Research Brief

Assessment of Healthy Food Availabilityin Washington State—Questioningthe Food Desert Paradigm Dennis McDermot, PhD1; Bridget Igoe, MPH, RD2; Mandy Stahre, PhD, MPH1

1OfficeDepartm2Office oment ofConflict owith thiAddressSurveillaRd, TukaydrupPublishehttp://dx

130

ABSTRACT

Objective: To assess the geographic distribution of healthy food retailers in Washington State andestimate the number of Washington State residents with restricted availability of healthy food.Methods: Street network service areas were drawn around Special Supplemental Nutrition Program forWomen, Infant, and Children retailers for multiple drive times and walking distances in urban and ruralWashington State. Population characteristics inside and outside each service area were examined.Results: Nearly all Washington State residents in urban areas lived within a 10-minute drive of a SpecialSupplemental Nutrition Program for Women, Infant, and Children retailer. Among rural residents, 4.6% werein census blocks outside a 20-minute drive, but the populations were dispersed. Differential access relatedto income was attributable to a lack of transportation.Conclusions and Implications: Disparities in nutrition described in the published literature may not bedue to the geographic distribution of healthy food retailers. Programs for improving nutrition shouldconsider broader interventions to increase access to healthy food.Key Words: food, transportation, geographic information systems, social determinants of health, fooddeserts (J Nutr Educ Behav. 2017;49:130-136.)

Accepted October 14, 2016.

INTRODUCTION

Numerous studies examined the associ-ation of physical access and proximityto different types of food stores with dietand diet-related outcomes.1-8 Much ofthis research suggested that neighborhoodresidents with better access to super-markets tend to have healthier dietsand lower risk for obesity, whereas livingin food deserts, or areas with poor accessto supermarkets, is associated with lesshealthy diets and higher risk for ob-esity.2,3,5-8 The food desert researchalso suggested that there are racial/ethnic,socioeconomic, and rural/urban disparities,with food deserts more commonly located

of Healthy Communities, Surveillanceent of Health, Olympia, WAf Healthy Communities, Community-Health, Olympia, WAf Interest Disclosure: The authors’ conflis article on www.jneb.org.for correspondence: Dennis McDermnce and Evaluation Section, Washingtmwater, WA 98504; Phone: (360)17@gmail.comd by Elsevier, Inc. on behalf of the Soc.doi.org/10.1016/j.jneb.2016.10.012

in predominately African American,low-income, and/or rural communities.3-10

As a result, policy makers have launchedmajor initiatives—eg, the $400 millionHealthy Food Financing Initiative—aimedat expanding the availability of super-markets and grocery stores, citing thisas a promising strategy to address fooddeserts and, consequently, disparitiesin diet quality and obesity,11,12 althoughevidence for the effectiveness of suchstructural and environmental interven-tions has been largely absent.13 Recentstudies, however, suggested that effortsto encourage grocery stores to locate inunderserved areas may not be enoughto improve diet quality and reduce

and Evaluation Section, Washington State

Based Programs, Washington State Depart-

ct of interest disclosures can be found online

ot, PhD, Office of Healthy Communities,on State Department of Health, 310 Israel236-3791; Fax: (360) 236-2323; E-mail:

iety for Nutrition Education and Behavior

Journal of Nutrition Education and Beh

obesity. In the first controlled studyof such an intervention, researchersfound that introducing a new neigh-borhood supermarket in an under-served area did not alter dietary habitsor obesity.13 Several studies failed tofind significant associations betweendistance to food outlets and dietaryintake and bodymass index.14,15 Othersfound that the effect of spatial disparitieson access to healthy food cannot explainthe large nutritional disparities in thepopulation.16 Proximity to grocerystores may not be as consequential todiet quality as has long been assumed.

Attempts to measure the food envi-ronment have typically limited thedefinition of healthy food retailers tosupermarkets or large chain grocerystores. Inparticular, theUSDepartmentofAgriculture (USDA)FoodAccessResearchAtlas (formerly the FoodDesert Locator)17

is commonly used by cities and statesto identify food deserts as areas forintervention.18TheAtlas excludes smallergrocery stores, healthy neighborhoodstores, and farmers markets, althoughthese outlets are heralded as key strate-gies in eliminating food deserts andincreasing access to healthy food.12,19

The USDA's newer and improved Food

avior � Volume 49, Number 2, 2017

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Environment Atlas20 enables users tomapawider setof foodretailers, includingsmaller grocery stores, farmers' mar-kets, and Special Supplemental NutritionProgram for Women, Infant, and Chil-dren (WIC)-authorized stores, but itstill summarizes access by county andcensus tracts, which do not alwayscorrespond toneighborhoods inwhichtargeted food access interventions occur.In addition, both versions of the Atlasare vulnerable to the modifiable arealunit problem, which is a statistical biasinspatial analysis inwhichresultsdifferdepending on which aggregation unitsare used (eg, county, census tract, blockgroup).21

Given the various limitations of ex-isting methods, the authors chose notto summarize availability by artificialboundaries such as counties, ZIP codes,or census tracts. Rather, this studyinvestigated the food environment inWashington State in a manner consis-tent with local intervention strategies.This study had 3 principle aims: (1) toassess the geographic distribution ofhealthy food availability in Washing-ton State and determine where and ifpublic health intervention to eliminatefood deserts may be needed; (2) to esti-mate the total number of WashingtonState residents with restricted availabil-ity of healthy food; and (3) to create atool by which local assessment can beperformedbased onmeaningful neigh-borhood designations.

METHODS

The authors chose theWIC retailers asthe proxy for healthy food retailers.Since 2009, WIC retailers have beenrequired to maintain a minimum in-ventory of fresh fruits and vegetables,whole grain and soy products, low-fatdairy, and other food products.22 Tobecome a WIC authorized retailer, anindividual store must meet certain se-lection criteria established by the stateagency (eg, prices of foods, history ofcompliance, geographic need, andthe variety and quantity of foodsavailable in the store). In WashingtonState, WIC retailers must be primarilyengaged in the retail sale of food prod-ucts and general merchandise as a full-line grocery store.23 Even so, WICauthorization is independent of storesize, so smaller full-line grocery andneighborhood stores can be included

in the analysis. Addresses of WIC re-tailers for 2013 were geocoded by theWashington State Department of In-formation Resources Management.

The researchers examined physicalaccess toWICretailers atmultiple levelsof proximity based on rural and urbansetting,modeoftransportation,andlevelof availability. In urban areas, conve-nient availability was defined as livingwithin 0.5-mile walking distance of aWICretailer for residents living inhouse-holdswithnovehicles, or livingwithina 5-minute drive of a WIC retailer forresidents living in households with atleast1vehicle. In rural areas, convenientavailabilitywasdefined as livingwithin0.5-mile walking distance for residentswithout cars or a 10-minute drive forresidents with cars. Reasonable avail-ability was defined to mean livingwithin a 1-mile walking distance (nocar) or 10-minute drive (with car) forurban residents, or a 1-mile walkingdistance (no car) or 20-minute drive(with car) for rural residents. Reason-able travel distances to food retailersare not well-established, especially inrural areas, and previous research useda range of distances and times.24,25 Forthe current study, appropriate drivetimes and walking distances were selectedbased on conversations with food accessexperts in the Nutrition and ObesityPolicy Research and Evaluation Networkat the University of Washington in2011. Different drive times for urbanand rural settings were chosen to reflectdifferences in travel patterns, retailmarket coverage, driving conditions,perception of acceptable distance, andwillingness to travel to access basicgoods and services.

The study authors used Esri ArcMap(version 10.0, Redlands, CA, 2010)network analyst to generate 0.5- and1-mile,and5-, 10-, and20-minutedrivetime service areas around WIC retailerlocations. Service areas consisted ofthe area extending 100 m from thecenterline of all street segments lessthan the specified distance, or drivetime, from aWIC retailer. For each ser-vice area, urban and rural census blockswere identified that intersected the ser-vice area (inside) and those that did not(outside). Urban census blocks werethose in US Census Bureau–designatedurbanized areas or urban clusters for2010. Rural census blocks were thosethat were not urban.Washington StateOffice of Financial Management 2012

intercensal estimateswereusedfor totalpopulation by census block. To esti-mate low-income and higher-incomepopulations by census block, total pop-ulation was multiplied at the blocklevel by the census tract level fractionof individuals at or below 185% federalpoverty level based on the US CensusBureau American Community Survey2008–2012.26Theauthors thensumma-rized the total low-income and higher-incomepopulation for urban and ruralcensus blocks inside and outside eachservice area. The fraction of individ-uals living in households with andwithout an available vehicle for low-income and higher-income residentsin rural and urban census tracts wasobtained from the 2008–2012 USCensus Bureau American CommunitySurvey. Urban census tracts weredefined as those that intersected USCensus Bureau urbanized areas or ur-ban clusters. Rural census tracts weredefined as those that were not urban.

To visualize the population lackingconveniently or reasonably availableWIC retailers, the authors mapped thelow-income population outside eachservice area as dot-density by censusblock.Resultingmapswerevisuallyscannedto identify areaswhere clusters of over-lapping dots indicated a dense popula-tion with limited availability of WICretailers. Neighborhoods identified inthis way then became candidates forcloser examination. The resulting toolcould thenbeused for local assessmentin a manner consistent with localintervention strategies. For example,a 5-minute drive time buffer could bedrawnaroundacommunitycenterwherenutrition education classes were held.In another context, tribal reservationboundaries might be considered themost appropriate neighborhood defi-nition. Investigators could then sum-marize demographic data for censusblocks in the neighborhood.

Estimatesgeneratedbythesemethodswere composites drawn frommultipledata sources with various methodolo-gies and at various spatial scales. In-ferential statistics based on designedexperiments and random samples weredeemed inappropriate for these data.

RESULTS

The 10-minute drive timeWIC retailerservice area covered almost the entire

132 McDermot et al Journal of Nutrition Education and Behavior � Volume 49, Number 2, 2017

urbanarea inWashingtonState (Figure1).Of 5.7million residents living inurbanareas, 53,455 (0.9%) were in censusblocks outside the 10-minute drive timeservice area (Table 1). An additional423,721 residents (7.4%) lived outsidethe 5-minute drive time service areabut inside the 10-minute drive timeservice area (Table 1). These residentswere mostly located on the fringes ofthe urban area (Figure 1, green dots).A few dense clusters in central urbanareas warranted closer examination.For example, the city of Fife, east of Ta-coma, showed a gap in convenientWICcoverage, with 23,000 residents livingoutside the 5-minute drive time ser-vice area, 5,500 of whom were low in-

Figure 1. Availability of Special SupplementaChildren (WIC) retailers in the Puget Sound meincomeurbanpopulation livingmore thana5-mcate low-income rural population living more th

come (24%) (Figure 1). This areacorresponded with the Puyallup In-dian Reservation. Although only thePuget Sound region is shown here, asystematic visual scan of the statewidemap revealed few other dense urbanareas outside the 5-minute drive timeservice area and very few outside the10-minute drive time service area.

The 20-minute drive time WICretailer service area covered nearly allpopulation centers inWashington State(Figure2).Of1.1million residents livingoutside urban areas, 50,386 were incensus blocks outside the 20-minutedrive time service area (4.6%) (Table 1).Thispopulationwasdispersed inremoteareas or isolated small towns. An addi-

l Nutrition Program for Women, Infant, andtropolitan area. Green dots represent low-inutedrive fromWIC retailers.Reddots indi-an a 20-minute drive from WIC retailers.

tional 230,878 (21.1%) lived outsidethe 10-minute drive time service areabut inside the 20-minute drive time ser-vicearea (Table1). Inurbanareas, 60.8%of thepopulation (3.5million residents)lived inside the 1-mile service area, and30.0% (1.7 million residents) lived in-side the 0.5-mile service area. In ruralareas, most residents were outside boththe 0.5-mile service area (92.7%; 1.0million residents) and 1-mile (87.3%;1.0 million residents) service area.

A smaller fraction of the low-incomepopulation lived outside WIC retailerservice areas compared with the higher-income population in all but 2 serviceareas. For rural 10-minute drive timeand 20-minute drive time service areas,a slightly larger fraction of low incomeresidents live outside the service areasthan did higher-income residents.

Applying the fraction of residentswithoutvehicles (Table2) to thepopula-tion totals outside each service area(Table 1), the authors estimated thenumber and percentage of low-incomeandhigher-income residentswho lackedconvenient or reasonable WIC retaileravailability. There were 117,344 low-income residents inWashington State(6%; 71,872 urban and 45,472 rural)who lacked reasonably available WICretailers.Of these, 91,239 (78%) lackedavailability owing to the lack of anavailable vehicle; that is, they were in-side the 10-minute drive time (urban)or 20-minute drive time (rural) area,outside the 1-mile area, and lived inhouseholds with no vehicle. An esti-mated 311,321 low-income residents(17%) lacked convenientWIC retailers(209,879 urban and101,442 rural). For139,774 of these (45%), the lack re-sulted from not having a vehicle. Bycontrast, 141,388 higher-income resi-dents (3%) lacked reasonable availabil-ity, 63,752 (45%)ofwhomexperiencedit because of a lack of transportation;and 671,501 higher-income residents(14%) lacked convenient availability,129,608 (19%) of whom also did nothave transportation.

DISCUSSION

In Washington State, there are racial/ethnic and socioeconomic disparitiesin nutrition and nutrition-related out-comes.27,28 However, these disparitiesdo not appear to be attributable to thegeographic distribution of healthyfood retailers. This study found few

Table 1. Population Residing Inside and Outside Special Supplemental Nutrition

Program for Women, Infant, and Children Retailer Service Areas

Service AreaIncome <185%

PovertyIncome $185%

Poverty Total

Urban (n ¼ 5,722,844)

0.5 mileOutside 1,014,124 2,990,437 4,004,561Inside 546,400 1,171,883 1,718,283

1 mileOutside 502,254 1,740,870 2,243,124Inside 1,058,270 2,421,450 3,479,720

5-min drive timeOutside 93,846 383,330 477,176Inside 1,466,678 3,778,990 5,245,668

10-min drive timeOutside 9,779 43,676 53,455Inside 1,550,745 4,118,644 5,669,389

Rural (n ¼ 1,094,886)

0.5 mileOutside 265,999 749,208 1,015,207Inside 28,100 51,579 79,679

1 mileOutside 247,490 708,698 956,188Inside 46,609 92,090 138,699

10-min drive timeOutside 77,701 203,563 281,264Inside 216,398 597,225 813,623

20-min drive timeOutside 16,326 34,060 50,386Inside 277,773 766,728 1,044,501

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places in Washington State that couldbe considered food deserts for residentswith access to cars. Less than 1% ofthe urban population lived outside the10-minute drive time buffer. Less than5% of rural residents lived outsidethe 20-minute drive time buffer, andthese populations were geographicallydispersed in isolated areas, not concen-trated in deserts. Lacking access to ahousehold vehicle may be a salientissue related to food access for low-income populations. Among low-incomeresidents without reasonable access toWIC retailers, the majority (78%) lackedaccess because of the lack of a vehicle.

Although it is necessary, ensuringtransportation may not be sufficient toreduce nutritional disparities. Emergingresearch shows that the nutritionalquality of purchases varies with the so-cioeconomic characteristics of house-holds shopping in the same store, withhousehold purchase quality signifi-cantly related to income and education.This could explain why the first

controlled study in the US to look atthe impact of improving food accessin an underserved area by developinga new supermarket found that theintervention moderately increased per-ceptions of food access but did not pro-duce the desired changes in residents’food purchasing and consumptionhabits.13 Food access is a multidimen-sional and complex concept.2 Whereasproximity to the nearest food storedominated food access research, it isnot the only factor to be considered.Studies showed that people do notnecessarily shop for food at the storeclosest to home,29-33 which suggeststhat proximity may not even be themost important factor. In addition tosocioeconomic factors,16 food quality,2

food price/affordability,2,16,34,35 in-storeselection,2 cultural acceptability,2 per-sonal preferences,2,16,35 store hours,2

and in-store environment34 are all fac-tors that influence food choice deci-sions and where people actually shopfor groceries.

In multiple states, evaluations ofstock inventories in small food stores,small grocery stores, and conveniencestores approved for WIC participationshowed significant improvements inthe availability of many healthy foodsowing to WIC's minimum stocking re-quirements that went into effect in2009.36,37 In July, 2015, WashingtonState further increased its minimumstocking requirements, and authorizedWIC retailers now must carry an evengreater number and variety of staples.2

These new requirements could affectthe landscape ofWIC retailer availabil-ity if smaller stores cannot meet thenew requirements owing to restrictedshelf and/or inventory space.

Use of WIC retailers as a proxy forhealthy food stores allowed smallerstores that sell healthy foods to beincluded in the analysis, but it limitedtheability todrawconclusions regardingincome-related disparities because WICfocuses on low-income populations.The finding that a larger proportion oflow-income residents lived in closerproximity to WIC retailers than didhigher-income residents may simplydemonstratethatWIChasbeeneffectivein its efforts to reach the low-incomepopulation inWashington State, or thatretailers inhigher-incomeneighborhoodsmay choose not to participate inWIC.

This study's findings differed fromthoseof theUSDAFoodAccessResearchand Food Environment Atlases, whichestimated that Washington State hasvast food deserts. Differences in buffersize and the Atlases' use of artificialboundaries such as counties and censustracts21 are likely explanations for thisdiscrepancy. Methodological heteroge-neity in the food desert research isconsiderable, which makes it difficultto compare across studies and has pro-duced inconsistent results amongstudiesthat examined associations between thefood environment and nutrition-relatedoutcomes.1-3,6 A previous study inSeattle–King County, WA demonstratedthat estimates of populations livingin food deserts depend on how thecriteria are defined andwhatmeasurementtechniques are employed.38

The approach used in this study hadadvantages, already discussed, but alsosome limitations. Although useful as aproxy, WIC retailers are not compre-hensive of all healthy food retail; somestores choose not to participate andsome may qualify but are not

Figure 2. Availability of Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) retailers in rural WashingtonState. Red dots indicate low-income rural population living more than a 20-minute drive from WIC retailers.

134 McDermot et al Journal of Nutrition Education and Behavior � Volume 49, Number 2, 2017

authorized. It is alsopossible thatnot allWIC retailers are in compliance withthe minimum stocking requirementsat all times. The assessment of food de-serts by visual inspectionwas subjectiveand vulnerable to perceptual bias.Vehicle accesswas limited to rural vs ur-ban percentages. A more nuanced anal-ysis would consider geographic variationin vehicle access at the census tract

Table 2. People Living in HouseholdsWithout a Vehicle26

Income Urban Rural

<185% poverty 12.6% 6.4%$185% poverty 2.7% 1.5%

level. The choice of reasonable andconvenient drive times and walkingdistances was arbitrary, although itwas guided by expert opinion and a re-view of the published literature. Finally,the methods were designed to providedescriptive assessment of the nutritionlandscape for the purpose of guidingpublichealth efforts; theyarenot appro-priate for statistical hypothesis testing.

IMPLICATIONS FORRESEARCH ANDPRACTICE

Transportation options including house-hold vehicle access should be includedin research on the food environment

and food access. Lackof transportationis a barrier to accessing food for low-income residents who do not own acar or cannot afford the cost of takingpublic transportation.3,39-44 Buildingnew stores or increasing healthy foodin existing stores may not improveaccess for the most vulnerable populationif transportation issues are not alsoaddressed. Because it is not feasible toput a healthy food store within a halfmile of every person in the state,expanding home delivery options,especially for individuals with limitedmobility or who lack vehicle accessand public transportation options, mightbe a more fruitful approach. For example,authorized by the 2014 Farm Bill, theUSDA is proposing for the first time

Journal of Nutrition Education and Behavior � Volume 49, Number 2, 2017 McDermot et al 135

to permit online grocery purchasing anddelivery services to accept SupplementalNutrition Assistance Program (SNAP) benefitsas payment, allowing for home deliveryto low-income customers who are un-able to shop for food.45

This study highlighted the pointthat assessment of the food environ-ment is highly sensitive to the choiceof method.38 Methods developed fora nationwide scale give local resultsthat are incomplete at best andmisleading at worst. For example, theUSDA Food Environment Atlas sug-gests that Washington State's manyand large protected wilderness areasand the Hanford Nuclear Site havelow food access, but clearly these arenot appropriate areas to target food ac-cess interventions. State and local orga-nizations are encouraged to developassessment methods that reflect localpriorities, geography, and meaningfulneighborhood designations. For ex-ample, in Washington State, manykey nutrition and food access inter-ventions focus on the WIC andSNAP programs, either directly or incollaboration. The use of WIC retailersas a proxy for healthy food helpedalign this study with public healthstrategies. The boundary-less approachis not feasible at a national scale, butat a state or local level it allows theuser to identify areas of concern thatmay not correspond to counties orcensus tracts, and to account for localfeatures not included in nationaldatasets.

Finally, future food access researchand practice should look beyondmere proximity to healthy foodstores as measured by distance or time-geography. Food environment researchhas been dominated by studies aimingto characterize and identify food de-serts, often neglecting other harder tomeasure but important factors suchas food cost, convenience, quality,and store accommodations. Publichealth policy and practice should alsoturn its attention to these in-storecharacteristics of the food environ-ment. Current strategies in WashingtonState focus on improving healthy foodpurchases in existing retailers throughdirect monetary incentives, expand-ing SNAP and WIC acceptance atfarmers’markets, and nutrition educa-tion. In light of this study, future ef-forts must also address barriers relatedto transportation.

ACKNOWLEDGMENTS

This researchwas supported by theCen-ters for Disease Control and PreventionState Public Health Actions to Prevent andControl Diabetes, Heart Disease, Obesityand Associated Risk Factors and PromoteSchool Health (CDC-FRA-DP13-1305).The funding body did not have a rolein the design of the study; in the collec-tion, analysis, and interpretation of data;or in writing the manuscript. The au-thors acknowledge the Nutrition andObesityPolicyResearchandEvaluationNetwork at theUniversity ofWashing-ton for their expertise and guidance.

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CONFLICT OF INTEREST

The authors have not stated any con-flicts of interest.