significant
of participants’ home least once in the last week relationship with GIS measures.
Interaction effect with attitude

variable was significant.
Thornton et al. (2009) 2547 GIS: Number of fast food restaurants within Purchase of fast food in the Variety of stores:
3 km of resident’s house; Variety of different last month (never, weekly, or Monthly: OR¼ 1.13 (1.02 to
fast food restaurants within 3 km; Road monthly) 1.25)
network distance to the nearest store No other statistically significant
relationship with GIS measures
Turrell and Giskes (2008) 1001 GIS: Number of takeaway stores within Purchase of fast food for No other statistically significant
2.5 km of centroid of neighborhood unit; consumption (4 consumption relationship with GIS measures
Average road distance to each type of store; categories)
closest road distance
1183
assessed by participant-report. The empirical assessment of these Steps for establishing the validity of different environmental
components of food access is still in its infancy, and currently, no measures might include: (a) specifying in advance the
gold standard exists for their measurement. dimension of food environment one wishes to capture; (b)
Even within the dimensions of availability and accessibility, specifying the dietary outcome of interest; (c) specifying the
GIS-based measures were surprisingly inconsistent in their rela- theoretical relationship between exposure and outcome; (d)
tionship with dietary outcomes. There are several possible expla- establishing the convergent validity of the proposed mea-
nations for this. First, it is possible that the geographic boundaries sure against alternative measures of the environmental
that GIS imposes are not always relevant to residents. Buffer dimension, recognizing that there is currently no accepted
distances, street network distances or other geographic domains ‘‘gold standard’’.
such as zipcodes and census tracts serve only as a rough estimate It is also not enough to develop and validate exposure
of a resident’s neighborhood. Calculating store densities within measures, but these measures must be considered in terms
those areas may be more of an exercise in pushing the limits of GIS of their relevance to public health (Lytle, 2009). Many
technology than a reflection of what a resident considers part of his studies on the food environment have discussed the char-
neighborhood. Second, GIS-based measures are usually derived acterization of the food environment, but more work should
from secondary source data that is not ground-truthed, and such be done in linking these constructs to relevant public health
data may misrepresent true geographic access, either by including outcomes. The proper measurement of dietary outcomes is
stores that are no longer open or by missing stores entirely (Liese particularly critical in the characterization of the food
et al., 2010). Third, it may be that other, primarily non-geographic, environment-health link. The brief instruments so com-
axes of food access are embedded in respondents’ reports of food monly used to measure fruit and vegetable intake and fast
availability and accessibility in their neighborhoods. Although food consumption have often not been validated, and the
accessibility is primarily a geographic notion, in perceived mea- intelligent use of multiple dietary outcomes – for instance
sures it may legitimately include the safety of walking routes or fruit and vegetable intake and a healthy eating index
the reliability of public transportation. Finally, it may be that same- (Beydoun et al., 2008, 2011) – may begin to establish
source bias on survey measures accounts for much of the excess convergent validity of such measures.
portion of the positive results found in perception-based studies. (2) Develop and refine understudied measures: Very few studies
An array of individual tastes and cognitive processes may serve as have so far examined acceptability measures, such as food
unmeasured confounders in the findings of survey measures. Those quality, but in general, the studies that have show some
who have an innate preference for unhealthy foods and those who promise. The availability of specialty foods that that might be
feel a need to self-justify unhealthy food consumption may also in demand by residents may be a relevant concept, but it has
under-report access to healthy foods. so far only been explored in the literature in terms of organic
Comparability between studies is made all the more challen- food selection (Dibsdall et al., 2003). Yet accurately defining
ging by the fact that different assessment techniques may food acceptability might require moving well beyond quality
inherently represent different underlying constructs. For example, and organics, and also examining constructs such as cultural
accessibility measured by a survey might more accurately reflect relevance and food familiarity. Cultural relevance might be
public transit options, which is a truly different construct from particularly salient in areas with larger immigrant popula-
distance to a store. The comparisons drawn between methods are, tions, where survey questions might begin to explore whether
therefore, inevitably limited by these conceptual differences. the range of neighborhood food products appeals to residents
or makes it easy to cook meals.
To date, there is almost no study looking at accommodation;
5. Recommendations notably, the one study that looked at the store hour for
greengrocers found that the total number of hours open was
Refining the measures used to capture multiple dimensions of associated with fruit consumption, and the number of hours a
food access should be a top priority for researchers conducting supermarket was open after 5:30pm was associated with
studies on the food environment–diet relationship. Based on this vegetable consumption (Thornton et al., 2010). Time of day,
review of 38 studies of the food environment, we make the day of the week, or accommodation to residents’ schedules
following recommendations for future research: might be a particularly relevant concept for farmer’s markets,
which are increasingly providing a large supply of seasonal
(1) Standardize and validate measures: The field is in need of more produce to neighborhoods, but tend to have extremely lim-
standardized measures for assessing the food environment. ited hours. Other relevant ways to assess accommodation
Studies using buffer distance-based measures only occasionally might include whether the stores or markets accept EBT
provided a rationale for the buffer distances they selected cards, or how well stores adapt to cultural food preferences
(Thornton et al., 2010; Timperio et al., 2008) and some research- or local residents’ demands.
ers have noted the lack of criteria for determining suitable buffer A final area for developing measures, directly related to food
distances (Jennings et al., 2011; Turrell and Giskes, 2008). As a access but tremendously understudied, is the utilization of
first step in discussing appropriate buffer distance, it may be food stores by area residents. Almost all of the articles
useful to examine the existing built environment literature to included in this study studied operate under the grand
help determine how far people typically walk or drive to services assumption that people use what is geographically proximate,
in their neighborhood, in both urban and non-urban areas. or what in their neighborhood. Yet a study examining shop-
Validated store audit measures, while promising, have only rarely ping behavior showed that low-income WIC recipients in
reported psychometric properties, even though methods for urban areas only rarely shopped at the closest supermarket,
applying psychometric terms to these environmental measures and did much of their grocery shopping outside of their own
have been suggested (Lytle, 2009). Defining the proper methods neighborhood (Hillier et al., 2011). Where people ultimately
for assessing perceived availability and accessibility dimensions decide to do their shopping likely depends on both individual
should also be a top priority for those who wish to accurately factors such as car ownership and employment, as well as
depict the food environment, as these measures have been the ‘‘social distance’’ to stores, reflected by the larger
inconsistently measured across surveys. socio-demographics of residents neighborhoods and the
surrounding areas (Hillier et al., 2011). Careful analyses of hold. It is often challenging to draw a categorical distinction
the gap between potential access and realized access between convenience stores and small grocery stores. Super-
(Sharkey, 2009) is essential in accurately depicting the food markets, of course, are comprised not only of the produce and
environment. fresh foods on the perimeter, but primarily of the packaged
(3) Revamp the notion of accessibility: The current body of litera- goods and sugar-sweetened beverages that line the isles.
ture suggests that it may be time to abandon purely distance- Hence, it may be overly simplistic to categorize certain stores
based measures of accessibility. Store distance has remark- as protective or detrimental to health. Ultimately, the char-
ably consistently showed no association with diet across a acterization of food availability both at the store level and the
variety of dietary outcomes. In their current form, the use of neighborhood level will add much to the discussion of the food
GIS-based measures of accessibility may not accurately reflect environment (Gustafson et al., 2011).
a the boundaries of participants’ neighborhoods, nor do these Combine methods: Given the complexities in defining the
measures take into account how easy or difficult it is for important features of food environments and the lack of
participants to get to stores that may be defined as accessible association with many purely distance-based measures, per-
solely based on distance. haps the single most important strategy for future research is
Current uses of GIS, however, may not represent the full combining multiple environmental assessment techniques.
potential of spatial measures of food access. Although distance Using an intelligent mix of store audit measures along with
and store presence are among the simplest and most common GIS-based methods would aid in providing an accurate char-
GIS-based measures, more sophisticated spatial techniques acterization of neighborhood food environments. For example,
exist, including kernel density estimation (a more precise two 2011 studies – Izumi et al. (2011), Sharkey et al. (2010) –
density measures that gives more weight to closer features), used GIS-based measures to define the geographic regions
estimates of walkability, and estimates of travel time by car relevant to participants. They next examined all types of food
that incorporate traffic density (Thornton et al., 2011). Such stores within those geographic boundaries for their merchan-
methods allow for a more multi-dimensional approach to dise and developed a metric – density or distance – of healthy
mapping ‘‘accessibility’’. Hence, the challenge in future foods in the neighborhood. Although the exposure assessment
research becomes pushing the current standards in GIS meth- technique for these studies fall under the category of GIS-based
odology past the one-dimensional, so that they reflect the most measures, ultimately, both of these studies examined the
relevant features of geographic access. relationship between food items and diet, not store types.
Perceived physical access to stores has also turned up dis- Reliable store audit measures have been underused; for exam-
appointing results with relation to diet (Gustafson et al., 2011; ple, only two studies in the current review relied on the
Inglis et al., 2008; Pearson et al., 2005; Williams et al., 2010). So validated NEMS (Franco et al., 2009; Gustafson et al., 2011).
far, the strongest association between perceived physical This measure could easily be combined with GIS, or even street
accessibility of stores and diet occurred in a measure of audits, which may be able to objectively capture features of the
accessibility that included how long it took participants to built environment relevant to access, like walkability in the
travel to the store (Rose and Richards, 2004). To further refine areas surrounding stores.
measure perceived availability, surveys might include ques- It is easy to see the appeal of using GIS-based measures only,
tions asking how people get to the store (not just if they own a given the relative ease and cost of using them, the ability to
car), how long it takes them, or other specific barriers to quickly measure multiple exposures, and their avoidance of
shopping. Furthermore, store audit tools might include less same-source bias issues. Though GIS measures are an indis-
obvious components of accessibility – for instance, whether pensible tool for assessing geographic components of food
the surrounding area is pedestrian-friendly, the placement of environments, these measures should be used rigorously and
food within stores, or – in the case of fast food outlets – only employed where the constructs they represented are
whether there is a drive through (Glanz et al., 2005). theoretically relevant – that is, if they truly represent those
(4) Pay attention to stores and food: Researchers might do well to things that can enable or hinder healthy consumption patterns.
acknowledge the distinction that has previously been made In many cases, this may mean supplementing broad geo-
between the community food environment versus the con- graphic information with specific information that can be
sumer food environment (Glanz et al., 2005; Kelly et al., 2011). derived only from asking actual people what is in their
Essentially, this entails distinguishing the measurement of neighborhood. Researchers have already begun to creatively
stores versus the measurement of foods. Neighborhood food integrate multiple methods for assessing food environments.
environments likely cannot be accurately depicted without The use of informant-report measures (Franco et al., 2009;
attention to both. Assessment of the actual food that stores are Moore et al., 2009) for example, cleverly sidesteps the same-
carrying seems an essential component, given the evidence source bias challenge by aggregating the reports of others in
from store audit studies (Thornton et al., 2010; Cheadle et al., the neighborhood besides the participant, although it still
1991; Franco et al., 2009; Fisher and Strogatz, 1999). Yet requires the time and effort of survey measures.
neighborhood store characteristics like size and price trends These studies, along with a handful of others that have used
may play an important role in determining residents’ food both GIS and perceived measures have produced nuanced
shopping patterns even beyond the food items they carry. analyses which are able to compare the relative merits of each
Produce at supermarkets may not be comparable to produce at type of measure (Moore et al., 2008, 2009; Williams et al., 2010;
corner stores, as it may be fresher (Webber et al., 2010; Zenk Gustafson et al., 2011; Sharkey et al., 2010). Indeed, perception-
et al., 2011) and cheaper (Chung and Myers, 1999). based measures have the unique advantage of being able to tap
It is, however, likely short-sighted to use store type alone as an into residents’ intentions to utilize nearby food outlets. And yet,
indicator of food healthfulness. While researchers have gen- these studies must consider the simultaneous measurement of
erally labeled supermarkets a desirable feature of neighbor- (and statistical control for) people’s food preferences in order to
hoods (Chung and Myers, 1999; Sallis et al., 1986), just as begin to make causal statements about food environment–diet
convenience stores are labeled detrimental (Pearce et al., 2008; relationships. These discussions of causality have begun to be
Morland et al., 2006), on a practical level, it is easy to see why explored in the built environment literature. In one study, Frank
the expected associations with dietary health do not always et al. (2007) measured the relationship between objective
walkability and walking behavior, as well as people’s prefer- Dibsdall, L.A., Lambert, N., Bobbin, R.F., Frewer, L.J., 2003. Low-income consumers’
ences for living in a walkable neighborhood (Frank et al., 2007). attitudes and behaviour towards access, availability and motivation to eat fruit
and vegetables. Public Health Nutrition 6 (2), 159–168.
This study elegantly showed not only that people with low Fisher, B.D., Strogatz, D.S., 1999. Community measures of low-fat milk consump-
preference for living in a walkable neighborhood walk less, but tion: comparing store shelves with households. American Journal of Public
also that, after stratifying by personal preferences, those living Health 89 (2), 235–237.
Ford, P., Dzewaltowski, D., 2008. Disparities in obesity prevalence due to variation
in objectively less walkable neighborhoods end up walking less. in the retail food environment: three testable hypotheses. Nutrition Reviews
Researchers have yet to demonstrate these principles for the 66 (4), 216–228.
local food environment. Franco, M., Diez-Roux, A.V., Nettleton, J.A., et al., 2009. Availability of healthy foods
and dietary patterns: the Multi-Ethnic Study of Atherosclerosis. The American
(5) Keep defining ‘‘food access’’: Finally, researchers should to Journal of Clinical Nutrition 89 (3), 897–904.
continue to expound upon the conceptual definitions of food Frank, L., Saelens, B., Powell, K., Chapman, J., 2007. Stepping towards causation:
access as they develop and refine new combinations of Do built environments or neighborhood and travel preferences explain
physical activity, driving, and obesity? Social Science and Medicine 65 (9),
measure for the food environment. The five dimensions of
1898–1914.
access which frame the discussion in this review are not the Fraser, L.K., Edwards, K.L., Cade, J., Clarke, G.P., 2010. The geography of Fast Food
only way to dice the weighty concept of ‘‘food access.’’ Models outlets: a review. International Journal of Environmental Research and Public
of community nutrition environments have previously put Health 7 (5), 2290–2308.
Glanz, K., Sallis, J.F., Saelens, B.E., Frank, L.D., 2005. Healthy nutrition environ-
forth suggestions for constructs related to the food environments: concepts and measures. American Journal of Health Promotion: AJHP
ment and outlined exogenous influences on food retail, such 19 (5), 330–333.
as advertising and government policies (Glanz et al., 2005); Glanz, K., Sallis, J.F., Saelens, B.E., Frank, L.D., 2007. Nutrition environment
measures survey in stores (NEMS-S): development and evaluation. American
other categories of access dimensions have also been pro- Journal of Preventive Medicine 32 (4), 282–289.
posed (for example, proximity, diversity, availability, afford- Gustafson, A.A., Sharkey, J., Samuel-Hodge, C.D., et al., 2011. Perceived and
ability, perception (Charreire et al., 2010)). Continuing to objective measures of the food store environment and the association with
weight and diet among low-income women in North Carolina. Public Health
cultivate a discussion around the underlying constructs con- Nutrition 14 (6), 1032–1038.
tained in measures seems a worthwhile endeavor given the Hillier, A., Cannuscio, C., Karpyn, A., et al., 2011. How far do low-income parents
continued need for research on disparities in food access. travel to shop for food? Empirical evidence from two urban neighborhoods.
Urban Geography 32 (5), 712–729.
Holsten, J.E., 2009. Obesity and the community food environment: a systematic
review. Public Health Nutrition 12 (3), 397–405.
6. Conclusion Inglis, V., Ball, K., Crawford, D., 2008. Socioeconomic variations in women’s diets:
what is the role of perceptions of the local food environment? Journal of
Epidemiology and Community Health 62 (3), 191–197.
The assessment of the local food environment is likely to be Izumi, B.T., Zenk, S.N., Schulz, A.J., Mentz, G.B., Wilson, C., 2011. Associations
the topic of a great number of studies in the coming years, if between neighborhood availability and individual consumption of dark-green
current trends continue (McKinnon et al., 2009). While many and orange vegetables among ethnically diverse adults in Detroit. Journal of
the American Dietetic Association 111 (2), 274–279.
measurement challenges remain, only through accurate and Jago, R., Baranowski, T., Baranowski, J.C., Cullen, K.W., Thompson, D., 2007.
comprehensive assessments of the food environment–diet rela- Distance to food stores & adolescent male fruit and vegetable consumption:
tionship can researchers provide insight into how the local mediation effects. The International Journal of Behavioral Nutrition and
Physical Activity 4, 35.
environment may be altered to elicit actual improvements in
Jeffery, R.W., Baxter, J., McGuire, M., Linde, J., 2006. Are fast food restaurants an
dietary health. Ultimately, the combination of rigorous spatial and environmental risk factor for obesity? The International Journal of Behavioral
store audit measures, coupled with the intelligent use of neigh- Nutrition and Physical Activity 3, 2.
borhood informant data may yield the best prospects for the Jennings, A., Welch, A., Jones, A.P., et al., 2011. Local food outlets, weight status,
and dietary intake: associations in children aged 9–10 years. American Journal
careful characterization of food environments. of Preventive Medicine 40 (4), 405–410.
Kelly, B., Flood, V.M., Yeatman, H., 2011. Measuring local food environments:
an overview of available methods and measures. Health & Place 17 (6),
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The Local Food Environment and Diet. A Systematic Review

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Health & Place 18 (2012) 1172–1187

Contents lists available at SciVerse ScienceDirect

Health & Place

The local food environment and diet: A systematic review

1. Introduction through which ‘‘obesogenic’’ settings operate – namely, the food

1. What should we measure? (e.g., access, quality, utilization)

Fig. 1. Unanswered challenges in the measurement of food environments.

Author (Year) Outcomes Location Cohort/Population

C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187

Other Availability Informant report Moore et al. (2008, 2009)

Survey Store audit GIS Other

Food diary Jennings et al. (2011), Michimi Wrigley et al. (2003)

BRFSS Caldwell et al. (2009), Zenk Caldwell et al. (2009)

Other Rose and Richards (2004) Cheadle et al. (1991), Fisher

GIS measure Perceived measure Store audit or other

Murakami 990 GIS: Quartile categories for Fruit and No statistically

Other relationships with

Zenk et al. 266 Participant-reported: Type of Fruit and Shopping at

Other relationships with

C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187

C.E. Caspi et al. / Health & Place 18 (2012) 1172–1187

Interaction effect with attitude

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