Creating Healthy Food and Eating Environments: Policy and

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Creating Healthy Food andEating Environments:Policy and EnvironmentalApproachesMary Story,1,3 Karen M. Kaphingst,1,3

Ramona Robinson-O’Brien,2,3 and Karen Glanz4

1Healthy Eating Research Program, 2Adolescent Health Protection ResearchTraining Program, 3Division of Epidemiology and Community Health, School ofPublic Health, University of Minnesota, Minneapolis, Minnesota 55454-1015;email: [email protected], [email protected], [email protected] Prevention Research Center, Department of Behavioral Sciences and HealthEducation, Rollins School of Public Health, Emory University, Atlanta, Georgia30322; email: [email protected]

Annu. Rev. Public Health 2008. 29:253–72

First published online as a Review in Advance onNovember 21, 2007

The Annual Review of Public Health is online athttp://publhealth.annualreviews.org

This article’s doi:10.1146/annurev.publhealth.29.020907.090926

Copyright c© 2008 by Annual Reviews.All rights reserved

0163-7525/08/0421-0253$20.00

Key Words

ecological framework, environmental and policy change, healthyeating environments

AbstractFood and eating environments likely contribute to the increasingepidemic of obesity and chronic diseases, over and above individualfactors such as knowledge, skills, and motivation. Environmentaland policy interventions may be among the most effective strate-gies for creating population-wide improvements in eating. This re-view describes an ecological framework for conceptualizing the manyfood environments and conditions that influence food choices, withan emphasis on current knowledge regarding the home, child care,school, work site, retail store, and restaurant settings. Important is-sues of disparities in food access for low-income and minority groupsand macrolevel issues are also reviewed. The status of measurementand evaluation of nutrition environments and the need for action toimprove health are highlighted.

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Environment:everything outsidethe person, incontrast withindividual orpersonal variables

Policies: laws,regulations,policymakingactions, or formaland informal rulesestablished bygovernment orformal organizations

Healthy eating:eating thetypes/amounts offoods/nutrientsrecommended in theDietary Guidelines forAmericans topromote health and ahealthy weight

Ecologicalframework:emphasizesconnections betweenpeople and theirenvironment; viewsbehavior as affectingand being affected bymultiple levels ofinteractinginfluences

INTRODUCTION

Substantial research clearly indicates that dietplays an important role in prevention ofchronic diseases and obesity (96, 98, 106).Nutrition has come to the fore as one ofthe major modifiable determinants of chronicdiseases (106). Changes in Americans’ di-etary and lifestyle patterns could produce sub-stantial gains in the population’s health (96).Specifically, increasing consumption of fruitsand vegetables, whole grains, and calcium-rich foods, while reducing saturated fats, transfats, sodium, added sugars, and excess caloriesand reducing obesity could dramatically im-prove Americans’ health and well-being (98).

Major changes in our food system andfood and eating environments over the pastdecades have been driven by technological ad-vances; U.S. food and agricultural policies;and economic, social, and lifestyle changes.Food is now readily available and accessi-ble in multiple settings throughout the day.More processed and convenience foods areavailable in larger portion sizes and at rela-tively low prices. Parents are working longerhours, there are fewer family meals, and moremeals are eaten away from home (51). Theschool food environment is remarkably dif-ferent than a few decades ago: High-calorie,low-nutrition foods are available in multiplevenues throughout the school day (91). Foodmarketing aimed at children has drastically in-creased over the past 30 years (50). We haveseen an exodus of grocery stores and an influxof fast-food outlets in low-income urban ar-eas, which has contributed to the income andracial/ethnic disparities in access to healthyfoods (66, 75). Collectively, these environ-mental changes have influenced what, where,and how much we eat and are believed to haveplayed a substantial role in the current obesityepidemic (50, 51).

Individual behavior to make healthychoices can occur only in a supportiveenvironment with accessible and affordablehealthy food choices (97). This articlepresents an overview of food environmentsand strategies for creating healthy eating

environments. A conceptual framework ispresented first, followed by a descriptionof key environmental factors organized byspecific settings: home, child care, schools,work sites, retail food stores, restaurants, andbroader macrolevel issues such as food andagriculture policy and food marketing. Issuesof disparities in food access for low-incomeand minority groups are highlighted. Theaim is to advance readers’ understanding ofhow the environment influences food choicesand to highlight promising intervention andpolicy strategies to promote population-widehealthy eating. Measurement and evaluationissues in conducting environmental and policyresearch and surveillance is also discussed.

AN ECOLOGICAL FRAMEWORK

Eating behavior is highly complex and resultsfrom the interplay of multiple influencesacross different contexts. An ecological ap-proach is useful to guide research and in-tervention efforts related to eating behaviorbecause of the emphasis on multilevel link-ages, the relationships among the multiplefactors that impact health and nutrition, andthe focus on the connections between peo-ple and their environments (83, 88, 93). Anecological framework depicting the multipleinfluences on what people eat is shown inFigure 1. Individual-level factors related tofood choices and eating behaviors includecognitions, behaviors, and biological and de-mographic factors. These individual factorscan impact food choices through character-istics such as motivations, self-efficacy, out-come expectations, and behavioral capability.Environmental contexts related to eating be-haviors include social environments, physi-cal environments, and macro-level environ-ments. The social environment includes in-teractions with family, friends, peers, andothers in the community and may impactfood choices through mechanisms such asrole modeling, social support, and socialnorms. The physical environment includesthe multiple settings where people eat orprocure food such as the home, work sites,

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schools, restaurants, and supermarkets. Thephysical settings within the community in-fluence which foods are available to eat andimpact barriers and opportunities that facili-tate or hinder healthy eating. Macrolevel en-vironmental factors play a more distal andindirect role but have a substantial and pow-erful effect on what people eat. Macro-levelfactors operating within the larger society in-clude food marketing, social norms, food pro-duction and distribution systems, agriculturepolicies, and economic price structures. Thesefour broad levels of influence (Figure 1)—individual, social environment, physical en-vironment, and macrolevel environments—all interact, both directly and indirectly, toimpact eating behaviors.

The study of environmental and policy in-fluences on nutrition and eating behaviors is anew and growing science. Thus, there are fewwell-articulated theoretical models with re-lated data to test the interactions among per-sonal, social, and environmental factors. Lit-tle is known about the mechanisms and causalpathways by which specific environmental in-fluences might interact with individual factorsto influence eating behaviors (3, 11). Further-more, little research has been done on whichaspects of the food environment are more in-fluential than others or about the most feasi-ble and effective interventions and policies toimprove food environments in various popu-lations (3, 11, 59, 100). The field is also ham-pered by a lack of validated environmentalmeasures (39). The challenge is to acceleratemultilevel ecological research in this area. Thefollowing section addresses key issues in en-vironmental settings and promising interven-tions and policies to improve population-leveleating behaviors.

SETTINGS AND PLACES FORHEALTHY EATING

Homes

National survey data indicate that Americansconsume roughly two thirds (68%) of their

Macro-LevelFactors: These“upstream” policyand environmentalfactors work at thehighest levels ofinfluence and haveimpact at thepopulation level

Environmentalinterventions:strategies thatinvolve changing thephysicalsurroundings, socialclimate, informationavailability, and/ororganizationalsystems to promotebehavior change

total calories from foods prepared withinthe home (43). A variety of factors withinthe home environment have been associatedwith healthful dietary behaviors; among thestrongest factors are availability and accessi-bility of healthy foods, the frequency of familymeals, and parental intake and parenting prac-tices (for children’s diets). Both householdfood availability (foods present in the house)and accessibility (whether available foods arein a form or location that facilitates their con-sumption, such as fruit on the counter) havebeen positively associated with healthful di-etary intake in youth (19, 42, 100). Neumark-Stzainer and colleagues (72) found that homeavailability and taste preferences were thetwo strongest correlates of fruit and vegetableintake among adolescents. Home availabilitywas mediated by parental social support forhealthy eating, family meals, and householdfood security. Even when taste preferencesfor fruits and vegetables were low, if fruits andvegetables were available in the home, intakesincreased. Collectively, studies suggest thatreadily available and easily accessible healthfulfoods within the home are likely to enhancehealthful dietary intake among youth andfamilies.

Availability of soft drinks in the homehas also been strongly associated with soft-drink consumption among children (42). Arecent home-based environmental pilot studywas conducted through weekly home deliver-ies of noncaloric beverages to displace sugar-sweetened beverages (SSBs) to reduce SSBconsumption among adolescents, who werefrequent consumers of SSB (23). The resultsof this relatively simple environmental inter-vention showed that SSB intake decreased inthe intervention group, and investigators sawa significant body mass index (BMI) changeamong adolescents in the highest BMI tertilegroup.

Social-environmental influences withinthe home such as modeling of healthful di-etary intake by parents and siblings, author-itative feeding style (i.e., high in limit set-ting but also high in nurturance), and more

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CACFP: Child andAdult Care FoodProgram

USDA: UnitedStates Departmentof Agriculture

frequent family meals may promote health-ful food consumption among children andadolescents. Parental fruit and vegetable in-take has been associated with fruit and veg-etable intake among youth (18, 27, 44) andmay be the strongest predictor of fruit andvegetable consumption among young chil-dren (18). A recent systematic review byvan der Horst and colleagues (100) reportan association between parent and childintake of fat, fruits, vegetables, and softdrinks.

Another factor that may influence chil-dren’s dietary intake is parental feeding styleand parenting practices. An authoritativefeeding style has been positively associatedwith preschool children’s intake of dairy andvegetables (73), and mother’s authoritativeparenting style is associated with adolescentintake of fruits and vegetables (63). Birch (5)found that parental practices such as restrict-ing foods, pressuring children to eat, or usingfoods as rewards may inadvertently promotebehaviors counter to their intentions. For ex-ample, parental pressure could result in de-creased preference for certain foods, whereasfood restriction could increase preferences forcertain foods.

Frequency of family meals may also havea positive impact on healthful dietary intakeamong youth. Research suggests that fam-ily meal frequency may be positively asso-ciated with child and adolescent intake ofseveral vitamins and minerals, fruits, vegeta-bles, grains, and calcium-rich foods and fewerfried foods, SSBs, and saturated and trans fat(34, 71).

There have been relatively few home-based interventions to improve dietary intake.A recent comprehensive research review oninterventions to reduce obesity and relatedchronic-disease risk factors in children andyouth found that of the 147 studies included inthe critical review only 4 interventions wereimplemented in the home (28). Thus envi-ronmental interventions targeting the homeenvironment represent an area for furtherstudy.

Child Care

Child care facilities provide a valuable op-portunity to promote healthy eating and en-ergy balance in children. Although much hasbeen written on creating healthy food envi-ronments in schools, surprisingly little hasbeen written regarding child care settings. Re-search examining the nutritional quality offoods and beverages served in child care set-tings has been extremely limited, and the fewstudies suggest that nutritional quality needsto be improved (90). Furthermore, little in-tervention research has been done on chang-ing the food environment. This is a missedopportunity because the majority of childrenunder age five (60%) spend an average of 29hours a week in some form of child care settingand 41% spend 35 or more hours per week(52).

The Child and Adult Care Food Program(CACFP), administered by the USDA (U.S.Department of Agriculture) through grantsto state agencies, provides meals and snacksfor nearly 2.1 million children in center-basedcare and almost 900,000 children in familychild-care homes (80). The CACFP guide-lines require that meals and snacks includea minimum number of age-appropriate serv-ings from four food categories, but they donot require meals and snacks to meet anynutrient-based standards or be consistent withthe Dietary Guidelines for Americans, nordo they prohibit offering foods or bever-ages that might be high-calorie, low-nutritionfoods. There are no funding provisions or leg-islative requirements for nutrition educationin the CACFP. To encourage healthier eat-ing among children, CACFP regulations formeals and snacks for children two and oldershould be consistent with the Dietary Guide-lines for Americans.

With the exception of the federal HeadStart program, child care facilities are reg-ulated by states, and state rules vary widely.Only 2 states require that meals and snacksfollow the Dietary Guidelines for Americans,and only 15 states specify the percentage of

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children’s daily nutritional requirements tobe provided per meal or per a given numberof hours in care (90). Stronger state licens-ing requirements on nutrition quality of foodsserved and training for child care providerscan help ensure healthier food environments.The current situation reflects an importantmissed opportunity to promote health.

Schools

The school food environment can have a largeimpact on children’s and adolescents’ dietaryintake because up to two meals and snacksare eaten at school every day (91). Food atschool is typically available through federallyreimbursed school meals and “competitivefoods,” so called because they compete withthe school meals program. Competitive foodsare all foods and beverages sold outside of thefederal meal programs and include vendingmachines, a la carte offerings in the cafete-ria, snack bars, school stores, and fundraisers.Meals served in the National School LunchProgram and School Breakfast Program mustmeet federally defined nutrition standards andthe Dietary Guidelines for Americans. How-ever, federal requirements currently do littleto limit the sale of competitive foods or to setschool-wide nutrition standards. Competitivefoods are widely available in schools; 9 out of10 schools sell them (99) and the majority ofofferings are high-fat or high-sugar foods andbeverages (45, 99).

In response to growing concerns over obe-sity, attention has focused on the need to es-tablish school nutrition standards and limitofferings of competitive foods. The Insti-tute of Medicine (IOM) Report NutritionStandards for Healthy Schools concluded thatfederally reimbursable school nutrition pro-grams should be the main source of food atschool and that competitive foods should belimited (49). The report set forth nutritionstandards for competitive foods and recom-mended that if competitive foods are available,they should consist solely of fruits, vegetables,whole grains, and nonfat/low-fat dairy prod-

ucts to help children and adolescents develophealthful eating patterns.

In recent years, many states and localschool districts have passed regulations or leg-islation on competitive foods (8), which aremore restrictive than USDA regulations, al-though they differ greatly in the type and ex-tent of restrictions. About half of all states(29) have adopted competitive school foodand beverage policies, and almost all this ac-tivity has occurred in the past five years (49).Only 16 states require nutrition standards forcompetitive foods and beverages at school,and none has standards as strong as the IOMrecommendations. The Center for Science inthe Public Interest issued a report evaluatingstate competitive food policies and concludedthat although changes are occurring at thestate level, such changes are “fragmented, in-cremental and not happening quickly enoughto reach all schools in a timely way. The na-tion has a patchwork of policies addressing thenutritional quality of school foods and bever-ages and the majority of states have weak po-lices” (15, p. 3). Congressional action to grantthe USDA broader authority to regulate thecontent and sale of competitive foods and torequire nutrition standards for all foods andbeverages sold during the school day couldimprove children’s health and nutrition.

A recent federal policy initiative that hasimplications for improving the school foodenvironment requires school districts partic-ipating in the federally reimbursable schoolmeal programs to establish local school well-ness policies addressing nutrition and physicalactivity. Although the school wellness policiesonly went into effect at the beginning of the2006–2007 school year, preliminary data showmixed results in terms of the implementation,compliance, and impact of the policies (1).

More support and regulatory action isneeded by federal, state, and local authori-ties to strengthen and improve healthy eat-ing and nutrition education in schools. Atthe federal level this could not only includestronger regulations for competitive foods inschools, but also expand the USDA fruit and


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vegetable pilot program to improve fruit andvegetable intake among school children, espe-cially among schools with a high proportionof low-income students. Other efforts to im-prove the quality of foods in schools couldinclude farm-to-school programs, which linklocal farmers providing fresh locally grownproduce to school food service cafeterias andschool gardening programs. There is also aneed for classroom nutrition education tocomplement changes in the school environ-ment to increase students’ skills for adoptinghealthy lifestyles.

After-School and Summer SchoolPrograms

After-school settings are important environ-ments for the promotion of healthy eating.More than 6.5 million youth are in after-school programs such as schools, park andrecreational centers, YMCAs, and Boys andGirls Clubs. African American and Hispanicchildren are more likely than other chil-dren to participate in after-school programs.More than half (55%) of high-poverty ur-ban schools provide summer-school programs(95). These settings also reach millions ofchildren through federal food assistance pro-grams, such as the Afterschool Snack Pro-gram, which provides free snacks to chil-dren and adolescents, and the Summer FoodService Program, which provides meals andsnacks to youth. Studies are needed to as-sess the nutritional quality of snack foods andbeverages in these programs and interventionstrategies to improve healthy eating in theseprograms.

After-school care programs in seven states(Delaware, Illinois, Michigan, Missouri, NewYork, Oregon, and Pennsylvania) were re-cently authorized by Congress to serve din-ner in addition to snacks to children in areaswhere more than 50% of the children qualifyfor free or reduced price school meals (30).This means that some low-income childrenmay consume three meals and a snack everyweekday during the school year from federal

food programs. This highlights the growingimportance of the federal child nutrition pro-grams in providing nutrition to children inlow-income families and the need to ensurethat the foods served through these programsare consistent with the Dietary Guidelines forAmericans.

Work Sites

As schools are for children, work sites areideal settings for reaching adults because 66%of U.S. adults are employed (12). The worksite environment provides opportunities forboth individual-level behavior changes andphysical and social work site environmentalchange. Research suggests that nutrition be-haviors can be positively influenced by worksite health-promotion programs that includehealthful modifications of the work site envi-ronment (4, 25, 86). Dietary intake has beenpositively influenced by environmental strate-gies such as increasing the availability and va-riety of healthful food options (54), reducingthe price of healthful food in work site cafete-rias (54) and vending machines (32), and send-ing tailored nutrition education email mes-sages (7). A recent systematic review of worksite health-promotion programs found thatfruit, vegetable, and fat intake can be posi-tively influenced by environmental strategiesthat include point-of-purchase labeling, pro-motional materials, expanded availability ofhealthy foods, and targeted food placement(25). A review of these programs found thatmost studies had small but significant de-creases in dietary fat and increases in fruits andvegetables or fiber (31). Although the changeswere modest, they may be meaningful from apopulation perspective.

Strengthening the social environment ofthe workplace may also be beneficial (4, 86).Involving employees in program planningand implementation and obtaining supervi-sory support and commitment from manage-ment are important for program sustainability(86). Priorities for future work site–based in-terventions include identifying and reducing

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barriers to organizational and environmentalchange, addressing social contextual factorsdriving behaviors, and building expanded net-works of community partnerships.

Retail Food Stores: Supermarketsand Small Grocery Stores

The presence of food stores, and the avail-ability of healthful products in those stores,are important contributors to healthy eatingpatterns among neighborhood residents (41).Grocery stores play a major role in food pur-chasing: Households make an average of twovisits to a supermarket per week, and aver-age weekly household grocery expenses were$93 in 2006 (29). Several studies have foundassociations between access to supermarketsand healthier food intakes (16, 60, 66). Forexample, Morland et al. (66) found that fruitand vegetable intake increased with each addi-tional supermarket in a census tract, and thatincrease was nearly three times as large forAfrican Americans. Laraia et al. (60) foundthat pregnant women who lived more thanfour miles from a supermarket were signif-icantly more likely to have poor diet qual-ity, even after controlling for individual socio-economic status and the availability of smallergrocery and convenience stores. Powell andothers (76) found that increased access tochain supermarkets was associated with loweradolescent BMI and that greater availabil-ity of convenience stores was associated withhigher BMI and overweight. Cheadle and oth-ers (16) found that the diets of neighbor-hood residents were healthier when the super-markets in their neighborhoods offered morehealthful products. However, a recent analy-sis found that both higher neighborhood den-sity of small grocery stores and closer prox-imity to chain supermarkets were associatedwith higher BMI among women (101). Moreemerging research should shed light on thecomplexities of these relationships.

Among various types of retail stores thatsell food, supermarkets offer the greatest va-riety of food at the lowest cost (29, 40). Low-

income and minority neighborhoods havefewer chain supermarkets than do middle- andupper-income neighborhoods (67, 77, 107). Arecent study linked availability of food storeoutlets in the United States across 28,050zip codes to Census 2000 data (77). Low-income neighborhoods had fewer chain su-permarkets with only 75% of stores avail-able in middle-income neighborhoods. Dataalso showed large disparities by race in theavailability of chain supermarkets even aftercontrolling for differences in income, similarto those found in the Detroit area by Zenkand others (107). For example, the availabil-ity of chain supermarkets in African Ameri-can neighborhoods was only 52% that of theircounterpart white neighborhoods (77). Thelack of availability of large supermarkets is ofconcern because large supermarkets tend tooffer food at lower prices and provide a widervariety of and higher-quality food productsthan do small grocery stores (47, 75).

Lack of access to supermarkets is also aproblem in some rural areas. Morton & Blan-chard (68) examined the distribution of U.S.counties in which residents have low accessto large food retailers (low access defined asliving more than 10 miles from any super-market or supercenter). They found that ofall U.S. counties, 418 are food deserts andmost of these had high poverty rates. Themost affected rural counties were in the GreatPlains and Rocky Mountain regions, the DeepSouth, the Appalachian region of Kentuckyand West Virginia, and the western half ofTexas. In rural America, it will take commu-nity action and public policy improvements tostrengthen the capacity of rural grocery storesto provide nutritious high-quality and afford-able foods.

Both large supermarkets and smaller gro-ceries and food stores are important en-vironments where environmental interven-tions may increase the availability of andaccess to healthier food choices (41). Point-of-choice nutrition information to help con-sumers identify healthier products can andhas been tried in grocery store settings, with


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mixed results but some notable successes (37,41). In addition, interventions to increaseavailability, variety, and convenience; pricing;and promotional strategies have been foundfeasible and modest evidence has demon-strated their efficacy in influencing healthyeating behavior (41). Thus, retail food envi-ronments at both the community level (e.g.,presence of supermarkets) and the consumerlevel (e.g., healthful, affordable foods in foodstores) are promising venues for positivechange (39).

Eating Out: Restaurantsand Fast-Food Outlets

Americans are eating out more often and con-suming more calories from away-from-homeestablishments than ever before. The Na-tional Restaurant Association estimates thatsales will total $537 billion in 2007 for the935,000 U.S. restaurants (70). The numberof food establishments in the U.S. has nearlydoubled in the past three decades (94). Todaynearly half (47.9%) of all food expendituresare spent eating out, up from 34% in 1974and nearly double from what it was in 1955(70). Away-from-home foods tend to be morecalorie dense and of poorer nutritional qualitythan foods prepared at home (43). Currently,Americans consume about 32% of their calo-ries from food away from home (43). Whereasfast-food restaurant meals are typically highin calories and fat, foods consumed at full-service restaurants can be as high or higherin fat, cholesterol, and sodium (87). An obser-vational study of 217 fast-food and sit-downrestaurants in the Atlanta area found that itwas not possible to choose a healthy main dishon the basis of readily available informationin most restaurants (81). Studies have linkedfrequent eating out to higher caloric intake,weight gain, and obesity (9, 65, 74).

Trends toward large portion sizes inrestaurants encourage over consumption be-cause people consume more food and morecalories when presented with large portions(102). Several restaurant items, such as soft

drinks and desserts, are now served in por-tions that are two or more times larger thanthe standard serving size (53). It is not uncom-mon for restaurant entrees to contain one halfto one day’s worth of recommended calories(1100 to 2350 calories) (53). Most consumersmay be unaware of the high levels of calories,fat, saturated fat, and sodium found in manymenu items (13, 46) and may underestimateactual calorie content by as much as 50% (13).

Federal and state laws do not requirerestaurants to provide nutrition content in-formation to consumers. Rather, the provi-sion of nutritional information for menu itemsis voluntary and the information may appearon menus, Web sites, brochures, tray liners,food wrapper packages, or posters. One sur-vey found that only 44% of the top 300 U.S.restaurant chains provided nutrition informa-tion for most of their standard menu items(104). Of the restaurants with nutrition in-formation, 86% provided it on the companyWeb site, which requires Internet access anddoes not make the information available at thepoint of decision making.

In 2006, the Keystone Center, a nonprofitpolicy organization, released a report re-quested by FDA to develop recommendationson away-from-home foods (94). Among therecommendations were that food establish-ments should provide consumers with caloricinformation in a standard, easily accessibleformat and should increase the availability oflow-calorie menu items. They also recom-mended that research should be conductedon how consumers use nutrition informa-tion for away-from-home foods, how thisinformation affects caloric intake, and hownutrition information affects restaurant op-erators. Restaurant executives identify theirmost important priorities as growing salesand increasing profits, so they will only offerhealthy food options if there is adequate con-sumer demand (38). Provision of nutritionalinformation at the point of choice may in-crease customer awareness and stimulate de-mand for smaller portions and more healthfulchoices. Although there are several models for

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changing environments and policies in restau-rants to increase healthy eating, most havenot been systematically evaluated (36). Thereis a need to disseminate promising strate-gies, increase public-private partnerships, andto study further the effects of policy andenvironmental changes including the provi-sion of nutrition information in restaurantsettings.

Legislation has been introduced inCongress and in more than a dozen statelegislatures that would require chain restau-rants and fast-food outlets to list calories andother nutrition information on their menusto make it easier for consumers to make morehealthful food choices (105). To date, noneof these measures have been enacted. Ona local level, the New York City Board ofHealth passed a regulation to require somerestaurants to post calorie information onmenus or menu boards. In a surprising at-tempt to circumvent this requirement, severalmajor chains took down their Web site–basednutrition information, suggesting the needfor fewer loopholes in such laws. Also, citiessuch as New York and Philadelphia haverecently passed bans or restrictions on transfats in restaurants, which will go into effect in2008.

Disparities in Food Accessin Low-Income Communities

Inequalities in income underlie many healthdisparities in the United States. In general,population groups that suffer the worst healthstatus, including nutritional health and obe-sity, are also those that have the highestpoverty rates (96). Several studies have showndifferential availability and affordability ofhealthy foods in low-income neighborhoods(2, 58, 62, 66, 67). Lack of access to afford-able and healthy foods may be contributingto disparities in diet-related chronic diseasesand obesity rates. (See section above on RetailStores for background).

Among the important opportunities to re-duce disparities are initiatives to encourage

the development of grocery retail investmentsin low-income communities. A recent surveyamong urban and economic planners in 32large cities found few activities to encourageany form of food retail in underserved areas,such as development of large supermarkets,farm stands, or assistance to neighborhoodgrocery businesses (75). Successful initiativeswere characterized by political leadership atthe highest levels and effective partnershipswith community-based nonprofit organiza-tions. Case studies showed supermarkets thathad entered deprived inner-city neighbor-hoods experienced significant business andcustomer loyalty. Creative strategies by thesestores included shuttle services, calculators oncarts, services provided to immigrants andnon-English speakers, automated teller ma-chines, rooftop parking, and technology link-ing inventory to checkout data to facilitateefficient flow of high-demand products inlimited spaces (75).

Other potential strategies to get healthy,local foods into low-income neighborhoodsinclude fostering neighborhood farmers mar-kets, cooperative food stores, community gar-dens; incorporating fresh produce and healthyfoods into corner stores and conveniencestores; having neighborhood churches andcommunity centers purchase produce fromlocal farmers to be sold to community mem-bers following church or community events;and having local community clinics and publichealth departments provide local produce topatients during clinic visits as part of a health-promotion initiative (61). We also need to findways to have food banks and food shelves ob-tain fresh produce and healthy foods.

Federal, state, and local efforts and public-private partnerships are needed to create andfacilitate new and expanded food systems pro-grams to help underserved areas develop re-tail food markets and increase access to ahealthy, affordable food supply. Because lit-tle research has been done on the most ef-fective and promising programs in this area,more evaluation and intervention efforts areneeded.


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MACRO-LEVEL APPROACHES

U.S. Food and Agriculture Policies

The obesity crisis has focused attention on therole of federal agricultural policies on the U.S.food supply and how policies may impact pub-lic health and diet-related chronic diseases andobesity. Agricultural policies determine whichcrops the government will support. Govern-ment support influences which crops U.S.farmers produce, the prices of those crops,and subsequently, which products food pro-cessors, distributors, and retailers make avail-able to consumers and at what market price(84). U.S. farm policies have contributed tothe overproduction of certain crops, specifi-cally commodity grain and oilseed crops (i.e.,corn and soybeans), thereby creating artifi-cially low prices, often below the cost of pro-duction (84). U.S. farm policy for commod-ity crops has made sugars and fats some ofthe most inexpensive food substances to pro-duce and may have indirectly influenced foodprocessors and manufacturers to expand theirproduct lines to include more fats and sweet-eners in their products (84, 85). High fruc-tose corn syrup and hydrogenated vegetableoils (high in trans fats)—products that did noteven exist a generation ago—are now preva-lent in foods, likely owing to the availabilityof inexpensive corn and soybeans (84). Foodcompanies can purchase these commodities atartificially cheap prices, contributing to theincreased prevalence of added sugars and fatsin our food supply. In the American foodsupply, per capita daily supply of added fatsand oils increased 38% from 1970 to 2000,and added caloric sweeteners increased 20%during this time (78). In 2000, the averageAmerican consumed 152 pounds of sweeten-ers, which was equivalent to 52 teaspoons ofadded sugar per day of which 40% came fromhigh fructose corn syrup (10). The currentU.S. diet derives close to 50% of calories fromadded sugars and fats (78).

The low cost of cheap corn and soybeansand higher-priced fruits and vegetables are

believed to be a direct consequence of U.S.agriculture policy over the past 30 years (69).Government support for grain and oilseedcrops comes in many forms, from researchdollars to infrastructure investments to sub-sidy payments that mitigate low prices (84).Healthy fruits, vegetables, and other specialtycrops (i.e., nuts) receive little government sup-port. This lack of government support may bereflected in the higher cost of fruits and veg-etables. Between 1985 and 2000, fruits andvegetables led all other food categories in re-tail price increases, with price increases forfresh fruits and vegetables being much higherthan those for processed products (78). Forexample, over this 15-year period the percentchange in food price increases was 118% forfruits and vegetables and only 35% for fats andoils, 46% for sugars and sweets, and 20% forcarbonated soft drinks (78). Although theremay be a correlation between the drop inprices and expanding production of corn andsoybeans, the increasing use of added fats andhigh-fructose corn syrup in processed foods,and the increase in obesity, these factors arecomplex and not well understood.

Current agricultural policies have helpedmake food environments less healthy forAmericans. Farm and food policy should bealigned with national public health and nu-trition goals. The key purpose of our foodand farming policies should be to advance thehealth and well-being of Americans. Someof the same reforms that could make ourfarm policy healthier would also benefit familyfarmers (84). Every five to seven years there isan opportunity to change the system throughthe federal Farm Bill, which addresses agri-cultural production, food and nutrition assis-tance, rural development, renewable energy,conservation policies, and research.

The Farm Bill also reauthorizes some ofthe key domestic food and nutrition assis-tance programs including the Food StampProgram, which serves 1 in 12 Americans,or nearly 24 million low-income people permonth, more than half of whom are children(30). Currently, food-stamp recipients have

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insufficient benefits to purchase the foods nec-essary for a healthy diet over the course of amonth. We need to ensure that all Americansare able to access and afford healthy foods.Increasing access to healthier foods in foodassistance programs could include expandingcoupon programs that allow food assistancebeneficiaries to purchase fruits and vegetables,whole grains, and other healthy foods at localfarmers markets and other retail food outlets;expanding the programs that bring fresh lo-cal farm products into schools; and revisingthe commodity portion of the food assistanceprograms (84, 85). A shift toward healthierfarm policies that would benefit the public’shealth also includes promoting local and re-gional sustainable food systems to increase ac-cess to healthier foods. Additionally, federaland state policies could facilitate increased in-stitutional and agency procurement of localand regional agricultural food products, suchas fruits and vegetables, by child care cen-ters and schools, hospitals, food banks, seniorcenters, and prisons (26).

Economic and Pricing Issues

The cost of food is the second most impor-tant factor affecting food decisions, behindtaste (35). Government regulations that af-fect price are consistent influences on the pur-chase of fresh fruits, vegetables, and meats(79). Drewnowski (21, 22) has hypothesizedthat the observed links between food sup-ply trends and rising obesity rates are medi-ated by the economics of food choices. Thecurrent structure of food prices is that high-sugar and high-fat foods provide calories atthe lowest cost (22). Thus individuals and fam-ilies with limited resources may select energy-dense foods high in refined grains, added sug-ars, and fats as a way to save money. Freshfruits and vegetables are more expensive ona per calorie basis than are fats and sugars.Little is known as to whether variations infood prices account for differences in dietquality or weight status. Sturm & Datar (92)merged data from the Early Childhood Lon-

gitudinal Study with metropolitan data onfood prices and found that lower neighbor-hood prices for fruits and vegetables predictedlower gains in BMI in young children. Low-income families spend less on fruits and veg-etables than do higher-income families (6).A 10% reduction in price for fruits and veg-etables increases consumption by 7.2% (48).Thus, reducing the price of healthy food mayincrease intake.

It is surprising how little is known aboutwhether healthier diets cost more. Recently,Jetter & Cassady (55) conducted a market-basket study in 25 stores in Los Angeles andSacramento to compare the cost of a stan-dard market basket [based on the USDA’sThrifty Food Plan (TFP)] to a market basketwith healthier substitutes. For the two-weekshopping list, the average TFP market-basketcost was $194 and the healthier market-basketplan was $230. The cost of the healthier bas-ket was due to higher costs for whole grains,lean ground beef, and skinless poultry. Thisstudy suggests that the higher cost of healthierfoods could be a deterrent to eating healthieramong low-income consumers. More stud-ies are needed on economic factors influenc-ing eating behavior and the relationship be-tween diet quality and food costs. This hasimportant implications for strategies to mod-ify the food environment, for national foodpolicy, and for food assistance programs forlow-income populations.

Food Marketing and MediaInfluences

Although multiple factors influence eating be-haviors of youth, one potent force is food mar-keting. Today’s youth live in a media-saturatedenvironment. Over the past few decades,U.S. children and adolescents have increas-ingly been targeted with aggressive forms offood marketing and advertising practices (50,89). Multiple techniques and channels areused to reach youth, beginning when theyare toddlers, to foster brand loyalty and in-fluence product purchase behavior. Recently


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the Kaiser Family Foundation conducted thelargest study on TV food advertising to chil-dren (57) and found that children ages 8–12see the most food ads on TV, an average of21 ads per day or more than 7600 per year.Most of the ads were for candy, snacks, sug-ared cereals, and fast foods; none of the 8854ads reviewed marketed fruits and vegetables.Food marketing to children now extends be-yond television, is widely prevalent on the In-ternet (56), and is expanding rapidly into aubiquitous digital media culture of new tech-niques including cell phones, instant messag-ing, video games, and three-dimensional vir-tual worlds, often under the radar of parents(17).

The IOM Committee on Food Marketingto Children and Youth conducted a system-atic review of the evidence and concluded thatfood and beverage marketing practices gearedto children and youth are out of balance withrecommended healthful diets and contributeto an environment that puts their health at risk(50). The report set forth recommendationsto guide the development of effective mar-keting strategies that promote healthier food,beverages, and meals for children and youth.Among the major recommendations for thefood, beverage, and restaurant industries wasthat industry should shift their advertisingand marketing emphasis to healthier child-and youth-oriented foods and beverages. Ifvoluntary efforts related to children’s televi-sion programming are unsuccessful in shift-ing the emphasis away from high-calorie andlow-nutrient foods and beverages to health-ful foods and beverages, Congress should en-act legislation mandating the shift. Advocacyand public health groups are also calling onthe Federal Trade Commission, the FederalCommunications Commission, and Congressto work together with industry to develop anew set of rules governing the marketing offood and beverages to children—rules thataccount for the full spectrum of advertisingand marketing practices across all media andwhich apply to all children, including adoles-cents (17). Marketing efforts need to serve,

rather than undermine, the health of children(17).

MEASUREMENT ISSUES

To make significant progress in the areaof eating and nutrition environments, weneed valid, reliable measures of nutritionenvironments and policies (39). Althoughthere are an increasing number of reportsof various dimensions of nutrition environ-ments, there is no guidance in the literatureon how best to measure nutrition environ-ments in a comprehensive manner. Researchon school food environments, neighbor-hood food environments (stores, restaurants),and state policies are illustrative of well-developed measurement tools and importantneeds in this area. This section providesexamples of accomplishments and needs inthe area of measurement of nutrition envi-ronments in schools, stores, and restaurantsettings.

Schools

A number of measures of school food envi-ronments have been carefully developed, mostoften for use in intervention research. Large-scale studies of school food policies and en-vironments have been conducted using sur-veys of school administrators and food servicemanagers (20, 103). These data are limited bythe usual concerns with self-report (bias, for-getting, etc.) and may also suffer from non-response bias. A state nutrition-environmentpolicy classification system has recently beendeveloped to track developments in 11 pol-icy areas, among them school meal envi-ronments, reimbursable school meals, BMIscreening, and competitive foods. This sys-tem is based on a social-ecological model andshould enhance the surveillance opportunitiesfor all 50 states and the District of Columbia(64).

Local and regional studies typically usea combination of data-collection methods,including surveys of food service managers,

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observations and data-based inventories offoods available, observations/analysis of stu-dents’ bag lunches, and food service sales data.Often the food availability and/or sales dataare combined with nutritional informationand subjected to nutrient analyses (33, 82).The measures are carefully designed and sub-jected to quality assurance, but few psycho-metric data are available. A key limitation ofon-site measures is that the sales data are usu-ally recorded manually rather than obtainedfrom automated cash register systems. Detailsof the instruments and protocols used in peer-reviewed research have not been widely dis-seminated, most likely because the tools weredeveloped in specific settings as part of largerintervention studies.

Neighborhood Food Environments:The Community NutritionEnvironment

Key categories of food sources in neighbor-hoods include stores and restaurants. It is use-ful to distinguish where people get food andwhat type of food they can get within those es-tablishments. The community nutrition envi-ronment is composed of the number, type, lo-cation, and accessibility of food outlets such asgrocery stores, fast-food restaurants, and full-service restaurants. The consumer nutritionenvironment is what consumers encounter inand around places where they buy food, suchas the availability, cost, and quality of health-ful food choices (39). Community nutritionenvironment data are available from variouscommercial sources such as Dun & Bradstreetbusiness lists (76, 77), as well as from countyhealth or agriculture department food licenselists, telephone books, and the Internet. Al-though national studies may rely on businesslists, local and regional studies suggest thatmore complete and accurate enumeration offood-sale locations can be achieved using acombination of sources (40, 81) and supple-mented with ground truthing by systemati-cally walking or driving each street in a neigh-borhood.

Consumer Nutrition Environmentsin Stores

Some of the earliest published measures ofavailability of healthy foods in stores were re-ported nearly two decades ago by Cheadle andothers (16), who calculated the percentage ofshelf space used for healthy food options, suchas low-fat milk, whole wheat bread, cheese,and lean meats. They found high inter-raterreliability (0.73 to 0.78) and test-retest relia-bility ranging from 0.44 to 1.00. These mea-sures are theoretically robust but may be dif-ficult to apply in contemporary grocery storesthat are larger and more varied in layout thanthey were two decades ago. Horowitz and oth-ers (47) measured availability of five diabetic-recommended foods in grocery stores and re-ported excellent inter-rater reliability rangingfrom 0.94 to 1.00. Other published reportshave been less clear about the rigor of theirmethods or did not report reliability of themeasures.

Recently, the Nutrition EnvironmentMeasures Study developed observationalmeasures of the nutrition environment withinretail food stores (NEMS-S) to assess avail-ability of healthy options, price, and qualityfor ten food categories (e.g., fruits) or indica-tor food items (e.g., ground beef), aligned withthe U.S. Dietary Guidelines (40). Inter-raterreliability and test-retest reliability of avail-ability were high: Inter-rater reliability kap-pas were 0.84 to 1.00, and test-retest reliabil-ities were 0.73 to 1.00. These measures arebeing disseminated through training work-shops (http://www.sph.emory.edu/NEMS),and as of mid-2007, raters and trainers in 28states have learned to use these tools and theNEMS-R restaurant measures.

Consumer Nutrition Environmentsin Restaurants

Research on the environment within restau-rants is limited. Some recent advancementshave been made in the measurement of foodenvironments within restaurants, including


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good interobserver reliability for availabilityof fruits and vegetables (24). Cassady and col-leagues (14) developed a reliable restaurantmenu checklist for use by community mem-bers, which assesses food preparation, num-ber of healthful choices, and fruit/vegetableavailability. However, this checklist did notassess the whole restaurant environment andwas tested in only 14 family-style restaurants.

The NEMS-R observational measure forrestaurants was recently developed to as-sess factors believed to contribute to foodchoices in restaurants, including availabilityof more healthy foods, facilitators and bar-riers to healthful eating, pricing, and sign-age/promotion of healthy and unhealthyfoods. Inter-rater and test-retest reliabilitywere assessed in 217 sit-down and fast-foodrestaurants in 4 neighborhoods, and inter-rater reliability was generally high, with mostkappa values >.80 (range 0.27–0.97) and allpercent agreement values >75% (77.6%–99.5%). Test-retest reliability was high, withmost kappa values >.80 (0.46–1.0) and all per-cent agreement values >80% (80.4%–100%)(81). Like the NEMS-S store measure, it hasbeen widely disseminated and continues to beadopted for research and community programuse.

There is much more work to be done indesigning and testing food-environment mea-sures that are adoptable to a variety of lo-cations. The options for self-reported mea-sures include survey reports from individualconsumers or residents (perceived reports)and reports from administrators or key in-formants (factual reports). Audit and observa-tional tools also comprise a range of measure-

ment methods: on-site observations, menureviews, sales data, inventories, policy doc-umentation, etc. Each type of method haspros and cons, and the relative advantages anddisadvantages should be carefully consideredwhen using or creating these measures for re-search and action projects. Developers andusers of these measures will be challenged tobe attentive to the nutritional meaningfulnessof indicators, relevance and feasibility of mea-sures, and potential for linking environmen-tal and individual assessments in subsequentstudies. A range of psychometrically soundmeasures are needed to obtain accurate andreliable estimates of the relation between nu-trition environments and individuals’ dietaryintake, as well as to evaluate change in nutri-tion environments secondary to intervention.

CONCLUSIONS

Improving dietary and lifestyle patterns andreducing obesity will require a sustained pub-lic health effort, which addresses not only in-dividual behaviors but also the environmen-tal context and conditions in which peoplelive and make choices. Individual behaviorchange is difficult to achieve without address-ing the context in which people make deci-sions. Initial, significant steps are needed tomake healthful food choices available, identi-fiable, and affordable to people of all races andincome levels and in all types of geographic lo-cations (e.g., urban, suburban, rural). Our ul-timate goals should be to structure neighbor-hoods, homes, and institutional environmentsso that healthy behaviors are the optimaldefaults.

DISCLOSURE STATEMENT

The authors are not aware of any biases that might be perceived as affecting the objectivity ofthis review.

ACKNOWLEDGMENTS

This project was partially funded through the Robert Wood Johnson Foundation’s HealthyEating Research program and also by a grant (MC00007-19) from the Maternal and ChildHealth Bureau, Health Resources, and Services Administration.

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www.annualreviews.org l Creating Healthy Food Environments C-1

Figure 1

An ecological framework depicting the multiple influences on what people eat.

Macro-levelenvironments

(sectors)

Physicalenvironments

(settings)

Socialenvironment(networks)

Individualfactors

(personal)

Home

Work sites

School, after school

Child care

Neighborhoods and communities

Restaurants and fast food outlets

Supermarkets

Convenience and corner stores

Cognitions (e.g., attitudes, preferences, knowledge, values)

Skills and behaviors

Lifestyle

Biological (e.g., genes, gender, age)

Demographics (e.g., income, race/ethnicity)

Access

Availability

Barriers

Opportunities

Outcome expectations

Motivations

Self-efficacy

Societal and cultural norms and values

Food and beverage industry

Food marketing and media

Food andagriculture policies

Economic systems

Food production and distribution systems

Government and political structures and policies

Food assistance programs

Health care systems

Land use and transportation

Practices

Legislative, regulatory, or policy actions

Family

Friends

Peers

Role modeling

Social support

Social norms

Behavioral capability

Story.qxd 02/14/2008 08:17 PM Page C-1

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AR337-FM ARI 22 February 2008 17:45

Annual Review ofPublic Health

Volume 29, 2008Contents

Commentary

Public Health Accreditation: Progress on National AccountabilityHugh H. Tilson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xv

Symposium: Climate Change and Health

Mitigating, Adapting, and Suffering: How Much of Each?Kirk R. Smith � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xxiii

Ancillary Benefits for Climate Change Mitigation and Air PollutionControl in the World’s Motor Vehicle FleetsMichael P. Walsh � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Co-Benefits of Climate Mitigation and Health Protection in EnergySystems: Scoping MethodsKirk R. Smith and Evan Haigler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

Health Impact Assessment of Global Climate Change: Expandingon Comparative Risk Assessment Approaches for Policy MakingJonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs,

and Rosalie Woodruff � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27

Heat Stress and Public Health: A Critical ReviewR. Sari Kovats and Shakoor Hajat � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41

Preparing the U.S. Health Community for Climate ChangeRichard Jackson and Kyra Naumoff Shields � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 57

Epidemiology and Biostatistics

Ecologic Studies RevisitedJonathan Wakefield � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 75

Recent Declines in Chronic Disability in the Elderly U.S. Population:Risk Factors and Future DynamicsKenneth G. Manton � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 91

vii

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The Descriptive Epidemiology of Commonly Occurring MentalDisorders in the United StatesRonald C. Kessler and Philip S. Wang � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �115

The Women’s Health Initiative: Lessons LearnedRoss L. Prentice and Garnet L. Anderson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �131

U.S. Disparities in Health: Descriptions, Causes, and MechanismsNancy E. Adler and David H. Rehkopf � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �235

Environmental and Occupational Health

Industrial Food Animal Production, Antimicrobial Resistance,and Human HealthEllen K. Silbergeld, Jay Graham, and Lance B. Price � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �151

The Diffusion and Impact of Clean Indoor Air LawsMichael P. Eriksen and Rebecca L. Cerak � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171

Ancillary Benefits for Climate Change Mitigation and Air PollutionControl in the World’s Motor Vehicle FleetsMichael P. Walsh � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �1

Co-Benefits of Climate Mitigation and Health Protection in EnergySystems: Scoping MethodsKirk R. Smith and Evan Haigler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

Health Impact Assessment of Global Climate Change: Expanding onComparative Risk Assessment Approaches for Policy MakingJonathan Patz, Diarmid Campbell-Lendrum, Holly Gibbs, and

Rosalie Woodruff � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27

Heat Stress and Public Health: A Critical ReviewR. Sari Kovats and Shakoor Hajat � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41

Preparing the U.S. Health Community for Climate ChangeRichard Jackson and Kyra Naumoff Shields � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 57

Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesisin Developing CountriesJohn D. Groopman, Thomas W. Kensler, and Christopher P. Wild � � � � � � � � � � � � � � � � � � �187

Public Health Practice

Protective Interventions to Prevent Aflatoxin-Induced Carcinogenesisin Developing CountriesJohn D. Groopman, Thomas W. Kensler, and Christopher P. Wild � � � � � � � � � � � � � � � � � � �187

Regionalization of Local Public Health Systems in the Era ofPreparednessHoward K. Koh, Loris J. Elqura, Christine M. Judge, and Michael A. Stoto � � � � � � � �205

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The Effectiveness of Mass Communication to Change Public BehaviorLorien C. Abroms and Edward W. Maibach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �219


The Diffusion and Impact of Clean Indoor Air LawsMichael P. Eriksen and Rebecca L. Cerak � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171

Public Health Services and Cost-Effectiveness AnalysisH. David Banta and G. Ardine de Wit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �383

Social Environment and Behavior

Creating Healthy Food and Eating Environments: Policyand Environmental ApproachesMary Story, Karen M. Kaphingst, Ramona Robinson-O’Brien,

and Karen Glanz � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �253

Why Is the Developed World Obese?Sara Bleich, David Cutler, Christopher Murray, and Alyce Adams � � � � � � � � � � � � � � � � � � �273

Global Calorie Counting: A Fitting Exercise for Obese SocietiesShiriki K. Kumanyika � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �297

The Health and Cost Benefits of Work Site Health-PromotionProgramsRon Z. Goetzel and Ronald J. Ozminkowski � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �303

The Value and Challenges of Participatory Research: StrengtheningIts PracticeMargaret Cargo and Shawna L. Mercer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �325

A Critical Review of Theory in Breast Cancer Screening Promotionacross CulturesRena J. Pasick and Nancy J. Burke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �351

The Effectiveness of Mass Communication to Change Public BehaviorLorien C. Abroms and Edward W. Maibach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �219


Health Services

A Critical Review of Theory in Breast Cancer Screening Promotionacross CulturesRena J. Pasick and Nancy J. Burke � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �351

Nursing Home Safety: Current Issues and Barriers to ImprovementAndrea Gruneir and Vincent Mor � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �369

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Public Health Services and Cost-Effectiveness AnalysisH. David Banta and G. Ardine de Wit � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �383

The Impact of Health Insurance on HealthHelen Levy and David Meltzer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �399

The Role of Health Care Systems in Increased Tobacco CessationSusan J. Curry, Paula A. Keller, C. Tracy Orleans, and Michael C. Fiore � � � � � � � � � � �411

Indexes

Cumulative Index of Contributing Authors, Volumes 20–29 � � � � � � � � � � � � � � � � � � � � � � � �429

Cumulative Index of Chapter Titles, Volumes 20–29 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �434

Errata

An online log of corrections to Annual Review of Public Health articles may be foundat http://publhealth.annualreviews.org/

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Creating Healthy Food and Eating Environments: Policy and

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Transcript of Creating Healthy Food and Eating Environments: Policy and