Food in the Desert
In a city where the deep-fryer is king, what does it take to sell yogurt, salad and wraps?
During the lunch-hour peak at Shareef's Grill in West Baltimore, a tightly packed line stretches all the way from the Plexiglas-enclosed counter straight out the front door.
Hungry customers chat in the 15-by-20-foot shop as they wait for the usual carryout fare of wings and fries, steak sandwich and Pepsi, as well as the not-so-usual: a hot veggie wrap, a turkey wrap, corn chowder, 100-percent juices and other healthy items. Also atypical for an urban carryout are signs on the walls that declare, "We only use peanut oil when frying foods," and "Shareef Sorbet: all natural, no high fructose corn syrup, pounds of fruit in every batch," and "One of Baltimore's Healthy Carryouts."
But then Shareef's, located in the economically depressed Harlem Park neighborhood, defies convention. The beneficiary of an initiative called Baltimore Healthy Carryouts led by the Bloomberg School's Center for Human Nutrition, Shareef's encourages its clientele to make better food choices. The project is just one way in which researchers, policymakers and others are making strides toward understanding "food deserts" and their toll on low-income urban populations.
Characterized by areas where the distance to a supermarket is more than one-quarter mile and where more than 40 percent of households do not have access to a vehicle, food deserts commonly plague large American cities like Baltimore, where one in five people lives in one.
With supermarkets out of easy reach, Baltimoreans living in food deserts often rely on corner stores and carryouts for their meals. According to 2012 data compiled by the School's Center for a Livable Future (CLF), the city teems with 440 such corner stores and 709 carryouts, while boasting just 47 supermarkets.
"If you went outside this building [in East Baltimore] and spun around in a circle and walked in whatever direction you wanted, you would probably have to walk a mile or more before you hit a supermarket-probably two miles," notes Joel Gittelsohn, PhD, MS, with both the Center for Human Nutrition and the Global Center for Childhood Obesity. "But if you walk a block or two, you're going to hit a corner store or a carryout or both."
The stakes are significant: The high-sugar, high-fat, low-fiber diet commonly consumed in poor communities is linked to elevated rates of obesity, which in turn raises the risk for diabetes, heart disease and some kinds of cancer.
Bringing healthy food to the city means working the angles of supply and demand.
Gittelsohn has spent the past 10 years exploring the relationship among low-income minority populations, food access and health via the Baltimore Healthy Stores initiative. He's identified barriers to healthy eating in the city and fashioned strategies to increase access to a nutritionally adequate diet, improve food security and reduce the risk of diet-related chronic diseases.
"It's a supply-and-demand issue," he explains. "We work with local food suppliers to increase the supply of healthy foods, and we work with local consumers to increase the demand for those foods, because you can't have one sustainably without the other."
Typically, corner stores and carryouts offer few, if any, options like whole wheat bread, fruits and vegetables, and low-fat milk. Instead, they sell a cornucopia of high-fat, high-sodium and high-sugar foods.
"Most of the people in these communities say that they would love to eat healthier foods," Gittelsohn notes, "but they cost too much or they're of poor quality or they are just not available." Residents have a "relatively good concept" of what healthy foods-and unhealthy ones-mean. Fruits and veggies: good. Sugary sodas: bad. "It's not so much of a knowledge-gap issue," he says.
Following research and feasibility studies, Gittelsohn's Healthy Stores has launched three programs to increase access to healthy foods: B'more Healthy: Retail Rewards; B'more Healthy: Communities for Kids; and Baltimore Healthy Carryouts.
Conducted in 2011, Healthy Carryouts worked with eight West Baltimore shops located in food deserts: four, including Shareef's Grill, emphasized healthy items; four others were left untouched, says former program coordinator Seung Hee Lee, PhD '13. The "healthy" carryouts redesigned menus and signage; promoted bottled water, juices, salads and yogurt; and offered new combo meals like a grilled chicken sandwich, baked chips and bottled water that were sold at a discount.
"In Baltimore City carryouts, the deep-fryer is king," Gittelsohn notes. "Many of these places do not even have a grill or a way to cook food in a low-fat way." To alleviate that problem, the program provided one of the shops with a George Foreman grill.
Sales of healthy foods at the intervention shops went up dramatically-even after just the menus and signage were changed, says Lee, now an Epidemic Intelligence Service officer with the CDC. The final numbers showed a 100 percent sales increase for healthy options and an overall increase in gross receipts; meanwhile, the control carryouts experienced an overall decrease in gross sales during the same time period.
Additionally, pre-intervention versus post-intervention customer surveys indicated a behavioral change. "We noticed that those who recognized the Baltimore Healthy Carryouts intervention materials were more likely to buy healthier items-and a greater variety of healthier items," Lee points out.
Count Tina Jackson among them. The Shareef's Grill customer took notice of the green-leaf-flagged hot jumbo lump crab wrap filled with broccoli before placing her order. "I'm trying to be more conscious about eating heart-healthy foods," she explains. "I like when food is healthy but still tastes good." Then she jokes, "Make me at least feel like I'm not eating healthy."
For his part, Gittelsohn expresses optimism in what the Healthy Carryouts study demonstrated: Not only did healthy food sales improve in the intervention carryouts, people also bought fewer unhealthy items. "Sometimes you worry about these interventions in that you could just get people to eat more healthy foods, but they will keep eating doughnuts and high-sugar cereals at the same time," he says.
For now, the four healthy carryouts "are on their own," he adds. "However, many more carryouts will be part of the B'more Healthy: Communities for Kids trial, which starts in spring 2014."
An A-Ha! Moment in City Markets
Baltimore Healthy Carryouts may have started a ripple effect. In 2012, the city government's Baltimore Food Policy Initiative (BFPI) adopted the program's basic model and introduced it to carryouts operating in two of the six city-owned public markets. First established in the mid-18th century, the markets sold fresh produce, meats and dairy products for more than 200 years, but over the past several decades they transitioned into offering mostly prepared meals.
"Some of the markets are more like food courts," says Holly Freishtat, the city's food policy director and head of BFPI-an amalgam of city departments that seeks to increase access to healthy food.
While serving an internship with BFPI in 2011 and 2012, Seung Hee Lee worked with its then healthy food coordinator, Rachel Yong, MSPH '13, to analyze a CLF food assessment survey of the markets. They found that four lie in food deserts, and 70 percent of vendors in all six markets operate as traditional carryouts-in effect, implicating the city itself in Baltimore's paucity of healthy food.
"That was an a-ha! moment," admits Freishtat.
Subsequently, BFPI worked with 30 vendors in the Lexington and Northeast markets, both located in food deserts, to implement Gittelsohn's multifaceted Healthy Carryouts strategy, dubbing its initiative Get Fresh Baltimore. That meant designing new green-leaf-highlighted menus to emphasize the existing healthy choices, introducing new options and creating nutritious combo meals.
"The markets' management now prioritizes and understands the dire need to have more healthy food venues," says Freishtat.
In formulating food-access policy, BFPI has also successfully tapped into CLF's food-mapping project (mdfoodsystemmap.org), which graphically depicts Maryland's food system, including farms, processors, distributors and retail food outlets. Its Baltimore City map effectively portrays the city's urgent need for solutions. "[The map is] very good at targeting where need exists, how many people live in a food desert and what a food desert looks like," she says.
Using CLF's map, BFPI worked with the USDA to revamp its own food desert map and how a food desert is defined. That resulted in increased federal Healthy Food financing that is used to develop and equip grocery stores, small retailers, corner stores and farmers markets selling healthy food in underserved areas.
The Supermarket as Lab
Not long after his wholesale/retail-food company bought a Southwest Baltimore grocery store in 2008, CEO Benjy Green roamed its aisles, discreetly noting his customers' purchases.
"They were filling their carts primarily with unhealthy stuff," he recalls, "and I couldn't stand seeing what people were buying. I really felt like I needed to give back [to the community]. I thought, 'What can I do?'"
The community can use the help. Food Depot serves a racially mixed, economically challenged neighborhood vexed by a high incidence of obesity, diabetes and hypertension. The neighborhood's average life expectancy of 65 is one the lowest in the city.
Wanting to understand his customers' shopping habits and help change their behavior, he contacted the CLF in 2010, suggesting collaboration: "I said, 'There's a need here. Use us as a lab.'"
CLF accepted Green's challenge. "It was a researcher's dream," says Anne Palmer, MAIA, program director of CLF's Food Communities and Public Health Program (FCPHP), which launched a two-year campaign in 2011 called Eat Right Live Well (ERLW). The campaign sought to answer a simple question: Can changing a supermarket's environment induce its shoppers to become more healthful consumers?
Can a supermarket's environment help consumers make healthy decisions?
First, investigators quizzed Food Depot customers to explore how their limited financial resources influenced their purchases. More than 70 percent receive federal Supplemental Nutrition Assistance Program [SNAP] benefits, the formal name for food stamps. They also asked shoppers how the store's layout affected their decisions to buy nutritious items and solicited suggestions on how to promote more healthful purchases.
Just as Gittelsohn contends, the results indicated that low-income residents know healthy from unhealthy. "They have thought about it significantly," Palmer observes, "and they're making very rational choices of what's available to them."
That includes looking elsewhere for healthy food. "People cannot purchase what is not accessible," explains Joyce Smith, who works with Palmer as a community liaison coordinator in Southwest Baltimore. "[When feasible] they travel to other communities-some beyond city limits-where better supermarkets are located."
In cooperation with Green, the FCPHP team moved into intervention mode in 2012. They reduced healthful foods' prices and gave in-store tests, moved healthy choices to eye level, displayed signage encouraging the purchase of low-fat, low-sodium and low-sugar options, set up end-of-cap aisles and register racks featuring healthy grab-n-go items and suggested recipes to customers. The team also worked with store employees on how to better promote healthier food choices and collaborated with a staff dietitian hired by Green.
By the time the intervention concluded, Food Depot had been transformed. Green replaced its warehouse-like sensibility with a warmer, more inviting atmosphere, hired more staff, improved the variety of produce (adding yucca, boniato, chayote squash and tomatillos), began buying locally when possible and started making low-fat prepared foods.
"It's unique in terms of a supermarket in a low-income neighborhood," says Palmer, "both visually and display-wise."
On a recent December morning, Theodora Morris was perusing the augmented produce section, with her husband, Eugene, following attentively. She was shopping for the two of them, their three children and one grandson. "I like to shop healthfully," notes Morris, placing two bags of mini carrots in her cart. "The vegetables here are good, and they have better prices."
Barbara Countee, at the store to buy salmon, is also price conscious. "Healthy choices can be very expensive," she says. Still, she prefers fresh vegetables-"cabbage, lettuce, greens, broccoli"-to frozen ones, and she avoids the canned variety entirely.
Meanwhile, over in the store's dairy section, Teshea Jackson-shopping for herself, her daughter, her fiancé and his daughter-hauls a gallon of 1 percent milk out of a chilled case. In an effort to consume less fat, "I made the change from [whole milk] about a year ago," she relates. But like Morris and Countee, she considers price extremely important; she cuts costs by choosing canned fruit over fresh.
It's too soon to say if the two-year program made a difference. Pam Surkan, PhD, ScD, the project's principal investigator and an assistant professor in International Health, is still analyzing the data.
From a business point of view, it's "an uphill battle," says Green. "People make their own choices; we can't tell them how to act. And we can't simply stop selling the stuff that may not be very good for them-we're in business," he says. "So we have the good and the bad stuff and everything in between."
Why It's Hard To Eat Healthy
The battle against food deserts may never end, but City food policy director Freishtat thinks they can be eliminated in some areas and at least reduced in others.
For her, the most imposing obstacle to that goal resides in Washington, not Baltimore: decreasing funds for SNAP benefits. In January 2014, the House of Representatives approved a Farm Bill cutting the federal food stamp budget by $8 billion over 10 years. (Initially House leaders had sought to cut $40 billion from the SNAP budget, which had doubled in size during the national recession.) On February 4, the Senate approved the bill. President Obama signed the bill into law on February 7.
"We cannot forget that SNAP is an economic driver in our city-$422 million annually is spent on SNAP in the city and surrounding areas," says Freishtat. "Retailers are impacted by any fluctuations to the SNAP budget, as are the individual residents."
Depending on how the SNAP reductions affect people and retailers, more food deserts could appear in Baltimore and other cities.
Anticipating additional cuts in SNAP funds, Food Depot's Green expects to see shopping patterns change at his store as customers choose cheaper, unhealthful items over more expensive, healthy ones. He cites processed white bread instead of whole wheat as an example.
Palmer believes that knowledge still holds the key to reducing food deserts. "We want to provide qualitative research to the public and academia that gives a better understanding of how hard it is for people to eat healthfully," she says. "So often we want to say, 'Oh, those poor people living in those neighborhoods,' or we victimize them-we do them a disservice, as if they don't understand or haven't thought about choosing and eating healthful foods.
"We need to turn that on its head and say, 'Why do we make it so hard for people to eat healthfully?' We need to convey how difficult it is to do what we're asking people to do, and really respect that they understand their circumstances way better than we ever could. They are partners in this."