Term paper on food deserts and obesity

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The Urban Environment’s Role in the Formation of Food Deserts as a Sociological Contributor to Obesity

Kelly Moltzen

Social and Behavioral Determinants of Health E.33.2355 – Fall 2008

December 11, 2008

Final term paper

Introduction

Obesity is an epidemic in many developed countries, notably the United States, where more than 30 percent of Americans are classified as obese 1,2. Obesity occurs more often in urban areas than in rural areas 3. At the same time, more and more cities around the world are becoming urbanized, with half of the world’s population now living in urban areas 1,2,4. Due to the forces of globalization, obesity is becoming a pandemic as fast food companies expand their empire in developed as well as developing countries through the process of “Americanization,” so much so that one billion adults in the world are overweight 2. Overweight is defined as having a Body Mass Index (BMI) of >24.9 kg/m2, and obesity is defined as having a BMI of >29.9 kg/m2. Obesity is a risk factor for other debilitating diseases, such as diabetes and cardiovascular disease, which decrease quality of life and lead to skyrocketing healthcare costs. For these reasons, it is of crucial importance to examine the characteristics of urban environments in terms of how they contribute to obesity. In this paper, the role of the urban environment in affecting living conditions that contribute to obesity will be examined, with a particular focus on food deserts in cities in developed countries such as New York.

The urban environment is a broad term encompassing urban planning, urban development, and urban zoning. These factors affect living conditions such as “housing, employment, education, equality, quality of living environment, social support, and health services” 4. The built environment encompasses the transportation system and land use patterns, which together influence opportunities for healthy eating and physical activity 5. In densely populated urban spaces, public transportation can allow for easier mobility, thereby increasing access to stores that sell healthy food, health services, education, and employment 4. How unevenly quality of housing is distributed within a city affects health, and so does poor transportation, which makes access to health services and employment more difficult 4. Land use patterns can affect the existence of food deserts in an area, where communities’ access to healthy food options is limited. Insufficient access to healthy food translates into less healthy diets, which translates into higher rates of obesity – especially without adequate access to physical activity-friendly environments. This is particularly relevant in low-income neighborhoods, where not only are food deserts more likely to exist, but poor people are more likely to be uninsured and therefore more apt to let their health go unchecked until they have already developed a chronic illness such as obesity and/or diabetes 6.

There are several other characteristics of the urban environment that can affect health 4. The social environment can play a key role in health maintenance in urban environments. Social support can mitigate the impact of stressors and enable access to goods or services, and organizations that work to improve living conditions can have a positive influence on the social environment 4. Availability and access to health and social services are important determinants of health, as are demographic characteristics such as race. Risk of obesity in urban areas is affected by such living conditions as “housing, employment, education, equality, quality of living environment, social support, and health services” 4.

Municipal level determinants such as government, markets and civil society are noteworthy contributors to health as well. Governance can influence many sectors of health. Markets can act positively on health – such as the existence of farmers’ markets – but they can also be very detrimental to health, such as through the fast food market. In the urban setting, the availability of supermarkets is particularly salient. Civic society, which Vlahov et al. defines as “the space not controlled by government or the market where residents interact to achieve common goals,” can work to improve social capital (social support, community capacity) 4. Government, markets, and civic society can work independently as well as collaboratively to critically influence an urban community’s risk for obesity, and these relationships will be explored further in this paper.

Methods

I have compiled a wide array of research by using various methods. I conducted literature searches of peer-reviewed journals through NYU Library’s electronic journals and database search engines, finding articles in World Development, Nutrition Reviews, and Environment & Urbanization, to name a few. I informally asked my network of professionals in the field for their expertise on food deserts, particularly through the American Dietetic Association’s Hunger & Environmental Nutrition Dietetic Practice Group’s list-serve. In this way I found out about many resources that I would not have otherwise known about. Through my network, I also found out about and attended various nutrition and food security related meetings and conferences in New York City, of which I attended a Food Systems Network of New York City (FSNYC) meeting, a NYC Nutrition Education Network (NYCNEN) meeting, and a Manhattan Borough President Politics of Food Steering Committee meeting. I was unable to make it to the Politics of Food Conference that was organized by the Borough President’s Steering Committee because it conflicted with the NYCNEN meeting, but many of the speeches are available online, so I was able to watch them on my own.

At the FSNYC meeting on November 11, 2008, Geri Henchy from the Food Research and Action Center gave an overview of the Women, Infants and Children Supplemental Nutrition Program (WIC) changes, and Bob Lewis of NYS Dept of Agriculture and Markets led a discussion on the impact of these changes on our local Farmers' Markets 7. At the NYCNEN meeting, the New York City Department of Health and Mental Hygiene’s (NYC DOHMH) new Green Cart initiative 8 was discussed 9. Manhattan Borough President Scott Springer has a Politics of Food Steering Committee, which organized a Politics of Food Conference that had speeches by Mayor Bloomberg, the President of the United Nations General Assembly Miguel d’Escoto, and Maya Wiley, the Director of the Center for Social Inclusion 10. Additionally, the conference had the following breakout sessions: “From Field to Market: A Blueprint for Food Distribution in New York City;” “Finding Healthy Food: Supermarkets, Farmers’ Markets, Community Supported Agriculture (CSAs) and Food Deserts;” “The Importance of Nutrition Education; Urban Farming: What Does It Look Like? What Makes It Work?;” “How Schools, Hospitals, and Other Institutions Can Serve Healthier Meals;” “Recession's Consequences for the Food Safety Net;” and “The Urban Food Agenda: Shaping City, State, and Federal Policy.”

The Steering Committee has had one follow-up meeting so far after the conference, where Scott Springer discussed the potential for introducing a bill to the city council for a new “Department of Food” in New York City 11. He has already developed the “Go Green East Harlem” Cookbook, an initiative developed by his steering committee in January 2008 12,13. [Note: document since published: Food in the Public Interest]

Results

There is much evidence that living in urban areas is associated with a greater prevalence of obesity, both in developed and developing countries. People in urban areas consume foods higher in fat, more animal products, more sugar, more food prepared away from the home, and more processed foods 3. In addition, urbanicity is traditionally associated with more service sectors jobs than agricultural jobs, and generally a more sedentary lifestyle. The urban effect exists even when income, food prices, and various other sociodemographic variables are controlled for, as found during a study in China 3. Kjellstrom and Mercado confirm this with the statement “urbanization itself is a determinant of health” 2. There are multiple reasons for this, including the interplay of the existence of food deserts, facets of the urban environment – such as urban planning, urban zoning and urban development – and racial discrimination. While urbanization and economic growth have generally gone hand in hand since the Industrial Revolution, they “give every sign of becoming dissociated” 3, leading more people to experience the urban health penalty than the urban advantage. This may be partially due to the unfortunate effect of decades of fighting poverty and working to increase fat consumption, which “led to an entrenched bureaucracy trained to encourage such activities” 3.

Another observation is that although the average income in urban areas is generally higher than the average income in rural areas, this difference can be misleading, as a majority of the wealth is concentrated in the hands of the few urban elite 2. In addition, the cost of living is much higher in urban areas – especially New York City – than in rural areas. This lack of finance leads to more food insecurity and poor nutrition status in developing countries as well as developed countries 2.

Land use and transportation, the components of the built environment, can significantly affect urban health. While land use and transportation systems should ideally work together to bring the most benefit to an area’s residents, in the United States they are structurally part of different levels of government: land use patterns are set by local governments and private developers, while transportation is run by the federal government. Therefore, increased coordination between these agencies is key to producing healthier environments 5.

Neighborhood design shapes “how people get from place to place (e.g., roads, transportation systems, bicycle and walking paths)…, where they exercise…, and the social norms and perceptions that impact how people use their neighborhoods (e.g., crime,…social capital)” 1. Decreased opportunities for physical activity contribute to the sedentary lifestyle that is found in individuals of lower socioeconomic status. Likewise, fear of crime and violence may decrease the likelihood of seeking outdoor physical activity in a neighborhood, especially for children whose parents perceive the area as dangerous 1.

The growth and expansion of highways by transportation authorities has pushed aside consideration for pedestrians and bicycle riders 5. However with the passage of the Intermodal Surface Transportation Efficiency Act (ISTEA), more pedestrian- and biker-friendly programs are being implemented, including providing over $400 for pedestrian and bicycle facilities, hiring a bicycle-pedestrian coordinator in each state, starting a $612 million Safe Routes to School program, as well as several other programs 5. Maryland has begun providing incentives for employees to live closer to work; London has implemented a “congestion pricing” program to discourage people from driving into certain areas at certain times by charging a fee; and “Location Efficient Mortgages” incentivize living in areas that are conducive to active travel instead of driving 5. Another idea is implementing voluntary travel reduction programs to educate residents on how to save time and money by cutting down on driving 5.

Most cities have high rates of inequality 4, and therefore in order to reduce the risk of widening disparities, community-specific inequalities must be accounted for. For example, there are neighborhood disparities in terms of obesity prevalence, with black neighborhoods having higher rates of obesity than white neighborhoods 1. African Americans are less likely to own a car in comparison to other races 6, which puts them at a disadvantage in terms of availability of transportation to get to healthy food vendors. Also, immigrants in a city like New York who move to the United States with the goal of making money to send back to their families, often start out with an economic disadvantage, and therefore cannot afford to buy healthy food for their families. They must buy what the food industry in the United States makes inexpensive – namely, unhealthy food. For these reasons, minorities have higher rates of obesity 14 and are therefore more prone to the urban health penalty as a contributor to obesity than whites.

According to Maya Wiley from the Center for Social Inclusion, urban zoning shows signs of segregation by race, especially in New York15. Out of the fifty largest metropolitan areas in the country, New York is the 4th most segregated. The top 5% of earners make 52 times the income of the lowest fifth, making the income disparity comparable to that in Namibia. Additionally, only the highest earning professionals can afford to live in Manhattan. Housing construction occurs much more often in wealthy areas of the City, with very limited construction in low-income neighborhoods 15. In addition, Blacks, Latinos and Asians are consistently victims of the illegal practices of “redlining” neighborhoods not considered loan worthy, and “steering” buyers to certain neighborhoods based on their race or ethnicity 15. Mandatory inclusionary zoning would incentivize developers to sell or rent a percentage of new units to low and moderate-income families at an affordable price 15, which would thereby work to decrease segregation.

While zoning ordinances of land use were originally established to improve public health by separating industrial activities from residential areas, the concern of property rights and separation of land usages eventually took over, leading to a separation of non-industrial establishments – such as stores and schools – from residential areas 5. The greater distances between destinations in a community, the less likely people are to walk or bike to get there, thus contributing to obesity through decreased physical activity. Yet “fast food restaurants aren’t usually labeled undesirable as a land use,” which means that they are allowed in low-income neighborhoods which have less restrictive zoning policies 5.

These policies brought about the existence of food deserts. Food deserts are areas “where access to healthy foods such as fresh fruits and vegetables is either limited, too expensive, or nonexistent. Inhabitants must opt for cheap and unhealthy foods based on whatever is available” 16. Food deserts exist both in rural areas – where the nearest supermarket may be miles and miles away – and in urban areas, where the number of fast food options far outweigh the number of supermarkets stocked with healthy choices, and the fast food choices are much more affordable than healthy foods. Urban areas are often characterized by a preponderance of corner stores which may not be adequately equipped with refrigerators, shelving, or advertisement messages for fresh fruits and vegetables; additionally, fresh fruits and vegetables may not be affordable or available 16.

The close proximity of fast-food and bodegas or convenience stores compounds the problem of increased distances to supermarkets that have affordable, healthy food. This is especially problematic for residents of low-income neighborhoods who are less likely to possess a car 17, as people who live far away from grocery stores and who do not have access to cars are less likely to travel distances to shop at them 6. In addition, fast food restaurants tend to be located around schools so that they can target their products to children and adolescents 5. Children in urban environments may be more likely to buy food at these establishments and bodegas on their way to and from school instead of eating a healthy breakfast in the morning, bringing lunch with them to school, or purchasing food from the school’s breakfast or lunch program offerings.

Meanwhile, “more affluent neighborhoods tend to restrict the number and location of [fast food] outlets through the formal land use planning process” 5, leading to even more health disparities between high and low-income neighborhoods. This is yet another contributor to the fact that areas with lower socioeconomic status have been shown to have less access to stores selling healthy food such as low-fat milk, high-fiber bread, fresh fruits, and vegetables 1.

Large chain supermarkets have the benefit of being able to offer lower prices and higher quality food options, but these benefits cancel out and contribute to health disparities if they are not accessible to low-income communities. Over the past 30 years, grocery stores have followed the white flight out of urban areas and established themselves in suburban areas, leading to an “urban grocery store gap” 18. They find it more economical to cut costs by buying in bulk and using large warehouses, which is easier to do in suburban areas 6. Research conducted by the University of Connecticut’s Food Marketing Policy Center found that for 21 cities across the US, there were 30 percent fewer supermarkets in low-income areas than in high-income areas 17. Data from research in Chicago suggests that the race of a neighborhood may be a deciding factor in whether large chain grocery stores come to an area or not 6,19. In addition, this study found that low-income neighborhoods that had no or distant grocery stores (but nearby fast food restaurants instead) had higher rates of premature death and chronic health conditions. Similar findings have been found in Philadelphia, where 70 new supermarkets would be needed in order to erase food deserts 6,20.

In order decrease the prevalence of food deserts in low-income communities, several interventions could be considered. These could include limiting the number of fast food stores and other vendors of unhealthy food by setting stricter zoning regulations, as well as giving incentives to supermarkets to locate in urban neighborhoods such as tax breaks and streamlined processes for obtaining permits 5. The development of public/private partnerships between governments and grocery stores could also be considered 17. However, adding more supermarkets to low-income neighborhoods in cities does not address the entire problem of food deserts, as will be discussed further on the following pages.

While large supermarket chains can successfully cut costs and consequently make foods cheaper, they have disadvantages as well. Food sold in large supermarkets that is shipped long distances has a diminished nutritional value, and there are high monetary and environmental costs of shipping, processing, and packaging 6. Also, supermarkets were designed for people with cars who could load up their cars with several days’ worth of groceries. They are not ideal for urban residents who have to worry about transporting the food items home.

In addition, supermarkets often run smaller stores out of business 6. Small stores are more likely to be near a community’s residential area, and therefore are more convenient for people who don’t own a car, can’t get a ride, can’t rely on public transportation, and can’t walk far distances. Single parents, people with disabilities, and the elderly all fall into this category 6. Yet, small grocers encounter a number of problems which makes it more difficult for them to provide fresh, healthy food. For instance, small grocers do not have the space or equipment needed to offer fresh produce regularly, normally do not carry a wide variety of produce, cannot buy in bulk quantities, and as a result must charge higher prices than chain supermarkets – up to 76 percent more 17.

The upshot is that cities should enable local citizens to obtain locally produced food. This can be done with urban agriculture, a phenomenon that is not new but was reintroduced to modern culture in the 1970’s when residents of New York’s East Village decided to clean up abandoned lots and plant gardens 6. Urban gardens require very little land and resources but can have a large output, increase a city’s green space, optimize production of unused land, and improve the quality of food (as it is produced closer to its eventual market and therefore does not need to be genetically modified) 6. Gardens can even have a huge environmental impact, as food miles – or, the distance food is transported from its production site to its distribution site – will be drastically reduced.

There is substantial evidence regarding the promise of urban gardens, and “the importance of urban and peri-urban agriculture and livestock keeping in sustaining the urban poor is being recognized globally” 2. Commercial food production relies on monocultures of crops that can prove devastating if the climate produces a poor harvest, as costs skyrocket with a decrease in supply. Urban agriculture can improve food security by increasing the stability of the nation’s food supply, as it decentralizes the food system and makes food available locally. It also drastically cuts down on food miles, improves the preservation of green space, and can benefit communities in terms of economic development 6. In addition, “micro-farming provides healthier produce” 6 and the nutritional quality does not decline with days of being transported from far distances.

Urban agriculture can be started in a number of ways. It can take the form of school gardens, where they can be used to educate children on skills that will last them for a lifetime. It can be entrepreneurial, where the food grown can be sold at local farmers’ markets. Community gardens are another idea, where the community members take charge through leadership and community organization. This can increase social capital, can have physical and psychological benefits, and can motivate youth and senior citizens to take a part in their communities 6.

Micro-farming has been used to boost the economy throughout United States history, such as via “Victory Gardens” during World Wars I and II. During this time, 40% of the nation’s food supply was grown by gardeners 6. Urban and community gardens represent a type of food sovereignty: “the right of peoples, communities, and countries to define their own agricultural, labor, fishing, food, and land policies which are ecologically, socially, economically, and culturally appropriate to their unique circumstances” 21. It “introduces a complete integration of social justice ideals,” where community based organizations can aid in achieving the local economy goals, community members can be hired to work on the farm sites, and the produce can be sold at local farmers’ markets and at neighborhood corner grocery stores 21. One example of a contribution to the community effort took place in Chicago, where good-quality compost was purchased by the truckload from a local urban farmer who collects vegetable waste from local restaurants and turns it into compost 21. University resources should also be utilized when developing urban farms, such as a local Cooperative Extension office that could be used to help identify suitable plant varieties. By taking a food systems approach and involving every aspect of the community, urban farming can allow a community to take advantage of the “urban advantage” and not have to suffer from the “urban health penalty.”

While access to healthy foods in low-income communities is essential to improving the obesity situation, it is not the only necessary component. Several generations of lacking access to healthy foods has led to a dearth of knowledge about how to prepare healthy foods, even when they do have access to them. Therefore, health education programs must be implemented in communities while simultaneously increasing access to healthy foods. There are various health-based efforts to shape the built environment, such as the World Health Organization’s Healthy Cities program to build relationships between public health officials, local planners and others; the Active Living by Design program to promote physical activity; Health Impact Assessments which state and federal governments could require for land use and transportation planning, and statewide health plans supported by the Centers for Disease Control and Prevention’s Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases 5. However, there are still many communities that have not been reached and still suffer from the problem of food deserts 6. National governments must adequately equip local governments “with the mandate, powers, jurisdiction, responsibilities, resources and capacity to undertake ‘healthy urban governance’” 2.

One way they could do this is by subsidizing seed programs to jump-start food sovereignty-based programs in low-income communities, such as the proposed Urban Agriculture and Education Center to be located in the center city of Indianapolis 6. This site will be a place where nutrition and culinary classes can take place, food can be grown and sold, and social networks can be strengthened. It has been modeled off of successful combinatory farmers’ markets and community centers, such as the City Market in Kansas City and Santa Caterina Market in Barcelona, Spain. Similarly, community-initiated development corporations can “compete for public funding opportunities to attract needed businesses to low-income communities, develop affordable housing, or provide education and skills opportunities to residents” 5.

Another promise for creating more equitable opportunities in the urban setting is to use financing schemes such as conditional cash transfers 2 and social welfare programs like the Supplemental Nutrition Assistance Program, which now allows users to shop at farmers’ markets 22. NYC DOHMH has come out with a Health Bucks Program where one Health Buck coupon will be given to each customer for every five dollars spent using food stamps 23. The Health Bucks can be used at farmers’ markets. This is promising because vouchers for fresh fruits and vegetables have been shown to increase consumption of produce in the past, as was shown in a study of the WIC program in Los Angeles, California 24. The Health Bucks Program is in addition to the DOHMH’s Green Carts Program, which has increased the number of fruit and vegetable vendors in New York City by 500 in 2008 and will increase it by another 500 in 2009 8. There are also new changes happening to the WIC Supplemental Nutrition Program, which will provide healthier food options starting in 2009 7. Vertical farming, a concept developed by Dickson Despommier at Columbia University, may hold potential for the future as well 25.

Discussion

While this paper set out to examine the research linking obesity to urban environments in developed countries, the majority of studies I found were based in the United States. This is not necessarily a bad thing, as public health interventions are best examined within the context of a particular community. Another limitation is while I originally set out to focus on the factors of the “urban environment” – urban planning, zoning, and development – the majority of the research focused on effects of urban planning and zoning in terms of placement of food vendors, and only a small amount of research was found on zoning of residential areas. Perhaps this is because it is easier to develop policies regarding where food stores can and should be located than to focus on altering residential patterns, which touches on the effects of urban renewal and redevelopment issues.

From the research, it is clear that there is indeed an urban health penalty felt by low-income communities across the United States which leads to increased rates of obesity. In many areas this impact is felt the strongest by African Americans, as they are the minority group that has been here the longest. Besides generations of outright discrimination in employment and being put at an economic disadvantage, they have been the victims of discriminatory zoning practices in cities. They also must have had the most generations suffer from lack of access to healthy foods and the concurrent loss of a knowledge and skill set on how to prepare healthy foods.

There are many interventions which can be considered when determining how to best decrease the effect of the urban health penalty and its associated risk for obesity among low-income communities. Changes can be made at the governmental level, such as: regulating where fast food restaurants are allowed to exist; working with the Department of Transportation and each state’s bicycle-pedestrian coordinator to expand and improve bicycle routes and pedestrian walkways; giving subsidies to vendors and community organizations that are willing to move into an area to sell healthy foods and educate residents on nutrition and cooking skills; and using social welfare programs to encourage low-income communities to purchase fresh fruits and vegetables. Governments can also take an even more radical step and develop a “Department of Food,” as is being considered in New York City. Many governmental interventions are best implemented at the local level, however, because the community must have the capacity to carry out the program.

It is also important to focus on community-level interventions because they help build social cohesion, which can go a long way in terms of actually bringing about change to a community. For instance, involving community members in the growing and selling of the foods they eat can give people a sense of pride and accomplishment while simultaneously improving their economic development opportunities, thereby increasing the chances that the program will be successful in the long term. Fortunately, there will be funding available for new interventions in the coming years in the U.S., as the 2008 Farm Bill has allotted $10.4 billion for urban agriculture and nutrition, aid for Historically Black Colleges and Universities, and a Healthy Urban Food Enterprise Development Program that will provide grants and technical assistance to communities to link farmers and grocery stores 26. One can only hope that this money will be used wisely by all parties involved.

References

(1) Black JL, Macinko J. Neighborhoods and Obesity. Nutrition Reviews 2008;66(1):2.

(2) Kjellstrom T, Mercado S. Towards Action on Social Determinants for health equity in urban settings. Environment & Urbanization 2008;20(2):551.

(3) Popkin BM. Urbanization, Lifestyle Changes and the Nutrition Transition. World Development, 1999 11;27(11):1905-1916.

(4) Vlahov D, Freudenberg N, Proietti F, Ompad D, Quinn A, Nandi V, et al. Urban as a Determinant of Health. Journal of Urban Health 2007;84(Supp.1).

(5) Handy S, Clifton K. Planning and the Built Environment: Implications for Obesity Prevention. In: Kumanyika S, Brownson R, editors. Handbook of Obesity Prevention. 8th ed. : Springer-Verlag New York Inc.; 2007. p. 171.

(6) Mossler, Adrienne Calise. Urban Agriculture and Education Center: An Answer to Urban Food Deserts [dissertation] University of Cincinnati; 2008.

(7) Food Systems Network NYC meeting: Overview of the Women Infants and Children supplemental nutrition Program (WIC) changes presented by Geri Henchy, from Food Research and Action Center and a discussion on the impact of these changes on our local Farmers' Markets with Bob Lewis of NYS Dept of Agriculture and Markets. November 11, 2008.

(8) NYC Green Carts. 2008; Available at: http://ezproxy.library.nyu.edu:3591/html/doh/html/cdp/cdp_pan_green_carts.shtml. Accessed 12/6, 2008.

(9) NYC Nutrition Education Network meeting: Food Justice & The Rising Cost of Food. November 19, 2008.

(10) The Politics of Food: A Conference on New York's Next Policy Challenge. November 19, 2008.

(11) Manhattan Borough President Scott M. Stringer's Politics of Food Steering Committee meeting. December 4, 2008.

(12) Borough President Stringer Releases “Go Green East Harlem” Cookbook. 2008; Available at: http://www.mbpo.org/newsroom_details.asp?id=1131. Accessed 12/6, 2008.

(13) Go Green East Harlem Cookbook. 2008; Available at: http://www.foodsystemsnyc.org/node/108. Accessed 12/6, 2008.

(14) Cook S, Weitzman M, Auinger P, Barlow SE. Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics 2005;116(1):112.

(15) New York City in Crisis: Racial Segregation, Concentrated Poverty and the New York City Mayoral Race. 2005.

(16) Getz L. Food Deserts: Where Healthy Options are only a Mirage. Today's Dietitian 2008;10(10):48.

(17) Nutrition Policy Profiles: Supermarket Access in Low-Income Communities.

(18) Cotterill R, Franklin A. The Urban Grocery Store Gap. 1995; Food Marketing Policy Issue Paper No. 8.

(19) Gallagher M. Examining the Impact of Food Deserts on Public Health in Chicago. Mari Gallagher Research and Consulting Group 2006:1-39.

(20) The Need for More Supermarkets in Philadelphia: Food for Every Child. The Food Trust 2002:1-8.

(21) Redmond L. Creating local food options in an urban setting. NewFarm.org.

(22) USDA Supplemental Nutrition Assistance Program. 2008; Available at: http://ezproxy.library.nyu.edu:3503/fsp/snap.htm. Accessed 12/6, 2008.

(23) NYC DOHMH Health Bucks Program. 2008; Available at: http://www.nyc.gov/html/doh/html/cdp/cdp_pan_health_bucks.shtml. Accessed 12/11, 2008.

(24) Herman DR, Harrison GG, Jenks E. Choices Made by Low-Income Women Provided with an Economic Supplement for Fresh Fruit and Vegetable Purchase. Journal of the American Dietetic Association 2006 5;106(5):740-744.

(25) Dickson Despommier, Kristen Anderson, Nicola Areshenko, Allen Brown, Jennifer Buskey, Amanda Colligan, et al. The Vertical Farm: Plans for the First Stage [dissertation] Columbia University Mailman School of Public Health; 2003.

(26) Rush B. Turning urban deserts into urban oases. The Hill.com 2008.