9

Innovations in Food Access and Affordability and Implications for Food Systems

The final session on innovation addressed innovations in food access and affordability. Roni Neff, session moderator, opened the session by explaining that it would focus on equity considerations, a recurrent theme throughout the workshop, with respect to people’s food-related choices, their ability to make those choices, the affordability of food, food insecurity, and food-related outcomes. She added that the session would also examine power dynamics, leadership, and who is involved in decision making.

REDESIGNING FOOD ACCESS

Nevin Cohen, City University of New York School of Public Health, spoke about the way food access is conceptualized, measured, and addressed, including limitations of existing approaches and innovative strategies.

Root Causes of Poor Food Access and Research Challenges

Cohen began by explaining that the term “food access” is used to describe a wide range of conditions involving diverse social movements focused on food sovereignty, food system control, and environmental justice activism. He asserted that a legacy of racism in the United States has led to spatial disparities in housing, economic development, and food deserts, and that great wealth disparities caused by racism, gender oppression, and other discrimination have contributed to large numbers of Americans living

in poverty and experiencing food insecurity as a result. Cohen suggested further that overweight and obesity are due in part to poverty and targeted marketing of ultraprocessed foods to communities of color.

Cohen explained that hunger and food insecurity have been conflated with physical food access as a result of technological innovations that facilitate the identification of food deserts, as well as policy approaches that frame hunger as market failure and point to popular policy solutions, such as food retailer subsidies, as an economic development tool. Considering the relationship among healthy diet, overweight and obesity, and cardiovascular disease risk, he added that public health experts have used supermarket access, with supermarkets as a proxy for the availability of healthy food and the likelihood of fruit and vegetable consumption, in ecological theories to explain the current high rates of overweight and obesity and race- and class-based health disparities.

Cohen, however, presented a contrasting view—that supermarket access is inadequate to fully explain the reasons for hunger and poor nutrition—arguing that the research supporting that explanation is flawed in several key ways. First, he observed, U.S. obesity rates have increased steadily since the 1960s across all age groups, genders, and ethnicities, suggesting that the likely cause is environmental changes rather than poor individual dietary choices. He pointed out that this explanation is consistent with research showing that since the 1970s, increased energy density has been associated with weight gain across countries. He also he pointed out that researchers typically focus specifically on the locations or density of food outlets using spatial or geographic analysis to assess the proximity of retail food establishments to residential locations. However, he said, small ethnic grocers or other retailers that do not respond to surveys are often not included in these studies, and they analyze only a very specific aspect of the food environment. In addition, he noted that supermarkets also offer many unhealthy options, that retail sales data may not be considered, that most studies are cross-sectional rather than longitudinal and fail to capture changes over time, and that most of the research takes place in major U.S. cities. Cohen suggested further that measures of food quality are also flawed. He observed as well that research often measures accessibility, availability, price, prominence in shelf positioning, and healthfulness of products without clearly defining what is healthy versus unhealthy. He cited additional methodological limitations with measuring what people eat, noting that self-reported dietary intake data are subject to recall bias, and that body weight is often self-reported.

As a result of these limitations, Cohen explained, most studies of food environments, diet, and health outcomes have found weak or inconsistent associations among supermarkets, fast food outlets, and obesity. However, he said, there continues to be a focus on geographic proximity to food

outlets, including in the Milan Urban Food Policy Pact, signed by about 200 cities, which requires tracking the number of households living in food deserts as a measure of food access.¹

Cohen acknowledged that some research has attempted to consider people’s daily activity patterns and how they buy food citywide in the course of their daily activities, as well as nontraditional food sources such as ethnic grocers and even vending machines. Nonetheless, he asserted, “Food environments and the way people interact with them are much more complex” than is captured by most existing research.

Potential Solutions for Challenges of Research on Food Access

Cohen then presented potential solutions to address some of the challenges he had described. First, he suggested using longitudinal studies to assess the relationship between the food environment and health outcomes over time. For example, using Google Maps’ Street View, he and his colleagues measured all existing food retailers in the Bronx in 2007 and 2017, observing growth in retail food outlets over the time period, most of which occurred in areas with more development and with government incentives for their establishment. The study also found growth in dollar stores that sell less expensive, mostly processed, shelf-stable food.

Cohen also suggested that social practice theory can be useful in understanding how people’s practices related to food buying and cooking are shaped by their material conditions, their knowledge, and the meaning they associate with particular practices, as well as how those practices have evolved over time. He described a study he conducted that used focus groups to understand how organizations for seniors could better help older adults eat more food at home rather than in meal programs. The study found that people’s practices in this regard are designed around their food environments and become normalized over time. Another project Cohen described uses deidentified data aggregated from location-tracking apps to monitor the locations of individuals as they travel to and from food retailers.

Innovations to Increase Food Access

With respect to innovations to increase food access, Cohen focused on the design of strategies that use technological and social innovations to address the economic conditions and scheduling constraints that impact

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¹ The Milan Monitoring Framework defines food deserts as disparity in the geospatial distribution of the food retail establishments and of socioeconomic population groups (Milan Urban Food Policy Pact, 2018).

people in low-income communities. He described three types of such innovations: (1) social supermarkets, (2) food buyers’ clubs, and (3) meal kits.

Cohen defined social supermarkets as nonprofit or socially oriented ventures that provide both community services, such as nutrition education, and lower-priced food in low-income communities. The stores may rely on donated food and services, negotiated discounts with utility companies and suppliers, or lower-cost financing. Cohen shared an example of a social supermarket in Baltimore created by the Salvation Army that offers low prices on food, free weekly items for Supplemental Nutrition Assistance Program (SNAP) participants, nutrition education, and meal planning assistance. The store is conveniently located near an elementary school in a low-income neighborhood and relies on donations of nonperishable food, negotiated discounts with distributors, discounted utilities, donated labor, and government-funded coupons to enable customers to buy fresh produce at a discount. Cohen pointed out that other food retailers, such as a dollar store, fast food restaurants, and a traditional grocery store, exist nearby, but the social supermarket is still needed to provide low-cost food to price-sensitive shoppers. He added that research shows that low-income consumers often shop at multiple stores to get the best prices, so customers of the social supermarket may also shop at some of the other nearby food outlets.

Turning to his second example of an innovative solution, Cohen described a food buyers’ club that has encouraged neighborhood residents to take advantage of a pilot project in New York City allowing people who receive SNAP to use these benefits at online grocers. Residents of a housing development in a Brooklyn neighborhood were engaged in a 7-month co-design process to identify potential options for food shopping. They decided to take advantage of the U.S. Department of Agriculture’s (USDA’s) pilot project to allow SNAP participants to use their electronic benefit transfer cards to shop online at Amazon. Cohen pointed out that sales data are not yet available with which to determine whether the intervention has been cost saving or whether it has affected the kinds of products purchased, but participants have stated in interviews that the initiative saves them time compared with shopping at stores far away, and they are happy with the quality, value, and convenience. Cohen added that the food club also has encouraged residents to discuss their shopping experiences with each other, and the food is delivered to their development’s community center run by a nonprofit organization, providing an opportunity for additional health and budgeting programming in the future. He suggested that this model could be replicated and scaled across the New York City Housing Authority, which has about a half million residents.

Finally, Cohen described a company that offers an inexpensive meal kit to low-income consumers. The kit is sold at a price of $2 per serving and is

targeted at parents of children in Head Start and public housing residents. The company keeps costs down by using conventional distributors, inexpensive packaging, volunteer assembly, and just-in-time delivery.

Final Remarks

In conclusion, Cohen recommended shifting toward theories of food access that focus on changing food practices and that explicitly address social inequities. He suggested using multidisciplinary approaches to measure food access. He also recommended better engaging study populations in the research and using co-design methods to develop and test interventions. In sum, he argued, moving beyond conventional methods of food distribution and marketing may be useful in increasing knowledge sharing, reducing disparities, and empowering communities.

BLACK CHURCH FOOD SECURITY NETWORK

Reverend Dr. Heber Brown III, Pleasant Hope Baptist Church, Baltimore, Maryland, described the work of the Black Church Food Security Network and his church in Baltimore in growing food and empowering others to use farming and gardening as a strategy for achieving food sovereignty.

Brown is focused on asset-based approaches to advancing food and land sovereignty among African Americans in rural and urban communities. He defined food sovereignty as “the right of peoples to healthy and culturally appropriate food produced through ecologically sound and sustainable methods and their right to define their own food and agriculture systems,” putting people who produce, distribute, and consume food at the heart of food systems and policies (La Via Campesina, 2013). He suggested replacing the term “food desert” with the term “food apartheid,” which considers the racial, geographic, faith, and economic aspects of a food system.

Pleasant Hope Baptist Church Story

Concerned that many of his congregants were suffering from diet-related diseases, Brown initially considered establishing a partnership with a fresh food market nearby. However, he decided the prices were too high, and he did not want his congregation to be in a position of subservience and dependency on the market. Instead, he rallied the congregation around creating a garden on a small plot of land adjacent to the church. He was grateful that the partnership with the congregation was the solution for the community, and the 1,500 square foot garden was established in 2010.

The garden grows about 1,200 pounds of produce each year. According to Brown, older members, many of whom had grown up on farms in the South and had expertise in agriculture, were particularly pivotal in maintaining the garden.

Historical Context and Examples

Brown explained that he realized that African American church communities have many assets, such as land, parking lots, commercial kitchens, classrooms, and facilities that are frequently underutilized, and saw opportunities to connect these assets, resources, and people in a systemic response to the systemic problem of food inequity. He learned that historically, African Americans such as Marcus Garvey and other members of the Universal Negro Improvement Association (UNIA) had organized to create their own grocery stores.

Brown described several historical church leaders who led initiatives to use the church’s land and assets to cultivate and provide food for their congregation and further food sovereignty in their community. For example, UNIA President James R. Stewart established a farm in Ohio based on the ideology that food, liberation, and freedom go together, and Reverend Vernon Johns was a farmer as well as a pastor, preacher, scholar, and seminary president. Brown explained how he integrated farming into his preaching and regularly sold crops in front of the church on Sunday. Johns started the Virginia Farm and City Enterprises and raised livestock on land in Prince Edward County, Virginia. He encouraged urban and rural African Americans to work together to create their own food system and related industries.

Brown also described how Fannie Lou Hamer furthered food sovereignty efforts in her community, arguing that food may be used as a political weapon. She stated, “If you have a pig in your backyard and you have some vegetables in your garden, you can feed yourself and your family and nobody can push you around.” Brown explained that she was part of an African American social–political movement that recognized that liberation, freedom, and opportunities for self- and community actualization may come through agriculture and control of the food system. Hamer worked with the Freedom Food Co-op, which owned 640 acres of land and had a pig bank in Sunflower County, Mississippi. In partnership with the National Council of Negro Women, the organization trained and taught families how to use the pigs to feed their families. As part of the agreement, families had to give piglets back to the bank for others to use. Brown noted that the National Council of Negro Women was focused at the time on helping people meet their own needs on their own terms.

Finally, Brown explained how Reverend Albert Cleage worked to connect urban and rural African Americans to advance food sovereignty. His goal was to ensure that African Americans would not be subject to the sometimes discriminatory or racist policies of local neighborhoods and communities. According to Brown, his strategy for pursuing this goal involved the church purchasing land, and noted that Cleage’s congregation owned 3,750 acres in South Carolina, even continuing with the vision of buying land after Cleage died.

Work of the Black Church Food Security Network

Brown articulated how his organization, the Black Church Food Security Network, also organizes the resources of the African American church community for an assets-based approach to food insecurity. The organization has two main objectives, he said, one of which involves working with black churches to help them grow food on their land. It engages in congregational organizing, identifying local leaders and organizers to champion the establishment of a garden and members to maintain it. Brown emphasized the organization’s focus on church-owned land because of his concerns regarding the potential for gentrification, dispossession, and displacement of government-owned land once value is added to the land through the gardens. In collaboration with the Johns Hopkins Center for a Livable Future, Brown has as a goal that the church gardens will overcome the food apartheid in the city of Baltimore, using the strength of the black churches as anchor institutions.

Brown also described efforts of the Black Church Food Security Network to bring pop-up farmers’ markets to churches on days of worship. He explained that doing so allows congregants to meet and directly support the black farmers from whom they purchase food.

Brown then described how he created a pipeline for young adults interested in the intersection of spirituality and food systems. He takes young people to see other churches that are advancing initiatives around such issues as food security and climate change, and works to inspire them to lead similar efforts in their own community. The organization is also developing a Young Adult Residential Fellowship Program, which will be located in a house owned by the church that Brown currently pastors, Pleasant Hope Baptist Church in Baltimore. Young adults will have the opportunity to live in the house for 18 months while studying food sovereignty, liberatory education, and social justice.

In closing, Brown emphasized that his role is to weave a network of local organizers and local leaders and provide them with resources and support.

FOOD QUALITY IN FOOD ASSISTANCE/EMERGENCY FOOD

Rhonda Gonzalez, Community Food Bank of Southern Arizona, discussed initiatives focused on food quality in the food bank/food rescue sector.

Overview of the Community Food Bank of Southern Arizona

Gonzalez began by describing the Community Food Bank of Southern Arizona, which serves five primarily rural counties spanning 23,000 miles just north of the Mexican border. The organization serves as a food bank—sourcing, warehousing, and distributing food—and a food pantry, delivering food in partnership with 350 to 400 partner agencies. Culinary training in the form of an 11-week free program for un- or underemployed clients is also offered in a community commercial kitchen. The organization also operates a 6-acre urban farm.

Gonzalez explained that for the past 20 years, the organization has considered how to transition from a charity organization to a justice organization. For the past 5 years, she said, this effort has involved incorporating into the organizational culture the recognition that food and health are human rights.

The organization is also working to better incorporate clients’ perspectives into its work, Gonzalez added, a university partner surveyed about 250 clients and identified their top priorities as nutrition, cooking, and managing chronic diseases. Gonzalez reported that 72 percent of survey respondents indicated that they or someone in their household had high blood pressure, high cholesterol, or type 2 diabetes. She noted that, overall, the incidence of type 2 diabetes is higher in low-income populations.

Finally, Gonzalez stated that the organization also helps to reduce food waste by obtaining unwanted produce from distributors in Mexico. The majority of the food received by the food bank is donated, she said, through either USDA commodity programs, private donations, or grocery rescue. Of the 63 million pounds of donated products, 52 million pounds consists of produce, mainly vegetables from the Mexican border.

Redefining Success

In its shift to becoming a social justice organization, Gonzalez continued, the food bank is looking at moving away from a focus on pounds of food distributed in how it defines success. Instead, she said, metrics are focused on (1) a combination of food and health; (2) education; and (3) community development, emphasizing client engagement.

As Gonzalez explained, the organization decided about 5 years ago in response to client surveys to increase its focus on health, and a formal

nutrition policy was adopted by the board in 2017. This policy states that all of the food the organization sources and distributes must align with the Dietary Guidelines for Americans, emphasizing nutrient density, food variety, and healthy eating across the lifespan (HHS and USDA, 2015). Gonzalez also pointed out that, consistent with the recommendation in the Dietary Guidelines for Americans to reduce consumption of sugar-sweetened beverages, the organization no longer accepts large-scale soft drink donations.

According to Gonzalez, the food bank is also considering how to implement the recommendation in the Dietary Guidelines for Americans that the majority of grains consumed be whole grains. She pointed out that this is a challenge, given that the majority of its food supply is donated. Her group is working to determine how to increase the distribution of whole-grain products, as well as the overall healthfulness of their food supply, in a way that is consistent with the preferences of their clients. Change in a complex organization such as a food bank is challenging, Gonzalez emphasized, as change in one area has impacts on others. For example, a change in just one food item affects how the bags are packed and how many bags go in each tote.

Gonzalez explained that the food bank has formed a nutrition advisory task force that includes both internal and external expertise. Additionally, it is engaged in educating internal and external stakeholders, including staff and donors, on why it is focused on nutrition and health.

Nutritional Analysis of Distributed Food

Gonzalez next described how the food bank partnered with the Mel and Enid Zuckerman College of Public Health at the University of Arizona to have a student analyze the nutritional quality of the food bags distributed by The Emergency Food Assistance Program (TEFAP) run by the food bank. The nutritional analysis of 25 bags found that they were high in sodium and low in whole grains and certain vitamins, including vitamin C and vitamin D. In partnership with the university, Gonzalez reported, an analysis was also conducted to estimate the proportion of donated bread-based products that were whole grain. Overall, 20 percent of the grains were found to be whole grain, short of the 50 percent minimum target recommended by the Dietary Guidelines for Americans.

Gonzalez explained that the food bank is working to empower clients through nutrition education classes, school pantries with in-class nutrition education, recipe sampling, and parent engagement. For example, it works with schools to identify parents who are engaged in the community. It then trains these individuals to serve as peer educators in working with other parents and children. Gonzalez noted that participating parents are provided with a stipend.

Gonzalez added that the food bank leads programs involving volunteer-led nutrition education and recipe sampling, particularly for products less commonly used by the food bank’s client base. It has also established partnerships with nearby federally qualified health centers (FQHCs) serving similar populations in three of its five counties.

In partnership with the nutritional sciences department at the University of Arizona, Gonzalez continued, the food bank has also completed two of three phases of developing a model food box based on TEFAP, assessing the quality of their clients’ diets, and asking about their preferences regarding which products to provide in the box. As Gonzalez described, phase 1 involved having about 200 clients complete a dietary recall survey to assess overall diet quality. The responses showed that clients’ current diets were slightly worse than the average U.S. diet overall and were low in greens, beans, seafood, plant proteins, dairy, and whole grains and high in added sugars and fats. According to Gonzalez, a key lesson from these findings was that clients’ diets were not low in protein, yet the food bank had emphasized the donation and distribution of protein-rich foods.

Phase 2 of the effort involved interviews with 10 English-speaking and 10 Spanish-speaking clients to obtain feedback on which items in the TEFAP box they liked and which they would prefer to replace. Gonzalez reported that overall, clients wanted the boxes to contain items that would help them make a meal and reduce their overall grocery bill. She pointed out that TEFAP orders must be placed 18 months ahead in 3-month increments, so it is challenging to make changes. As a result of the interviews, however, the food bank was able to substitute black beans for split peas and remove a high-sodium tomato soup. Gonzalez added that clients stated their preference to also add canola oil and oatmeal in place of other items.

Gonzalez described Phase 3 as involving a diabetes education intervention building on the lessons learned from Phases 1 and 2. As part of a future project, she said, the organization is also considering a feasibility study on how best to roll out the model TEFAP box and incorporate health outcome data with its federally qualified health center partners.

Finally, Gonzalez explained additional ways in which the food bank is working to engage clients. For example, through a grant from Feeding America focused on addressing hunger among seniors, it created a core team of seniors to help in planning additional programming in that area.

AUDIENCE DISCUSSION

An audience member commented that she was disappointed that the food club participants described in Cohen’s presentation chose to use Amazon as their food delivery source because she believes the company has poor labor practices, and a stated goal of the food club is to empower

community members. She suggested that a more empowering option could have been to link with a national food co-op movement. Cohen responded that the original hope was to source food from a wholesale producer or distributor, but that a larger number of customers would have been required to ensure sufficient demand to allow for efficient delivery. The requirement that low-income consumers be able to use SNAP dollars to purchase the food also eliminated other options. Cohen pointed out that the community’s top criterion was easy access, and online purchasing through Amazon best met that need in the short term.

Another audience member asked Brown how best to apply a systems approach to his work. He responded that while his work is focused in Baltimore and the mid-Atlantic region, his goal is to create a model that could be used across the country to lift up examples of leadership and partnership through the local black church, the most sustainable institution in the black community.

An audience member asked Gonzalez about how the food bank manages spoilage of produce, given the large proportion of donations that consist of fresh fruit and vegetables. Gonzalez responded the food bank has a fairly low spoilage rate of 2–3 percent, and that the spoiled produce is disposed of through pig farming and composting in the food bank’s gardens.

Finally, Wilson asked the panelists whether they are evaluating the impact of their work. Cohen, Brown, and Gonzalez all responded that they are working toward that goal, but there is much more work to be done in that regard.

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