Promoting healthful food purchases through in-store interventions: Empirical evidence from rural food deserts.

Effective ways to promote healthful food intake in rural areas are understudied. The paper evaluated whether a two-component, in-store intervention designed to encourage healthy food purchases was associated with improved healthfulness scores of food items purchased by shoppers in rural food deserts. One component introduced a point-of-sales label that assigned a single numerical score to each food item facilitating direct comparisons of the product's nutrition with those of other products shelved around it. The other component was a one-day nutrition education workshop promoted within the store. Interventions took place in 2015 at two stores in rural counties in the U.S. Midwest. Four stores in similar communities were selected as the control group. We applied a difference-in-difference model to estimate changes in the healthfulness of food items purchased attributable to the intervention among shoppers at the treatment stores (n = 486) and control stores (n = 10,759) using store transaction data. Healthfulness of food items was measured in terms of food scores published by the Environmental Working Group on a 1-10 scale. Both components had minimal impacts on the scores, although 0.2 and 0.1 points increases in the score per item and score per dollar were statistically significant at the 1% level respectively. A year after the intervention, these small effects of the intervention further diminished compared to the immediately after implementation. Results suggest the average effects of intervention across the study communities had limited practical significance but benefited some rural residents who were exposed to the intervention.

Food Desert Residence Is Not Associated With Dietary Adherence or Complication Rates in Patients With Isolated Mandibular Fractures.

BACKGROUND: Mandible fracture management requires postoperative dietary modifications to promote healing. Over 20 million Americans live in food deserts, low-income neighborhoods over one mile from a grocery store. The relationship between food desert residence (FDR) and adherence to postoperative dietary instructions remains unexplored. PURPOSE: This study's purpose is to evaluate the relationships between FDR, known risk factors, dietary adherence, and complications among patients with isolated mandible fractures. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study was conducted at a level 1 trauma center and analyzed patients with mandible fractures between January 2015 and December 2020. Inclusion criteria included operative treatment of adult patients for mandible fractures; pregnant, incarcerated, and patients with incomplete data were excluded. PREDICTOR VARIABLE: FDR was the predictor variable of interest. FDR (coded yes or no) was generated by converting patient addresses to census tract GeoIDs and comparing them to the US Department of Agriculture Food Access Research Atlas. MAIN OUTCOME VARIABLES: The study examined two outcome variables: dietary adherence and postoperative complications. Dietary adherence was coded as adherent or nonadherent, indicating documented compliance with postoperative dietary modifications. Postoperative complications were coded as present or absent, reflecting infection, hardware failure, and mandible malunion or nonunion. COVARIATES: The covariates analyzed included age, sex, ethnicity, mechanism of injury, medical and psychiatric comorbidities (including diagnoses such as diabetes, hypertension, and schizophrenia), and tobacco use. ANALYSES: Relative risks (RRs) and multivariate logistic regression models were generated for both outcome variables. Two-tailed P values < 0.05 were considered statistically significant. RESULTS: During the study period, 143 patients had complete data allowing for FDR and dietary adherence determination, 124 of whom (86.7%) had complication data recorded. Of the cohort, 51/143 (35.7%) resided within a food desert, 30/143 (21.0%) exhibited dietary nonadherence, and 46/124 (37.1%) experienced complications. FDR was not associated with increased risk of dietary nonadherence (RR 0.92, 95% confidence interval [CI] 0.52 to 1.61, P = .76) or complications (RR 1.19, 95% CI 0.75 to 1.89; P = .46). On multivariate regression, dietary nonadherence was associated with increased complications (odds ratio 2.85, 95% CI 1.01 to 8.09, P = .049). CONCLUSION AND RELEVANCE: There was no association between FDR and dietary nonadherence or complications in mandible fracture patients. However, dietary nonadherence was associated with complications, highlighting the need for further research and intervention.

Association of Food Deserts and COVID-19 Severity in Pregnancy as Reflected by Need for Hospitalization.

BACKGROUND: Socioeconomic disparities play an important role in disease epidemiology and outcomes in pregnancy. OBJECTIVE: The objective was to evaluate whether pregnant women with COVID-19 living in a food desert, are at increased risk of more severe disease reflected by symptoms at presentation and need for hospitalization. METHODS: In this retrospective observational study, the electronic medical records of all pregnant patients with documented SARS-CoV-2 infection were reviewed. Food deserts were defined by the USDA and the patient's residence was mapped on the Food Access Research Atlas to determine whether each patient lived within a food desert. Comparisons between those with documented symptomatic COVID-19 required hospitalization to those with documented COVID-19 without need for hospitalization were made using univariate analysis and multivariable logistic regression analysis. RESULTS: The cohort consisted of 129 pregnant patients with COVID-19, with 59.7% (n = 77) asymptomatic and 33.3% (n = 43) requiring admission due to disease severity. The majority were Hispanic (70.5%), and obese (median BMI 31.91 kg/m2), with 33.3% living in a food desert. Patients with disease severity necessitating admission were significantly more likely to reside in a food desert (46.5% vs. 27.9%, P 0.037, OR 2.246, 95% CI 1.048-4.814). No other significant differences were identified on univariate. Multivariable binary logistic regression modeling confirmed food desert residence to be the only independent predictor of more severe COVID-19. CONCLUSION FOR PRACTICE: There is a strong association between living in a food desert and the development of symptomatic COVID-19 requiring hospitalization in pregnancy.

Social inequities in food deserts and food swamps in a northeastern Brazilian capital.

This study identified food deserts and swamps, investigating their associations with socioeconomic and demographic conditions. This ecological study was conducted using data from urban census tracts in the city of Recife, which were considered the unit of analysis. Information on food retail was obtained from government sources in 2019. Census tracts below the 25th percentile in the density of healthy food retail (i.e., those that predominantly sell natural or minimally processed foods, mixed businesses, and super- and hypermarkets) were classified as food deserts. Census tracts above the 25th percentile in the density of unhealthy food retail (i.e., those selling primarily ultra-processed foods) were considered food swamps. The socioeconomic and demographic conditions of the census tracts were evaluated using variables from the 2010 census (per capita income, average income, race, literacy of the head of household, and the availability of essential services) and the Health Vulnerability Index. Census tracts considered food deserts (28.5%) were more vulnerable, characterized by lower income and access to essential services, more illiterate residents and more minorities (Black/Indigenous/mixed race). Food swamps (73.47%) were more prevalent in less vulnerable neighbourhoods characterized by higher percentages of literate residents and Whites, greater purchasing power, and better basic sanitation. The characteristics of Recife's food deserts and swamps demonstrate social inequalities in the food environment. Public facilities could play a vital role in promoting healthy eating within food deserts. Additionally, future implementation of taxes on ultra-processed foods and the provision of tax subsidies to natural or minimally processed food sellers might contribute to fostering healthier dietary choices.

Association of Living in a Food Desert and Poor Periconceptional Diet Quality in a Cohort of Nulliparous Pregnant Individuals.

BACKGROUND: A poor diet can result from adverse social determinants of health and increases the risk of adverse pregnancy outcomes. OBJECTIVE: We aimed to assess, using data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be prospective cohort, whether nulliparous pregnant individuals who lived in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert. METHODS: The exposure was living in a food desert based on a spatial overview of food access indicators by income and supermarket access per the Food Access Research Atlas. The outcome was periconceptional diet quality per the Healthy Eating Index (HEI)-2010, analyzed by quartile (Q) from the highest or best (Q4, reference) to the lowest or worst dietary quality (Q1); and secondarily, nonadherence (yes or no) to 12 key aspects of dietary quality. RESULTS: Among 7,956 assessed individuals, 24.9% lived in a food desert. The mean HEI-2010 score was 61.1 of 100 (SD: 12.5). Poorer periconceptional dietary quality was more common among those who lived in a food desert compared with those who did not live in a food desert (Q4: 19.8%, Q3: 23.6%, Q2: 26.5%, and Q1: 30.0% vs. Q4: 26.8%, Q3: 25.8%, Q2: 24.5%, and Q1: 22.9%; overall P < 0.001). Individuals living in a food desert were more likely to report a diet in lower quartiles of the HEI-2010 (i.e., poorer dietary quality) (aOR: 1.34 per quartile; 95% CI: 1.21, 1.49). They were more likely to be nonadherent to recommended standards for 5 adequacy components of the HEI-2010, including fruit, total vegetables, greens and beans, seafood and plant proteins, and fatty acids, and less likely to report excess intake of empty calories. CONCLUSIONS: Nulliparous pregnant individuals living in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

Changes of Grocery Shopping Frequencies and Associations with Food Deserts during the COVID-19 Pandemic in the United States.

The COVID-19 pandemic has dramatically altered people's lives in multiple aspects, including grocery shopping behaviors. Yet, the changing trend of grocery shopping frequencies during the COVID-19 and its associations with food deserts remain unclear. We aimed to (1) examine variations of grocery shopping frequencies at county level in the USA during the COVID-19 pandemic from March 2020 to December 2021; (2) investigate associations between grocery shopping frequencies and food deserts during the COVID-19 pandemic; and (3) explore heterogeneity in grocery shopping frequencies-food desert associations across urban and rural areas. The county-level grocery shopping frequencies were derived from a grocery pattern dataset obtained from SafeGraph. We divided the 22-month period into 5 stages and employed the growth curve modeling to estimate the trajectories of grocery shopping frequencies and the associations between grocery shopping frequencies and food deserts in each stage, separately. Results revealed that grocery shopping frequencies experienced a "W-shaped" pattern from March 2020 to December 2021. Counties with the least percent of food deserts had slower decrease in grocery shopping frequencies at the initial stage and recovered more rapidly at later stages. Counties with the highest percent of food deserts were subject to deprivation amplification as a result of the pandemic. We also found differences existed in the grocery shopping frequencies-food desert associations between metropolitan counties and rural counties. Our findings suggest the impacts of COVID-19 on grocery shopping frequencies varied across different time periods, shedding light on designing different strategies to reduce the risk of contagion while shopping inside of grocery stores. Further, our findings highlight an urgent need to help people living in food deserts (especially in rural counties) to procure healthy foods safely during health emergencies like COVID-19 pandemic which disrupt mobility and social behaviors.

Combining crowd-sourcing, census data, and public review forums for real-time, high-resolution food desert estimation.

BACKGROUND: It has been hypothesized that low access to healthy and nutritious food increases health disparities. Low-accessibility areas, called food deserts, are particularly commonplace in lower-income neighborhoods. The metrics for measuring the food environment's health, called food desert indices, are primarily based on decadal census data, limiting their frequency and geographical resolution to that of the census. We aimed to create a food desert index with finer geographic resolution than census data and better responsiveness to environmental changes. MATERIALS AND METHODS: We augmented decadal census data with real-time data from platforms such as Yelp and Google Maps and crowd-sourced answers to questionnaires by the Amazon Mechanical Turks to create a real-time, context-aware, and geographically refined food desert index. Finally, we used this refined index in a concept application that suggests alternative routes with similar ETAs between a source and destination in the Atlanta metropolitan area as an intervention to expose a traveler to better food environments. RESULTS: We made 139,000 pull requests to Yelp, analyzing 15,000 unique food retailers in the metro Atlanta area. In addition, we performed 248,000 walking and driving route analyses on these retailers using Google Maps' API. As a result, we discovered that the metro Atlanta food environment creates a strong bias towards eating out rather than preparing a meal at home when access to vehicles is limited. Contrary to the food desert index that we started with, which changed values only at neighborhood boundaries, the food desert index that we built on top of it captured the changing exposure of a subject as they walked or drove through the city. This model was also sensitive to the changes in the environment that occurred after the census data was collected. CONCLUSIONS: Research on the environmental components of health disparities is flourishing. New machine learning models have the potential to augment various information sources and create fine-tuned models of the environment. This opens the way to better understanding the environment and its effects on health and suggesting better interventions.

Ecological study of the association between socioeconomic inequality and food deserts and swamps around schools in Rio de Janeiro, Brazil.

BACKGROUND: Previous research suggests that unhealthy community food environments around schools contribute to unhealthy eating habits and negative health outcomes among the youth. However, little is known about how socioeconomic inequalities in those community food environments are associated with food deserts and food swamps across schools' neighborhoods. METHODS: An ecological study was carried out in all 3,159 public and private schools in Rio de Janeiro, Brazil. Three measures of socioeconomic inequality were evaluated: per capita income, segregation index and deprivation index. The community school food environment was analyzed by metrics of food swamps and food deserts. RESULTS: Food deserts and food swamps were simultaneously more prevalent in neighborhoods of the lowest income, high deprivation, and high segregation. Spatial socioeconomic disparities at the neighborhoods of schools were associated with food deserts and food swamps in Rio de Janeiro. CONCLUSIONS: Our results point to a spatial socioeconomic inequality of establishments that sell food around schools in a Brazilian metropolis, indicating that the areas of greatest deprivation of food services are also the areas with the worst socioeconomic characteristics.

Prevalence of Food Insecurity and Living in a Food Desert among Individuals with Serious Mental Illnesses in Public Mental Health Clinics.

Very little is known about the prevalence of food insecurity-and living in a food desert-among persons with serious mental illnesses, such as schizophrenia and major mood disorders. This study evaluated those prevalences and assessed for associations with six other variables. Surveys were conducted with 300 patients with a psychotic or mood disorder receiving outpatient services at five community mental health agencies in Washington, D.C. The prevalences of low food security and very low food security were 68.9% and 46.8%, compared to national rates of 13.7% (13.2% in Washington, D.C.) and 5.4% (4.8% in Washington, D.C.). 50.0% of participants lived in food desert census tracts, which was associated with both severe and morbid obesity (p = .02 and p = .03, respectively). Additional research, evaluation of clinical implications, and potential policy approaches to these concerning social determinants of physical and mental health, in an already vulnerable patient population, are warranted.

Violence Within Food Deserts: A Block-Group Examination of Food Access, Racial Composition, and Violent Crime.

While there is substantial public health literature that documents the negative impacts of living in "food deserts" (e.g., obesity and diabetes), little is known regarding whether living in a food desert is associated with increased criminal victimization. With the block group as the unit of analysis, the present study examines whether there is a relationship between food deserts and elevated crime counts, and whether this relationship varies by racial composition. Results from multiple count models suggest that living in a food desert is not associated with higher levels of violent or property crime. But multiplicative models interacting percent Black with food deserts revealed statistically significant associations with violent crime but not property crime. Alternatively, multiplicative models interacting percent White with food deserts revealed statistically significant associational reductions in violent crimes. Several policy and research implications are discussed.

The Earliest Food Deserts: Availability of Infant and Follow-on Formula, and Lactation Support Products among Stores in Black and Non-Hispanic White Zip Codes in Los Angeles County.

OBJECTIVES: This study investigates the availability, accessibility, and product depth of in-store infant feeding and galactagogues products in majority Black and majority white zip codes in Los Angeles County. METHODS: A cross-sectional study was conducted to determine racial/ethnic neighborhood differences in the availability of infant and follow-on formula and galactagogues products in 47 retail stores in 21 zip codes. Store-level data were collected in June 2019 and an observational tool for galactagogues products and infant/follow-on formula (availability, accessibility, product depth) was employed at each store. RESULTS: Most of the stores were grocery stores (87.2%). Stores in majority Black zip codes had less availability of infant formula ready-to-use (p = 0.001), less accessibility of follow-on powder (p = 0.028), and availability of galactagogues beverages (p = 0.036) versus majority white zip codes. Product depth (number of brands sold) of stores with one or more brands of the aforementioned products was consistently higher in majority white zip codes compared to majority Black zip codes. Stores in majority Black zip codes were most likely to have lower availability of infant formula and galactagogues products, an important part of the food environment for infant feeding options, in particular, for lactation support. CONCLUSIONS FOR PRACTICE: Most studies investigating the association of the food environment and health outcomes have focused only on solid foods. However, additional food products (e.g., liquids, powders) may be contributors to extensive disparities in infant mortality between Black and white infants and may lead to health disparities beyond infant stage (e.g., children, adolescents, and adults). Lastly, for breastfeeding inequities to decrease, pregnant and postpartum Black persons need equitable access and education on safe and quality galactagogues products.

Food for thought: Can community pharmacists help patients living in food deserts?

BACKGROUND: Community pharmacists can play an important role in helping patients who live in food deserts through screening, adjusting therapeutic recommendations and counseling practices, and making referrals to community resources. However, literature regarding community pharmacists' knowledge, practices, and attitudes regarding food deserts is scant. OBJECTIVES: The primary objective of this study was to assess Ohio community pharmacists' knowledge regarding food deserts. Secondary objectives included determining their attitudes, practices, and perceived barriers related to this topic. METHODS: An anonymous 26-question survey was created and distributed to a random sample of 500 licensed community pharmacists in Ohio. Participants were granted 3 weeks to complete the survey and were offered a link to free Accreditation Council for Pharmacy Education-approved continuing pharmacy education as an incentive. The survey was deemed exempt by the Institutional Review Board. RESULTS: The survey was successfully delivered to 491 pharmacists; 72 participated (14.7% response rate). About 43% of respondents were familiar with the term "food desert," and less than one-third (31.9%) reported being aware of community resources. Of those who thought that some of their patients lived in food deserts, the majority indicated that they did not consider it in patient interactions (65.1%) and "never" adjusted their counseling practices (65.1%). Barriers that prevented them from referring patients included lack of knowledge and confidence as well as workflow constraints. About 68% of respondents somewhat or strongly agreed that pharmacists could help patients living in food deserts, and 65.3% were interested in learning more information about food deserts. CONCLUSION: Deficiencies in knowledge regarding food deserts and available resources were found among Ohio community pharmacists, but they showed interest in learning more information. Efforts should be made to educate community pharmacists about food deserts and to determine how to optimize their ability to assist patients as needed.

Association of Living in Urban Food Deserts with Mortality from Breast and Colorectal Cancer.

BACKGROUND: Food deserts are neighborhoods with low access to healthy foods and are associated with poor health metrics. We investigated association of food desert residence and cancer outcomes. METHODS: In this population-based study, data from the 2000-2012 California Cancer Registry was used to identify patients with stage II/III breast or colorectal cancer. Patient residence at time of diagnosis was linked by census tract to food desert using the USDA Food Access Research Atlas. Treatment and outcomes were compared by food desert residential status. RESULTS: Among 64,987 female breast cancer patients identified, 66.8% were < 65 years old, and 5.7% resided in food deserts. Five-year survival for food desert residents was 78% compared with 80% for non-desert residents (p < 0.0001). Among 48,666 colorectal cancer patients identified, 50.4% were female, 39% were > 65 years old, and 6.4% resided in food deserts. Five-year survival for food desert residents was 60% compared with 64% for non-desert residents (p < 0.001). Living in food deserts was significantly associated with diabetes, tobacco use, poor insurance coverage, and low socioeconomic status (p < 0.05) for both cancers. There was no significant difference in rates of surgery or chemotherapy by food desert residential status for either diagnosis. Multivariable analyses showed that food desert residence was associated with higher mortality. CONCLUSION: Survival, despite treatment for stage II/III breast and colorectal cancers was worse for those living in food deserts. This association remained significant without differences in use of surgery or chemotherapy, suggesting factors other than differential care access may link food desert residence and cancer outcomes.

Social inequalities in the surrounding areas of food deserts and food swamps in a Brazilian metropolis.

BACKGROUND: Food deserts are neighborhoods with little or no access to healthy food, whereas food swamps are neighborhoods where unhealthy food options prevail over healthy ones. The main aims of the current study are to feature and compare the neighborhoods of food deserts and food swamps based on social inequality. METHODS: Ecological study carried out in Belo Horizonte City, Minas Gerais State, Brazil. Information about commercial food establishments derived from two different databases. It was measured by secondary governmental databases, which were virtually conferred in the present study. Census tracts were considered as analysis units and classified as food deserts and food swamps, based on the Brazilian methodology. Take into consideration the density of establishments classified as selling fresh or minimally-processed food, mixed establishments, and establishments selling ultra-processed food. The Brazilian methodology evaluates food deserts by the density of healthy establishments (establishments classified as mostly selling fresh or minimally-processed food and mixed establishments) per 10 thousand inhabitants. And the metric to evaluate food swamps considers the density of unhealthy establishments (establishments mostly selling ultra-processed food) per 10 thousand inhabitants. Information about social inequalities comprised aspects such as income, population count, number of households, number of literate individuals, race, water and energy supply, and garbage collection. The Health Vulnerability Index (HVI) was used as a synthetic social vulnerability indicator. RESULTS: Neighborhoods of food deserts presented worse essential service availability, lower income per capita, and smaller mean number of literate individuals. Census tracts classified as food swamps presented better socio-demographic conditions than those areas food deserts. Neighborhoods simultaneously classified as food deserts and food swamps presented lower income per capita and were more often observed in census sectors presenting medium and high HVI. CONCLUSION: The food environment in Belo Horizonte was featured by the strong presence of food deserts and food swamps. However, the potential influence of these areas on food intake has changed depending on social inequalities.

Food deserts and cardiovascular health among young adults.

OBJECTIVE: This study assesses the association between living in a food desert and cardiovascular health risk among young adults in the USA, as well as evaluates whether personal and area socioeconomic status moderates this relationship. DESIGN: A cross-sectional analysis was performed using data from Wave I (1993-1994) and Wave IV (2008) from the National Longitudinal Study of Adolescent to Adult Health. Ordinary least squares regression models assessing the association between living in a food desert and cardiovascular health were performed. Mediation and moderation analyses assessed the degree to which this association was conditioned by area and personal socioeconomic status. SETTING: Sample of respondents living in urban census tracts in the USA in 2008. PARTICIPANTS: Young adults (n 8896) aged 24-34 years. RESULTS: Net of covariates living in a food desert had a statistically significant association with cardiovascular health risk (range 0-14) (ß = 0·048, P < 0·01). This association was partially mediated by area and personal socioeconomic status. Further analyses demonstrate that the adverse association between living in a food desert and cardiovascular health is concentrated among low socioeconomic status respondents. CONCLUSIONS: The findings from this study suggest a complex interplay between food deserts and economic conditions for the cardiovascular health of young adults. Developing interventions that aim to improve health behaviour among lower-income populations may yield benefits for preventing the development of cardiovascular health problems.

Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia.

BACKGROUND: Living in a food desert has been associated with increased cardiovascular risk; however, its impact on vascular surgery outcomes is unknown. This study hypothesized that living in a food desert would be associated with increased postoperative complications in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI). METHODS: This was a single-center retrospective analysis of open and endovascular infrainguinal revascularization for CLTI between April 2013 and December 2015. A food desert was defined using the US Department of Agriculture's Food Access Research Atlas. Bivariate analyses were performed appropriate to the data. Binary logistic regression was performed assessing the association of food desert status with 30-day postoperative complications. RESULTS: In total, 152 cases were included, of which 17% (n = 26) resided in food deserts. Patients in the food desert cohort were less likely to be low income (27% vs. 54%, P = 0.01). Living in a food desert was associated with increased 30-day readmission [(39% vs. 20%, P = 0.04), unadjusted OR: 2.5 (CI: 1.0-6.2)]. FD cases also had a higher proportion of wound complications [12 (46%) vs. 28 (22%), P = 0.01)]. The overall wound complication rate was 27% with the majority being due to infections (63%). On multivariable analysis, food desert status remained associated with increased odds of 30-day readmission (OR: 2.7, CI: 1.2-8.4, P = 0.047). Reasons for readmission in the food desert group were all due to wound complications (100% vs. 72%, P = 0.08). CONCLUSIONS: Living in a food desert was associated with nearly three times the odds of 30-day readmission after lower extremity revascularization for CLTI. This increase in readmission may be explained through increased wound complications. These findings support considering access to healthy food as a potential modifiable risk factor for adverse outcomes, particularly in CLTI revascularization.

Qualitative perspectives of the North Carolina healthy food small retailer program among customers in participating stores located in food deserts.

BACKGROUND: The North Carolina Healthy Food Small Retailer Program (NC HFSRP) was established through a policy passed by the state legislature to provide funding for small food retailers located in food deserts with the goal of increasing access to and sales of healthy foods and beverages among local residents. The purpose of this study was to qualitatively examine perceptions of the NC HFSRP among store customers. METHODS: Qualitative interviews were conducted with 29 customers from five NC HFSRP stores in food deserts across eastern NC. Interview questions were related to shoppers' food and beverage purchases at NC HFSRP stores, whether they had noticed any in-store efforts to promote healthier foods and beverages, their suggestions for promoting healthier foods and beverages, their familiarity with and support of the NC HFSRP, and how their shopping and consumption habits had changed since implementation of the NC HFSRP. A codebook was developed based on deductive (from the interview guide questions) and inductive (emerged from the data) codes and operational definitions. Verbatim transcripts were double-coded and a thematic analysis was conducted based on code frequency, and depth of participant responses for each code. RESULTS: Although very few participants were aware of the NC HFSRP legislation, they recognized changes within the store. Customers noted that the provision of healthier foods and beverages in the store had encouraged them to make healthier purchase and consumption choices. When a description of the NC HFSRP was provided to them, all participants were supportive of the state-funded program. Participants discussed program benefits including improving food access in low-income and/or rural areas and making healthy choices easier for youth and for those most at risk of diet-related chronic diseases. CONCLUSIONS: Findings can inform future healthy corner store initiatives in terms of framing a rationale for funding or policies by focusing on increased food access among vulnerable populations.

Effect of Neighborhood Food Environment and Socioeconomic Status on Serum Phosphorus Level for Patients on Chronic Dialysis.

BACKGROUND: Elevated blood phosphorus levels are common and associated with a greater risk of death for patients receiving chronic dialysis. Phosphorus-rich foods are prevalent in the American diet, and low-phosphorus foods, including fruits and vegetables, are often less available in areas with more poverty. The relative contributions of neighborhood food availability and socioeconomic status to phosphorus control in patients receiving dialysis are unknown. METHODS: Using longitudinal data from a national dialysis provider, we constructed hierarchical, linear mixed-effects models to evaluate the relationships between neighborhood food environment or socioeconomic status and serum phosphorus level among patients receiving incident dialysis. RESULTS: Our cohort included 258,510 patients receiving chronic hemodialysis in 2005-2013. Median age at dialysis initiation was 64 years, 45% were female, 32% were Black, and 15% were Hispanic. Within their residential zip code, patients had a median of 25 "less-healthy" food outlets (interquartile range, 11-40) available to them compared with a median of four "healthy" food outlets (interquartile range, 2-6). Living in a neighborhood with better availability of healthy food was not associated with a lower phosphorus level. Neighborhood income also was not associated with differences in phosphorus. Patient age, race, cause of ESKD, and mean monthly dialysis duration were most closely associated with phosphorus level. CONCLUSIONS: Neither neighborhood availability of healthy food options nor neighborhood income was associated with phosphorus levels in patients receiving chronic dialysis. Modifying factors, such as nutrition literacy, individual-level financial resources, and adherence to diet restrictions and medications, may be more powerful contributors than food environment to elevated phosphorus.

Influence of Gestational Weight Gain on the Risk of Preterm Birth for Underweight Women Living in Food Deserts.

OBJECTIVE: Preterm birth (PTB) and food insecurity are two of the most significant public health crises in the United States. Effects of being underweight among populations with low food security are not well understood. We assess whether the protective effect of gestational weight gain (GWG) for women with low prepregnancy body mass index (BMI) differs by accessibility to sources of healthy food. STUDY DESIGN: Population-based retrospective cohort study using Ohio birth records analyzing all live births, 2006 to 2015. Analyses were stratified by maternal BMI (underweight, normal, overweight, and obese), Institute of Medicine (IOM) recommended GWG (under vs. met), and whether the U.S. Department of Agriculture (USDA) classified the residential census tract for each birth as a food desert. Food access data were retrieved from the USDA's 2018 Food Access Research Atlas. Covariates were selected using least absolute shrinkage and selection operator regression. Logistic regression models estimated the risk ratio (RR) of PTB for each group based on under or exceeded recommended GWG (reference = met), adjusting for coexisting risk factors. RESULTS: Analysis was performed on 1,124,299 births. PTB risk was highest for underweight women below GWG recommendations (no food desert: 21.3%, RR = 2.15, 95% confidence interval [CI]: 1.81-2.57; food desert: 21.0%, RR = 1.46, 95% CI: 0.96-2.21). Underweight women living in food deserts who exceeded GWG recommendations had lower PTB risk than those who met GWG recommendations (13.5 vs. 14.3%, RR = 0.85, 95% CI: 0.51-1.41). Factors other than GWG significantly associated with PTB included in the adjusted analysis include maternal age and race, education, marital status, interpregnancy interval, and presence of prepregnancy diabetes or hypertension. CONCLUSION: Underweight women who do not meet GWG recommendations are at high risk for PTB. Increasing pregnancy weight gain to a level that exceeds IOM recommendations was not associated with a reduction in PTB risk for underweight women who reside in food deserts compared with women who met GWG recommendations. KEY POINTS: · Women with low prepregnancy BMI are at high risk of PTB.. · Food insecurity increases the risk of PTB for underweight women.. · Excessive GWG for underweight women in food deserts does not reduce PTB risk..

Association between Food Deserts and Gestational Diabetes Mellitus in a Large Metropolitan Area.

OBJECTIVE: The aim of this study is to determine the relationship between urban food deserts and frequency and obstetric outcomes related to gestational diabetes. STUDY DESIGN: We conducted a retrospective cohort study of singleton births in Chicago from 2010 to 2014. Birth certificate data were analyzed and geomapped by census tract. Census tracts were categorized as "food deserts" according to the USDA Food Access Research Atlas. The primary outcome was frequency of gestational diabetes. Secondary outcomes were assessed among women with gestational diabetes and their neonates. RESULTS: Of the 191,947 eligible women, 8,709 (4.5%) were diagnosed with gestational diabetes. Those in food deserts were more likely to be younger, obese, minority race/ethnicity, and multiparous. Women in food deserts were less likely to develop gestational diabetes (3.8 vs. 4.8%, p < 0.01; adjusted odds ratio 0.91, 95% confidence interval 0.86-0.96). Women with gestational diabetes did not experience worse maternal and neonatal outcomes after controlling for potential confounders. CONCLUSION: In contrast to prior work, women in Chicago living within food deserts were less likely to develop gestational diabetes and did not experience poorer outcomes, suggesting environmental factors other than food access contribute to perinatal outcomes.