Background

In recent decades, the influence of food environments on health-related outcomes and dietary
choices have become a growing public health concern. According to the National Collaborative
on Childhood Obesity Research (NCCOR) (Lytle et al., 2016), the constituent parts of the food
environment include the physical, social and person-centered environments. While the effects of
food environments in low-income urban areas have been documented (2, 3), there is a dearth of
information on these same impacts in rural communities. In the United States1 in 5 Americans
live in rural areas of which 16.5% are faced with household food insecurity (5). These
communities are often at higher risk for poor health outcomes than their urban counterparts
(Lytle et al., 2016; Morland et al., 2009). It is therefore important to understand how the
interaction between individuals and their physical food environments impact health and food
intake within rural settings.

Dietary choice, intake and health-related behaviors are predominantly influenced by the built
environment (Morland et al., 2009), specifically the food environment (Lytle et al., 2016).
Access and availability of healthy choices in one’s food environment is therefore paramount to
securing better health. The physical food environment encompasses the availability and
accessibility of food in education centers, the home, and community venues such as restaurants,
grocery stores, or community centers. While these are physical locations from which food is
obtained, the physical food environment also includes the presence of food information and retail
food advertisement (Lytle et al., 2016).

In this systematic literature review, we aim to examine the effects of physical food environments
on dietary choices and risk factors for poor health outcomes among rural and low-income
communities. We will also examine potential gaps in the literature to inform future research.

Methods
Type of Studies
We considered both randomized and non-randomized studies for this review. Published reports
on policy or programs related to the food environment were also included. Gray literature
sources such as the United States Department of Agriculture, Centers for Disease Control and
Prevention, the United States Census Bureau, and The Food Research & Action Center were
included in the search strategy.

Type of Population
Included studies were conducted among rural or low-income populations. Rurality was defined
as being sparsely populated with low housing density and are located far from urban centers (21).
The individuals who reside within these rural areas are often less educated than their urban
counterparts, face higher income and employment disparities, and have an overall higher age
range (Institute of Medicine Roundtable on Environmental Health Sciences & Medicine, 2006).

Type of Exposure
Food environments encompass physical, social, and person-centered environments that influence
the eating habits of an individual (Lytle et al., 2016). However, this review focused on the
physical component of food environments. Exposure variables included the availability and
accessibility of foods in venues such as homes, schools, and community centers define the
physical food environment (Lytle et al., 2016). This can also include the distribution and
proximity of people to food stores, food services, or any physical location where food can be
obtained (23).

Outcomes and Outcome Measures

Data was extracted on dietary behavior (choices), dietary consumption, and dietary related
disease risk. For this review, dietary behavior was as assessed as where to buy food, what food
products to purchase, or how much to spend on food. Diet related data were included as reported
by study authors. For dietary related disease risks, we considered dietary patterns of limited
fruits and vegetables, an excess consumption of processed foods, salt, sugar, and fat. Long-term
outcomes such as trends in obesity, hypertension and diabetes, were also collected.

Inclusion Exclusion Criteria

Studies were included in this review if the populations included individuals living in rural or
underserved communities, women and children, or ethnic and minority groups. Studies also had
to include measures of physical food environments, such as grocery stores or restaurants, and
how physical food environments effect dietary health, disease risk, and personal health
behaviors. Studies were excluded if they addressed only social food environments, used schools
or the home as physical food environments.

Search Strategy
Electronic searches were conducted to identify published literature relating to physical food
environments and their impact on rural communities. Searches were conducted in May 2021
(Appendix 1). Search filters for US geographic location and English language were included.
Additional citations from studies identified in electronic search were also screened.
1. EBSCOhost 1981 to current.
2. PubMed/MEDLINE In-Process & Other Non-Indexed Citations and PubMed MEDLINE 1946
to present.

Data Collection and Analysis

Data Extraction and Management
Retrieved studies were collated and duplicates removed using Zotero. Citations were reviewed
and categorized (included and excluded studies) by title and abstracts (Appendix 1). Full-text of
included studies were extracted into data tables according to broad themes of health disparities,
health outcomes, and limitations to access. Each study can be found on the data table (Appendix
2) and elements such as limitations or gaps, main findings, and common themes were identified
from each.
Data synthesis
This systematic review took a narrative thematic approach for synthesizing data. Results from
included studies were organized thematically according to outcomes. In cases where outcomes
were not reported within a specific theme, this informed our gap analysis.

Results
The search strategy revealed 10,068 references and, based on title and abstract 54 studies were
selected to be read in full text (Figure 1). Of these reviews, 26 were included and 28 were
excluded. Exclusion after the full text had been read was due to the focus of the research being
on social food environments or the article did not discuss health outcomes.

Characteristics of Included Studies

Characteristics of the included studies are outlined in appendix 2. All the included studies were
conducted within the United States, except for one published in the Netherlands (Poelman et al.,
2018). All the studies were published in English, and range in date from 1997 to 2020. The
populations of the included studies consisted of rural and urban individuals, white, Hispanic, and
African American individuals, women, and the elderly. Settings ranged from rural communities
to national scale surveys. Major themes addressed transportation, lower socioeconomic status,
formal social support, and limited access to and availability of healthy foods. Common health
outcomes identified were cardiovascular disease, diabetes, and obesity.

Limitations to Access
In rural communities there are many things that can limit an individual’s access to physical food
environments and healthy foods. In the studies reviewed, a reccurring limitation was
transportation and distance to food stores (Garasky et al., 2006; Lyonnais et al., 2020; Olson).
While more urban than rural residents are estimated to live in food deserts, urban residents are
closer to food stores, with the nearest supermarket being within one mile. In contrast to this, rural
residents are estimated to need to travel between 10-20 miles to the nearest supermarket (10).
Rural residents who lack access to transportation are more likely to be food insecure and have
unhealthy dietary behaviors as this limits their ability to seek food stores that are further away
(Garasky et al., 2006; Holston et al., 2020; Lombe et al., 2016; Lorts et al., 2019). Due to this
lack of transportation, residents of rural communities who face food insecurities may be more
likely to shop at convivence stores closer to their homes which will have fewer healthy choice
options (Lyonnais et al., 2020). Rural areas typically lack the transportation infrastructure that
urban cities have, and residents rely heavily on personal vehicles to meet their needs as opposed
to public transportation or walking which are common in urban areas (10). This lack of access
can contribute to the food choices an individual makes and can alter dietary and health behaviors
in a negative way to satisfy restrictions presented by limited transportation.

Formal Social Support

Many of the studies also highlighted governmental support programs such as The Supplemental
Nutrition Assistance Program (SNAP) and The Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC) (Garasky et al., 2006). These programs are important for
increasing the likelihood of healthy foods being purchased, but they are insufficient at preventing
food insecurity alone (Garasky et al., 2006; Lombe et al., 2016). In one study by Holston et al, it
found that many people who receive these benefits are frustrated with them as they only provide
an average of $35 of support monthly. In addition, some stores may not have the allowed foods
that SNAP and WIC benefits can be used for. This causes more issues for individuals who have
these benefits as they have to travel to other stores to obtain specific food items, thus causing
more issues with transportation (Holston et al., 2020). Price gouging is also an issue with
governmental benefits. In the same study, it was found that food retailers would increase the cost
of SNAP and WIC permitted foods between the 1st and 15th of every month when benefits were
delivered (Holston et al., 2020) . This practice prevents recipients from using their benefits to
their full potential and limits what they can purchase. Considering this, it has been found that
SNAP recipients are less likely to purchase fresh produce and nutritious foods with their benefits
as the cost is higher than less nutritious foods (Lombe et al., 2016; Lorts et al., 2019). Although
intended to provide financial support and allow individuals to purchase healthy foods, formal
governmental support programs like SNAP and WIC face barriers that can potentially perpetuate
food insecurity and lead to poor dietary behavior and consumption practices.

Income Disparities
Six of the identified studies also discussed disparities faced by rural communities such as income
status and race or ethnicity (8, 9, 12-15). Income is a common disparity indicator explored in
relation to food access and dietary behaviors. It was shown that individuals with lower incomes
will usually have a poor diet, limited healthy food options, and adverse health outcomes (13, 14,
15). In the United States, many rural low-income areas are classified as food deserts based on the
fact that residents do not live near supermarkets that carry affordable, nutritious foods (14). This
perpetuates the cycle of low-income families not being able to access affordable foods because
chain supermarkets, which offer inexpensive healthy foods, are inaccessible (Morland et al.,
2002; Kariburyo et al., 2020). A study conducted by Kaufman, found that low-income families,
while spending overall less on food costs, spend a higher percentage of their overall income on
food as compared to high income families (16). This is due in part to low-income areas having
cheaper food options, but less income to supplement food expenditures.

Racial Disparities
Race and ethnicity also play a large role when addressing rural disparities. In three studies, race
was identified as a determinant of health in rural communities as it can be linked to income
levels and food access (Morland et al., 2002; Powell et al., 2007(Kariburyo et al., 2020).
Neighborhoods with higher proportions of minority residents are likely to have fewer chain
supermarkets, influencing dietary behavior, than their white counterparts. These white
neighborhoods reported approximately 4 times as many supermarkets (Morland et al., 2002;
Powell et al., 2007). Without access to chain supermarkets, which stock healthy food items at
lower prices, minority groups may not have equal access to healthy, inexpensive food items
(Morland et al., 2002; Kariburyo et al., 2020). In a national study aimed at evaluating differences
in diet quality by racial groups, it found that minority groups had poorer diet quality compared to
their non-Hispanic white counterparts (Wang & Chen, 2011). This is largely due to the fact that
rural, low-income and minority neighborhoods have an increased exposure to unhealthy
advertisements, have less supermarkets, and more convenience and corner stores (8-13).
Therefore, lack of healthy food stores enhances the likelihood of individuals within these
communities purchasing and consuming unhealthy food products because that is what their
limited access areas provide to them.

Health Outcomes & Increased Risk of Disease

Of the included studies, obesity was the most common health outcome addressed in relation to
food environments (8, 15, 17, 18, 19, 20). Though the literature is inconsistent at times, there is
evidence that suggests access to, and availability of different food stores can have an impact on
individual’s susceptibility to being overweight or obese (Laxy et al., 2015). Living in an area
defined as a ‘food desert’ has been found to increase the risk of obesity due to the limited
availability of inexpensive healthy foods (Cooksey-Stowers et al., 2017). In contrast to this,
living in an area defined as a ‘food swamp’ in which fast food, convenience stores, and
restaurants are in abundance, presents higher rates of obesity. It has been well documented that
food environments whether sparsely or densely populated have a significant impact on the food
consumed and dietary behaviors of individuals (15, 19, 20). Geographical locations dominated
by convenience stores and fast-food restaurants were found to be positively associated with
higher rates of obesity and were more likely to promote unhealthy eating habits (19, 20). Since
rural areas are most commonly classified as food deserts or food swamps, the individuals living
in these areas are disproportionally affected by the lack of food establishments that offer healthy
foods and are more likely to suffer the health consequences because of it.

Discussion
This systematic review examined and synthesized existing literature on food environments
within rural communities in the United States. Overall, we found that rural communities had
limited access to healthy food environments and were restricted in dietary behavior and
consumption even with social support such as WIC and SNAP. Income and race disparities
persists with low-income families more likely to reside in food desserts and minority
neighborhoods had worse food environment than white communities. Diet related disease risk
factors such as obesity was disproportionately more prevalent in unhealthy food environments
affecting rural communities.

Several barriers to access were identified, including, lack of transportation, lower income levels,
and in some cases race/ethnicity. This review documents data confirming that access to
transportation is an indicator of whether an individual will have access to healthy food or not,
especially in rural environments. In widely dispersed areas, such as rural communities,
transportation is required to be able to access a grocery store or retail food markets. Lack of
transportation pushes people to look for food establishments closer to home which typically
could limit them to convenience and corner stores, or fast food. This impact on food choice
influences consumption of high calorie, high fat, processed foods which consequently results in
adverse health outcomes such as obesity and cardiovascular diseases (Anand et al., 2015).

Governmental social support was also a reoccurring theme found within the literature. In some
studies, participation in SNAP and WIC governmental programs were discovered to offer little to
no help in eliminating food insecurity, despite that being their main goal. It was common for
recipients of these supplemental support programs to report that the extra income was not enough
to support their families for the whole month. Participants receiving financial support
experienced issues with stores not stocking foods allowed to be purchased with the SNAP or
WIC funds, price gouging, and limited options. Some of the studies included on SNAP
participation also found that recipients were more likely to spend their funds on unhealthy or
processed foods because they are generally cheaper than healthy foods and could make their
SNAP or WIC dollars go further. It is therefore imperative that these issues be addressed
(Holston et al., 2020).
Disparities in income is often predicated on race or minority status (Mode et al., 2016) The
collinearity of these determinants also influences access to healthy foods in physical food
environments and adverse health outcomes and mortality (Mode et al., 2016). Many of the
studies found that most minority groups within rural settings are likely to be low-income and are
more likely to live in food deserts or geographic locations that are not close to food
environments. This is characteristic of rural environments as they can be home to higher
populations of low-income minority groups. Racial/ ethnic minority neighborhoods was found to
be more likely to have limited access to chain supermarkets and a higher density of convenience
and corner stores as compared to White communities. Restricted access to chain supermarkets or
food retailers with a healthy variety of foods was found to be a major indicator regarding low-
income minority health. Such areas, densely populated with unhealthy food choices ultimately
predisposes communities to higher chronic disease risk factors and cardiovascular outcomes
(Poelman et al., 2018). In particular, convenience stores and fast-food restaurant access has been
associated with increased obesity rate. In contrast, access to full-service grocery stores
(supermarket) is predictive of less obesity rate in a racial/ethnic minority community (Huang,
2021).

Limitations
Limitations of this study may include an overall absence of rural health research. Also, the study
was limited to rural communities and did not examine urban or metro settings and was limited to
the United States alone.

Strengths & Weakness of Review

Strengths of this review include highlighting an underserved population of public health research
and identifying gaps and potential areas relating to food environments and rural health for future
research. Weakness may be found in our limited number of included research studies.

Conclusion
Significant disparities effect rural community members in obtaining food and maintaining a
healthy diet. While physical food environments are intended to provide people with the
necessary nutrition, they need to live healthy lives, access to food in rural communities is
severely impacted by a number of constraints. Our systematic literature review found that low-
income, minority individuals living in rural communities are the most at risk for dietary health
issues. These risks are exemplified by isolated geographic regions, limited transportation, lower
socioeconomic status, and a general lack of healthy food options. It is important that health
researchers understand the issues rural communities face when trying access healthy foods and
should aim to increase awareness of rural health and the health disparities faced by rural,
underserved communities.
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Identification 10,068 Studies

Retrieved by search Figure 1.

10,014 Studies
Excluded at title and
abstract screening

Screening

54 Studies
Identified for full text review

Eligibility

13 Studies
Full text unavailable for review

15 Studies
Excluded based on inclusion
exclusion criteria

Included

26 Studies
Included in review
 Characteristics of Included Studies (Appendix 2)

Year Title PECO Main findings Limitations/gap Themes

Author
FRAC 2019 Rural Hunger ~ Rural households ~ Formal Social
face more food support
insecurity than
urban Food insecurity

SNAP
participation is
highest among
rural communities
Nasser, H. E 2019 What is rural ~ Defining rural ~ Rural community
America? populations

Lytle, L., & 2016 Measuring Food ~

Myers, Environments –
NCCOR Measures
Registry User
Guides
Garasky, S 2006 The effects of the P: two rural Iowa The local food No reported Local food
local food counties (population of environment, Limitations environment
environment and 10,147 & 16,900) – transportation, and
social support on income levels below state Informal support Socioeconomic
rural food effect household
average, 19 & 21% demographics
insecurity food insecurity
elderly people in counties GAPS
The rural food
Transportation
environment Did not address
E: food access and predicts food racial disparities Formal social
insecurity insecurity - High support (food
prices and not Did not address stamps)
O: 10% of households having enough health outcomes
were food insecure - stores are Informal social
Mean age was 54 - 58% positively related support
 to being food
were educated beyond HS insecure
- Avg income was 42,000
 Found formal
support systems
to be insignificant
in relation to food
insecurity
Olson, C 1997 Factors contributing P: Rural New York limited access to No reported Limited
to household food County 193 women aged supermarkets, and limitations supermarket
insecurity in a rural 20-40yrs, less than 16 as a consequence, availability
upstate new York years of education, had decreased GAPS
county children living at home availability of Limited food
fresh foods, an Did not address availability
E: household food increased cost of health outcomes
insecurity food, and Higher cost of
ultimately an Did not address foods
increased risk for racial disparities
food insecurity Formal social
support
Lyonnais, M 2020 Examining P: rural eastern NC Food insecure No reported Local food
shopping patterns, Beaufort County– 370 participants were limitations environment
use of Food-Related more likely to report
respondents shopping for
resources, and GAPS Transportation
groceries at a
proposed solutions
E: physical food convenience/discount
to improve healthy
food access among
environments, availability store, less likely to Did not address Physical food
use their own vehicle health outcomes environment
food insecure and for transportation,
food secure eastern O: and less likely to
(convenience
north carolina purchase food from Did not address Stores)
residents local producers and racial disparities
participate in formal Cost of foods
social support
Formal social
Food insecure
 participants were support
more likely to suggest
solutions related to
reducing the cost of
healthy food, while
food secure
participants were
more likely to suggest
educational or
convenience-related
interventions.
Holston, D 2020 Perceptions of the P: 44 adults – majority found that price Participants were Store choice/ Food
food environment black (41) and female drove volunteers: self- availability
and access among (36), avg age 52 (26-81) outshopping selection may have
predominantly resulted in a non-
behaviors, and representative sample
Formal social
black Low-Income
E: physical food that outshopping support
residents of rural
louisiana
environments, food often depended on participants could
communities insecurity paying others for have influenced group Transportation
transportation and dynamics and each
limited food others’ responses Physical food
dollars. The social environment
participants’
and natural (convenience
experiences with food
environments access may not be stores)
made food transferable to all low-
insecurity less income individuals Outshopping
severe for some residing in rural areas,
participants, while especially those
outside of the South
Hunting/fishing &
others were gathering
unaware of
existing
GAPS
community
resources
Did not address
health outcomes
 Did not address
racial disparities
Lombe, M 2016 Examining effects P: NHANES survey Black (29%) and knowledge of the Formal social
of food insecurity Hispanic (33%) MyPyramid nutritional
respondents 18+, 185% plan is only one type of support
(Sinha) and food choices on of the poverty line experienced higher nutritional knowledge
health outcomes in (N=2,171) rates of food and may not adequately Health outcomes
households in insecurity capture the cultural
aspects associated with (diabetes,
poverty compared to non-
Hispanic Whites consumption and hypertension,
nutrition obesity, mental
(23%)
health, anxiety)
needs more
Blacks had higher
participation in
nuanced approach USDA
SNAP to measurement MyPyramid

Whites had more food choices and

knowledge of food security are
MyPyramid cyclical

Significant racial dependent

differences in variables (diet
hypertension related health risk
(higher for & malaise) not
whites/blacks) exhaustive

Whites higher rate

of poor mental
health
Powell, L. M., 2007 Food store P: National Study Non-chain supermarkets Limited to within Race/ethnicity
availability and and grocery stores are
280,675,874 people more prevalent in low- zip codes and did
neighborhood across 28,050 zip codes income and minority not account for SES/income
characteristics in neighborhoods in both characteristics of
the united states rural and urban settings
E: access to physical food Availability of
 adjoining zips
environments zip codes falling into food stores
the lowest income Study can be
quintile have fewer
chain supermarkets
subject to error if Access/proximity
list of food stores
in the D&B
database is
incorrect

Database does not

include farm
stands, or markets
Corbett, A. 2018 Food access in ~ Rural ~ Transportation
rural communities communities must Obesity
travel 10-20 Poverty
minutes for food Food Deserts

Lower rates of
vehicle access in
food deserts

Adults/youth in
rural community
more likely to be
obese/overweight
Lorts, C. 2019 Participation in the P: 983 respondents (588 SNAP All variables were Formal social
supplemental SNAP participants) with participation was self-reported support (SNAP)
nutrition assistance income below 130% associated with
program and dietary federal poverty level higher frequency SNAP Access/proximity
behaviors: Role of of SSB when participation was to food stores
community food
living closer to a based on the
environment
small grocery previous year not
current status
 store/supermarket
Other outlets to
SNAP parts who buy food rather
did not live close than those
to supermarkets included in the
had lower SSB study
consumptions
Random digit
Those living more dialing excluded
than ½ mile from those without a
supermarket/small phone
grocery store had
lover fruit/veg GAPS
consumptions Health outcomes
Transportation
Morland, K 2002 Neighborhood 216 census tracts in there are over 3 No reported SES
characteristics Jackson City, Mississippi; times as many limitations
associated with the Forsyth County, North supermarkets in Race/ethnicity
location of food Carolina; Washington the wealthier GAPS
stores and food County, Maryland; and neighborhoods Availability/type
service places
selected suburbs of compared to the Does not address of food stores
Minneapolis, Minnesota lowest-wealth health outcomes or
(Brooklyn Center, areas impacts on food Transportation
Brooklyn Park, Crystal, choice
Golden Valley, New supermarkets and
Hope, Plymouth, and specialty food stores
Robbinsdale are more common in
racially mixed and
predominately white
neighborhoods

supermarkets are 4
times more common
in predominately
 white neighborhoods
compared to
predominately black
neighborhoods
French, S. A., 2019 Nutrition quality of P: 202 urban households Lower income Did not separately Low income/SES
food purchases households examine income
varies by household E: food availability & purchase less and education in Formal social
income: The access healthful foods relationship to support (SNAP)
SHoPPER study compared with food purchasing
higher income behaviors Food quality
households
Receipts may not
represent all food
purchases, no set
number of receipts
required from each
household,

Household
configuration may
impact the quality
or foods
purchased

GAPS

No racial disparity
analysis

No health
outcomes
Ver Ploeg, M 2010 Access to ~ Limited access to ~ Transportation
Affordable, grocery stores
 Nutritious Food Is
Limited in “Food Low-income SES
Deserts households shop
where food prices Neighborhood
are cheaper attractiveness for
stores
Kariburyo, M. 2020 Place effects and P: West Virginia hot spots are Did not separate Food deserts/oases
S. chronic disease healthier between healthy
rates in a rural state: environments and unhealthy Health effects
Evidence from a with decreases in food stores
triangulation of diabetes and SES
methods
obesity rates Could not study
compared to non- whether the
hot spots, while differences in
cold spots obesity and
increase the rates diabetes rates
for both chronic between hot and
diseases colds spots and
compared to non- nonhot and non-
cold spots cold spots was
caused by demand
rural cold spots tastes orby the
have higher supply
chronic disease
rates, increasing GAPS
household income
for the lower- No racial analysis
income groups in
these cold spots Access/availability
results in a of foods
lowering of
chronic disease Transportation
rates.
Kaufman, 1997 Do the poor pay Lower-income Price studies &
Phillip R. more for food? Item households face food cost
selection and price higher food comparisons
differences affect
Low-Income
prices, but spend
household food costs less for food on SES
average than over
households Geographic
location

Formal social
support
Wang, Y., 2011 How much of P: national study: 16,103 NH Whites Weight and height Racial disparities
Racial/Ethnic people reported better were self-reported & differences
disparities in dietary awareness of
intakes, exercise, and
weight status can be
nutrition-related Based on cross- SES
explained by health risks sectional surveys
nutrition- and Health outcomes
Health-Related women, older
psychosocial factors Americans, those NHRPF & HEI
and socioeconomic with higher SES,
status among US and people with
adults
comorbidities had
better NHRPF
and HEI
Laxy, M 2015 The association P: 1507 survey neighborhood the accuracy and Health outcomes
between respondents economic hardship is validity of the proxies (obesity)
neighborhood associated with an to define the retail
economic hardship, unfavorable retail food environment
the retail food
E: food environments, food environment might be limited Economic
environment, fast health outcomes, SES hardship
food intake, and higher access to fast GAPS
obesity: findings food restaurants is
from the Survey of associated with a
higher likelihood of Limitations to
the Health of
regular fast-food access
Wisconsin
 consumption and that
fast food
consumption is
associated with
obesity

Cooksey- 2017 Food Swamps P: all 3141 US counties Food swamps highways are an Health outcomes
Stowers, K Predict Obesity based on 211 food have a higher imperfect instrument (obesity)
Rates Better Than environments indicators effect on obesity
Food Deserts in the density of highway
United States
rates than food exits influences
Transportation
E: food deserts/swamps deserts obesity rates through
mechanisms other Food
Transportation than “food swamp” deserts/swamps
can affect obesity environments
rates Neighborhood
more highways may
decrease the appeal of
characteristics
physical activity
SES/demographics
this study did not
examine mechanisms Recreation,
linking food physical activity,
environments to
obesity
fitness facilities
Ahern, M 2011 A National Study of P: Food Environment Lower adjusted obesity county-level ecological
the Association rates were associated and cross-sectional de-
Atlas and CDC data – with more per capita sign - metro counties are
Between Food county level (metro and full-service restaurants likely to be more
Environments and and grocery stores. homogeneous than non-
County-Level Health
non-metro areas)
Unexpectedly, obesity metro counties, which
Outcomes rates were positively can encompass
associated with per significant diversity
capita grocery stores
and negatively the study could not
associated with fast explore the associations
food restaurants between individual
characteristics, food
 choices, and health
outcomes.

the study could not

control for spatial
spillovers

the time periods captured

by the various data
sources are not
consistent. Obesity, for
example, was based on
data from 2006 to 2008
while mortality was from
2005 to 2006.

this study used the Food

Environment Atlas,
which is a relatively new
tool not yet validated in
terms of accuracy of the
data in describing food
environments
Nasser, H.E. 2017 What is Rural ~ 60 million people live in ~ ~
America? rural communities

19.3% of population
lives in rural America
Gilbert, D 2006 Rebuilding the Unity P: rural America- focus Covers the role of the ~ Food prices
of Health and the social, natural, and built
on Iowa/Midwest USA environments in health
Environment in Food quality
of rural Americans
Rural America:
Workshop Summary
Americans consume
large amounts of
unhealthy foods
Centers for 2014 General Food ~ Defines food ~ ~
Environment environment
Disease
Control and Resources
Connected system for
Prevention
 access to foods

Distribution of stores,
food service, and
physical entities
Anand S.S. 2015 Food Consumption ~ Reviews the link No limitations listed Cardiovascular
and its Impact on between macronutrients
and CVD disease
Cardiovascular GAPS
Disease: Importance
of Solutions Focused Reducing the risk of Does not address the Food processing
CVD can be done by effects of physical food
on the Globalized consuming the environments on
Food System appropriate amount of personal choices, does
healthy foods, (fruits, not discuss disparities in
vegetables, legumes, access to foods
fish, poultry, etc.)
Poelman, M. 2020 Relations between P: combination of 3 CVD incidence was Could not adjust for Cardiovascular
the residential fast- higher in urban areas individual-level risk
national registries where fast-food was factors such as dietary disease
food environment (2,472,004 adults) free within a 500m buffer as intake, alcohol
and the individual opposed to areas with consumption or
risk of
from CVD, living at the Fast food
no fast-food smoking.
cardiovascular same address for 15+ availability
diseases in The years Did not have exact
Netherlands: A linkage with combining
nationwide follow- E: fast food environments registries which may
up study have resulted into non-
differential
O: people with easy misclassification of the
access to fast food are exposure or outcome
more likely to develop
CVD calculated FFD
(fast food density)
only for one time
stamp in 2009

Mode, Nicole 2016 Race, Neighborhood P: N=3675, white and Participants with HANDLS sample may SES
Economic Status, higher income had not represent African
A. African Americans living Americans and Whites
Income Inequality
 and Mortality in 46 census tracts in lower health risks living outside of
Baltimore
Baltimore, Maryland Race/ethnicity
African American men
below the poverty line Variables of
E: effect of economic had 2x mortality risk incarceration history or Cardiovascular
status, and race on wealth were not disease
collected
mortality
Data was collected at Neighborhood
census tract level and economic status
may not represent
meaningful
neighborhood units

Only neighborhood data

at study enrollment was
collected (participants
may have moved to
better/worse
neighborhoods during
the study)

Gap Map (Figure 2)

 Limitation to Access Formal Social Race/Ethnicity Income Status or SES
Support

Health Outcomes

Personal Food
Choices

Number of 0 1-2 3-5 6+

Articles

Search Strategy (Appendix 2)

1 Underserved communities
2 Ethnic minorities
3 Rural communities
4 Rural
5 Neighborhood food environment
6 Community food environment
7 Poverty
8 Women and children
9 Education
10 Employment
11 Physical food environments
12 Access to foods
13 Food supply
14 Food access
15 Food availability
16 Availability of food stores
17 Food deserts/swamps/oasis
18 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8
19 #8 OR #9 OR #10 OR #11
20 #12 AND #13

(ethnic group OR rural population OR women OR children OR education OR employment) AND (food supply OR food access OR
food availability)

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