10/5/12 ¡ Working to improve the food Topics environment in urban settings: • Changing the Food Environment Findings, lessons learned and policy • Baltimore linkages ▫ Part 1. Working with small food stores ▫ Part 2. Working with prepared food Policy Joel Gittelsohn, PhD sources Linkages Betsy Anderson Steeves, MS, RD ▫ Part 3. Multi-institutional Center for Human Nutrition interventions Johns Hopkins Global Center on Childhood Obesity Johns Hopkins Bloomberg School of Public Health • Summary and Lessons Learned October 5, 2012 Food Environment and Obesity Ways to Change the Food Environment (1) • Food availability associated with diet and higher • Changing access to foods within retail food youth BMI (French 2001) stores & prepared food sources by: • Fewer supermarkets is associated with higher BMI and chronic disease rates (Morland 2006; Bodor JN 2010) ▫ Decreasing availability of less healthy foods ▫ Increasing availability of healthy foods in small • Distance of 1.76 miles or greater from home to stores grocery store was a predictor of increased BMI ▫ Changing the physical location of foods (e.g., store (Inagami et al 2006) layout) ▫ Store renovations (e.g., adding refrigeration units • More small stores and prepared food sources are for produce) associated with higher BMI and chronic disease ▫ Manipulating price rates (Bodor JN 2010 Maddock, 2004) 3 Ways to Change the Food Environment (3) Ways to Change the Food Environment (2) • Policy • Changing access to foods within ▫ Setting small store criteria/standards neighborhoods by: ▫ Menu labeling ▫ Building new supermarkets ▫ Rezoning ▫ Developing farmer’s markets ▫ Taxes (E.g., SSB tax) ▫ Improving transportation • Work in multiple settings/ institutions at the • Changing setting for provision of information (e.g., POP promotions) same time ▫ Integrating interventions in food stores, restaurants, schools, worksites, etc. 1 ¡
10/5/12 ¡ Ways to Change the Food Environment (4) Some questions • Other approaches: • Which approach most effective? ▫ Improving food networks (distributors, • Which combination of approaches are needed? producers, retailers) • How to develop/select approaches? ▫ Improving local production (producers) ▫ Increasing nutrient content of foods • Which approaches are more cost-effective – for (manufacturers) all stakeholders? ▫ Changing packaging of foods (manufacturers) • How to enhance sustainability? Corner stores Example. Baltimore City Food Environment Part 1. Working in Small Stores Baltimore Baltimore Baltimore Healthy Stores A A L L T T E E H H H H Y Y S S S S S S S S • East Baltimore: T T E E E E T T O O O O R R R R intervention area • West Baltimore: comparison area • Store sample ▫ 2 supermarkets/area ▫ 6-7 small stores/area • Consumer sample ▫ ~87 respondents/area Behind the glass 2 ¡
10/5/12 ¡ Top ten sources of energy, fat and sugar of low income African American adults in Baltimore (Sharma et al, 2009) Key Issues from Interviews Energy Sugar Food Item (%) Food Item Fat (%) Food Item (%) • From Store Customers: “I would love to buy/eat Sodas 9.5 Chicken 12.1 Sodas 34.1 Hot dogs, Sugary drinks (iced healthy foods but they are…” Chicken 8.2 sausages 8.1 tea, punch) 15.2 ▫ Too expensive Breads 6.0 Chips 6.3 Juices 9.0 Cake, donut and ▫ Not available in the stores I shop in other pastry 4.2 Meat dishes 5.2 Sugar and syrup 8.3 ▫ Are of poor quality in the stores I shop in Sandwiches and Margarine and Cake, pastry and burgers 4.0 butter 5.2 donut 4.2 Cake, donut and • From Store Owners/Managers: “ I would love to Sugary drinks 3.8 other pastry 5.1 Candies 4.1 stock healthy foods but …” Mayo, salad Chips 3.7 dressing, dips 4.9 Ice cream 3.2 ▫ No one buys them Sandwiches and ▫ The last time I stocked (xxxxx) it just sat on the shelves Pasta dishes 3.3 burgers 4.5 Cookies 2.5 Meat dishes 3.1 Cheese 4.3 Fruits 2.1 Candies 2.9 Eggs 4.0 Cereals 1.6 Total 48.7 Total 59.8 Total 84.3 Baltimore Baltimore A L L T A T Community workshops for planning E E H H Increasing supply: Corner H H Y Y S S S S S S S S E E stores stock healthier foods T T T T E E O O O O R R R R • 1-3 new foods per store per phase • Start with “low-hanging fruit” • Incentives/Information ▫ Stocking guidelines ▫ Promotional materials to create demand ▫ Incentive card to wholesaler ▫ Provide small supply Interactive Sessions in large and Increasing Demand: Visual Materials small food stores 3 ¡
10/5/12 ¡ Materials and training for Korean Impact o on S Stocki king a and S Sales American store owners • Nutrition Education l Cultural Guidelines Stocking Score Sales Score Booklet (Korean) (Korean) (range 0-10) (range 0-10) Intervention Comparison Significance Intervention Comparison Significance Baseline 5.9 ± 2.0 6.8 ± 1.6 NS 4.4 ± 1.8 5 ± 1.5 NS Post - phase 8.3 ± 1.0 6 ± 1.8 0.004 7.1 ± 2.0 5.8 ± 1.8 0.05 Post- 7 ± 2.0 5.5 ± 1.5 0.009 6.4 ± 1.8 4.7 ± 1.5 0.003 intervention Song et al, Public Health Nutrition, 2009 20 / 63 Baltimore Food Policy Advisory Consumer Results Committee (Food PAC) • N=85 respondents measured pre and post • Early 2009: Baltimore City Food Policy Task • After adjustment for baseline value, age, sex and SES: Force develops report with recommendations ▫ Significant impact on food preparation methods and • Late 2009: Holly Freishtat, MS, CN, named frequency of purchase of promoted foods Baltimore City Food Policy Director ▫ Positive trend for healthy food intentions • Early 2010: Baltimore Food PAC forms, begins to implement recommendations of the task force Gittelsohn et al, Health Education and Behavior, 2009 Policy: Baltimore Cornerstore Criteria Program Part 2. Changing the prepared food • Phase 1: Pilot source environment: Baltimore ▫ Work with 2-3 stores ▫ Star system for healthy stores Healthy Carryouts ▫ Produce display or small store structural incentive (< $300) ▫ Promotional signage for healthy foods ▫ Monitored by BHCK study staff • Phase 2: Optional criteria ▫ Same Phase 1, for up to 100 stores ▫ Monitored by City Health Department • Phase 3: Legislation ▫ Same as Phase 1 and 2, for all small stores ▫ Increased fees for non-compliance ▫ Monitored by City Health Department 4 ¡
10/5/12 ¡ Background: Prepared Food Consumption Patterns Prepared Food Sources in Baltimore • Americans spend nearly half of their food dollars • A total of 144 Prepared Food Sources (PFSs ) were observed eating out (USDA 2011) (ground-truthing method) in low-income neighborhoods of Baltimore (Lee et al. 2010) • One-third of daily caloric intake comes from foods purchased and/or eaten away from home (Guthrie et ▫ 72% carryouts (n=104) al 2002) ▫ 15% corner stores with deli/take-out • A large proportion (76.8%) of foods eaten away from ▫ 10% Fast food restaurants home consists of prepared foods purchased at fast food restaurants and carryouts (USDA 2011) ▫ 5% Sit-down restaurants • Prepared foods are typically calorically dense and higher in fat and are associated with increased BMI Carryouts : Food establishments selling ready- and weight gain (Pereira et al 2005, Duffey et al 2007, to-eat food and beverage for off-premises consumption (Zoning Code of Baltimore City. 1-123.1 ) Beydoun et al 2011) Exterior & Interior of Carryouts Average Monthly Expenditures by Food Sources in Baltimore Fast food , $44 Covered market, $43 Prepared food sources : $288 Sit-down restaurant, $48 Supermarket , $274 Carryout, $153 Corner Store, $140 Palmer et al 2007 Study Design: BHC Pilot Trial Baltimore Healthy Carryout Aims • To develop, implement and evaluate a culturally appropriate multi-component carryout intervention to reduce risk factors for diet-related chronic diseases in a Intervention group Comparison group low income urban setting N= 4 N= 4 1 st generation Korean 1 st generation Korean American owned carryouts Ø Conduct formative research on the availability, pricing American owned carryouts (N=2) (N=2) and consumption of carryout foods Ø Develop and test interventions African American owned African American owned carryouts (N=2) carryouts (N=2) Ø Develop and pilot instruments to assess the efficacy of environmental interventions in carryouts ▫ Matching variables : ethnicity, location, physical environment of the carry-out 5 ¡
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