The Leading Voices in Food Duke World Food Policy Center

Today we're talking about who has access to full-service supermarkets in America's cities, suburbs, small towns and rural communities. According to The Reinvestment Fund's "2023 Limited Supermarket Access Analysis Report," 8.5% of people in the US live in areas with limited access to full-service supermarkets. This means that families must travel further to get fresh foods, and it creates a barrier to adequate nutrition. This is the 10th year The Reinvestment Fund has published the "Supermarket Access Report," which provides data and context about grocery store access across the country. Here to discuss the latest figures is policy and analyst Michael Norton.
 
Interview Summary
 
This is a really interesting and kind of nuanced topic, so I'm happy we can talk about it in some detail. Why don't we just start off with kind of a broad question. What do we know now about areas of limited supermarket access in the US?

Kelly, I think the big thing to take away at the very beginning is that the share of people living in places that would be considered low access is roughly the same as it's been over the past 10 years. We have about 8.5% of the population living in low-access areas across the country. That's pretty consistent to what it's been for over a decade. But what's important is that how low-access areas are distributed across the country varies quite a bit. And where they exist, the density of the populations where they exist, really informs the kinds of interventions that are available for addressing these needs. These vary considerably in different parts of the country and at different geographic scales. And what I mean by that is suburban areas, rural areas, and then some of the most remote areas across the country. So we do have a sort of consistent number or share of people. The actual number has gone up a little bit because the population has continued to increase. They become distributed in different ways that follow different kinds of development patterns, on the one hand. But then also places where you end up getting patterns of residential and racial segregation in more developed parts of the country.
 
It's so interesting. So, given that the average has stayed essentially the same over the 10 years you've been doing the reports, have there been pressures pulling in either direction that might have changed over the years? So, for example, are there pressures that are making access to full-service supermarkets less likely? Are they pulling out of some places, for example? And might that offset by some positive developments in other areas? So, while the average stays the same, the contours look different?

I think the way to think about that is that we see a lot of expansion of low-access areas in the big metro areas that are expanding the fastest. So, the biggest increases in populations living with limited access are in big state in the South and out west in places like Arizona, Nevada, Texas, where you have these large metros that are growing at a really rapid rate. And the reason for that is that oftentimes residential development will show up before commercial development. So, in those kinds of places, food retail is trailing behind residential development. And probably those places are going to be well served by the time we update this analysis again in four or five years because of what those development patterns look like, right? So, when you're building more houses in more urban and remote areas, there's still folks who are first in buying out in those places. They're still going to have to go a long way to get their groceries for a few years until supermarket identifies this as a place where there's going to be enough demand for us to put one of our Krogers or Targets or Walmarts or what have you. But we've also seen, and this is more common in urban places, is the expansion of these low-access areas that have smaller populations, right? And so these are places with between 1,000 and 5,000 res

Nonprofit organizations can play a very important role in building healthy communities by providing services that contribute to community stability, social mobility, public policy, and decision-making. Today we're speaking with Kathy Higgins, CEO of the Alliance for Healthier Generation. The Alliance is a nonprofit organization, a well-known one at that, that promotes healthy environments so that young people can achieve lifelong good health.
Interview Summary
 
Kathy, it's really wonderful to reconnect that you and I interacted some when you were in North Carolina and head of the Blue Cross and Blue Shield of North Carolina Foundation, and then you got called upon to be the CEO of the Alliance, a really interesting position. It's really wonderful to be able to talk to you again. Let's start maybe with a little bit of the history of the Alliance for a Healthier Generation. Can you tell us a bit about how it got started and over the years, how it's evolved?

We've existed for almost 19 years now. We celebrate our 20-year anniversary next year. And we were started by two vital public health forces: the Clinton Foundation and President Clinton and also the American Heart Association. They came together 20 years ago and began discussing childhood obesity and what could a leading public health organization do to really work in systems change across the country at a local level. It is those two organizations that we look to as our founders and who helped us advance our work.

It's a time flies story because it seems like just yesterday that the Alliance was created. There was a lot of excitement at the time for it, and over the work. It's done some really interesting things. So, in today's iteration of the Alliance, what are some of the main areas of focus?

As I mentioned, we are a systems change organization. What we do is take a continuous improvement approach to advancing children's health. So, we are working typically in schools or after school time and certainly in communities to work on policy and practice change that are about promoting physical activity and healthy eating. And then addressing critical child health and adolescent health issues, which as we know, were exacerbated with the pandemic. Things like food access and social connectedness are just so important. Quality sleep, which our children are not getting enough of, or other things like vaping and tobacco sensation and on time vaccinations. Another thing that we know is that the pandemic had a dramatic impact on families and children on time vaccinations. So, this is the work that we do and working with the policy and practice change so that there there can be opportunity for healthy environments for the children.

I think most everybody would probably agree that the targets that you're working on, healthy diet, physical activity, smoking, vaping habits and things like that are really important. But people might be a little less familiar with what you mean by addressing systems. Could you give some examples of what you mean by that?

Right. What we know is that in United States, in fact, every public school must have a wellness policy and areas that need to be addressed. But what we'll do is work with the school in making sure that those policies are best suited for the families, the community, and the school, and what they want to do to support the health of children from a collaborative and supportive role. What we know is that we can create great change when that occurs. We work with more than 56,000 schools across the United States, and one of the things that we know is that our approach is really reflected in the America's Healthiest Schools recognition program each year.

It's interesting to hear you talk about schools as an example of system change. And boy, working with 56,000 schools is pretty darn impressive. And it allows for out-sized influence of an organization like yours because if you can affect things like these school wellnes

Is it possible to decarbonize agriculture and make the food system more resilient to climate change? Today, I'm speaking with agricultural policy expert Peter Lehner about his climate neutral agriculture ideas and the science, law and policy needed to achieve these ambitious goals. Lehner is an environmental lawyer at Earthjustice and directs the organization's Sustainable Food and Farming Program.
Transcript
How does agriculture impact the climate? And I guess as important as that question is why don't more people know about this?
It's unfortunate that more people don't know about it because Congress and other policy makers only really respond to public pressure. And there isn't enough public pressure now to address agriculture's contribution to climate change. Where does it come from? Most people think about climate change as a result of burning fossil fuels, coal and oil, and the release of carbon dioxide. And there's some of that in agriculture. Think about tractors and ventilation fans and electricity used for pumps for irrigation. But most of agriculture's contribution to climate change comes from other processes that are not in the fossil fuel or the power sector. Where are those? The first is nitrous oxide. Nitrous oxide is a greenhouse gas about 300 times more potent than carbon dioxide. And it comes because most farmers around the world and in the U.S. put about twice as much nitrogen fertilizer on their crops, on the land, as the plants can absorb. That extra nitrogen goes somewhere. Some of it goes off into the water. I'm sure your listeners have heard about harmful algae outbreaks or eutrophication of areas like the Chesapeake Bay and other bays where you just get too many nutrients and too much algae and very sick ecosystem. A lot of that nitrogen, though, also goes into the atmosphere as nitrous oxide. About 80% of nitrous oxide emissions in the U.S. come from agriculture. Excess fertilization of our hundreds of millions of acres of crop land.
Quick question. Why would, because the farmers have to pay money for this, why do they apply twice as much as the plants can absorb?
Great question. It's because of several different factors. Partly it is essentially technical or mechanical. A farmer may want to have the fertilizer on the land right at the spring when the crops are growing but the land may be a little muddy then. So they may have put it on in the fall, which is unfortunate because in the United States, in our temperate area, no plants are taking up fertilizers in the fall. Also, a plant is like you or me. They want to eat continually but a farmer may not want to apply fertilizer continuous. Every time you apply it, it takes tractor time and effort and it is more difficult. So they'll put a ton of fertilizer on at one point and then hope it lasts for a while, knowing that some of it will run off, but hopeful that some will remain to satisfy the plant. There's a lot of effort now to try to improve fertilizer application. To make sure it's applied in ways just the right amount at the right time. And perhaps with these what's called extended release fertilizers where you put it on and it will continue to release the nutrients to the plant over the next couple of weeks and not run off. But we have a long way to go.
Okay, thanks. I appreciate that discussion and I'm sorry I diverted you from the track you were on talking about the overall impact of agriculture on the climate.
I think what's so exciting about this area is that everyone cares about our food. We eat it three times a day or more and yet we know very little about where it comes from and its impacts on the world around us. It's wonderful to be talking about this. The second major source of climate change impact in agriculture is methane. Methane is another greenhouse gas much more powerful than carbon dioxide. About 30 times more powerful over a hundred years and about 85 times more powerful than carbon dioxide over 20 years. Which is I thin

The first nutrition labels mandated by the Food and Drug Administration appeared on food packages in 1994. A key update occurred in 2016, informed by new science on the link between diet and chronic disease. Along the way, things like trans fats and added sugars were required, but all along, the labels have been laden with numbers and appear on the back or side of packages. There has long been interest in more succinct and consumer-friendly labeling systems that might appear on the front of packages. Such systems exist outside the US, but for political reasons and lobbying by the food industry, have been blocked in the United States. There's new hope, however, described in a recent opinion piece by Christina Roberto, Alyssa Moran, and Kelly Brownell in the Washington Post. Today, we welcome Dr. Christina Roberto, lead author of that piece. She is the Mitchell J. Blutt and Margot Krody Blutt Presidential Associate Professor of Health Policy in the School of Medicine at the University of Pennsylvania.
Interview Summary
This is a really important topic, and if the nation gets this right, it really could make a difference in the way people make product decisions as they're in the supermarket. So, let's talk first about the importance of labeling on the front of the package. Why is that important when all the information is somewhere else, namely on the side or the back?
I think there's a couple of key reasons why it's good to do front of packaging food labeling specifically. So, as you mentioned, it was a huge deal in 1994 to get this information mandated to be on food packaging to begin with, right? All of a sudden, there was much more transparency about what's in our food supply, but that being said, when you think about the nutrition facts label, it's pretty dense. There's a lot of percentages, there's a lot of numbers, there's a lot of information to process. And when people are actually in the supermarket shopping, they're making these split-second decisions, right? So, it's not to say that some consumers are turning it around and inspecting that packaging, but the reality is, for most people, it's a very habitual behavior. And so, we want to be in a place where that information is prominent, it's easily accessible, and it's easy to understand so that when you're making those snap judgements, they can be informed judgments.
So, you're not talking about taking what's on the back and just moving it to the front. You're talking about a different set of information and symbols that might be available?
That's right. Yeah. What front of package labeling is designed to do is just take some of the key bits of information that we know from science is going to be most important for consumers to base their nutritional decisions on. That's things like saturated fat, sodium, added sugars, right? And moving that to the front of the package and communicating about it in a very simple, clear way. So, no numbers, no percentages, just very straightforward language. And ideally some sort of icon, like an exclamation point, that would draw attention to that symbol and just quickly let consumers know that this product is high in those nutrients that you need to be concerned about and you need to try to limit.
Why is it an important time to be thinking about this issue in the US?
It's an important and it's an exciting time because the FDA right now is highly interested in actually moving forward on a policy that would require these types of front of package labels. And that hasn't been true, as you noted, for about a decade. But last year, the White House convened a very significant conference that hadn't happened in 50 years about nutrition, health, and hunger. And front of package labeling actually made it into their report in that conference as a key objective for this country in terms of a food policy that, under the Biden administration, they want to achieve. What we're seeing the FDA do now is actually undertake a series of r

Traditional clinical weight loss interventions can be costly, time consuming, and inaccessible to low-income populations and people without adequate health insurance. Today's guest, Dr. Gary Bennett, has developed an Interactive Obesity Treatment Approach, or iOTA for short, that represents a real advance in this area. Dr. Bennett is Professor of Psychology and Neuroscience, Medicine and Global Health at Duke University, where he is also Dean of Trinity College of Arts and Sciences.
Interview Summary
You know, in this time when people are talking about more expensive, and kind of more intrusive interventions, like the big weight loss drugs, it's nice to know that there may be alternatives that could be accessible to more people. Could we start off with you telling our listeners what the iOTA approach is and how it works?

Sure. This is an approach for weight management. It's useful for weight loss or preventing weight gain or maintaining one's weight after you've lost weight. The idea here is that it's a technology that's designed to be highly accessible, and useful for a range of different types of populations. So, as you described, we have developed and tested this primarily for folks who are medically vulnerable, who are low income, who are racial, ethnic minority, who live in rural communities, and where we have traditionally had real difficulty reaching populations with effective weight loss tools. So, iOTA is a fully digital approach. It uses technologies smartphone apps, but it can also use text messaging, interactive voice response, those are like robocalls, automated telephone calls, websites. We've tested this on a wide range of different types of technology platforms, and we've tested it in a range of different types of populations all over the country and indeed even in other countries.

So, give us some examples of what kind of information people might be receiving through these various forms of media.

The underlying kind of technology, the underlying approach, I should say, for iOTA is actually reasonably simple. It operates from the perspective that creating weight loss is really about making an energy deficit. That is to say, helping people to consume fewer calories than they are expending. The realization we had years ago is that you can get there, you can create that calorie deficit in a whole host of different ways. Some people diet, some people try to get more active, there are limitations around that kind of approach. But fundamentally, you can also just get there by asking people to do some reasonably straightforward behaviors. Like not consuming sugary beverages, or consuming fewer chips, cookies and candies. Or changing the amount of red meat that they put on the plate. And, if you frame those things out as goals, then you can prescribe those goals to people in ways that make sense to them personally. The trick though is actually in the idea of personalizing those goals to the given individual. And that's where technology comes in and gets very helpful. The case is, if you have a large library of these goals, you'd want to try to provide these in a highly personalized way. That really are aligned with what people's needs are and noting that those needs may change over time. So, what we do with iOTA is deliver a very short survey. That survey then helps us to be able to look into our library of goals and pick the ones that are most useful for our users. We prescribe those goals, and then we ask folks to self-monitor those goals. Self-monitoring or tracking is an extraordinarily powerful part of behavior change science. And so, we ask them to track using one of our technologies: the chat bot or the text message or interactive voice response or the smartphone app. Every time that we receive data from one of our users, we give them highly personalized feedback that is designed around principles of behavior change science. And then over time we also give them support. We do support sometimes from

Fast food is part of American life. As much a part of our background as the sky and the clouds. But it wasn't always that way, and over the decades, the fast food landscape has changed in quite profound ways. Race is a key part of that picture. A landmark exploration of this has been published by today's guest, Dr. Naa Oyo Kwate. She is an Associate Professor in the Department of Africana Studies and the Department of Human Ecology at Rutgers University. Her book, recently published, is entitled White Burgers, Black Cash: Fast Food From Black Exclusion to Exploitation. The book has been received very positively by the field. And was recently named the best book in the field of urban affairs by the Urban Affairs Association.
 
Interview Summary
I was so happy to see your book because people have talked about the issue of race off and on in the field, but to see this kind of scholarly treatment of it like you provided has been really a welcome addition. Let me start with a general question. Let's begin with the fast food situation today and then rewind to where it began. Are there patterns to where fast food restaurants are located and who fast food is marketed to?

Absolutely. There's quite a bit of research, and you just alluded to the work that's been done in the field. There's a lot of research that shows fast food is most dense in African American communities. Not every study has the same finding, but overall that's what the accumulated evidence shows. On the one hand you have the fact that Black communities are disproportionately saturated with these outlets. Then there's also the case that apart from the physical locations of the restaurants, fast food is strongly racialized as Black in terms of how it's portrayed to the public. It [Fast Food] relies on images of Blackness and Black cultural productions such as Black music for its marketing. These sometimes these veer into racial caricature as well. One of the things I talked about in the book briefly is the TV commercial character Annie who Popeye's introduced in 2009. They basically created this Black woman that Adweek at the time was calling "feisty," but it's really just this stereotypical idea of the sassy Black woman and she's in the kitchen frying up the chicken for Popeye's. And actually, some of the language that was used in those commercials really evokes the copy on late 19th century and Aunt Jemima pancake mix packaging. It's a really strong departure from fast food's early days, the way that fast food is now relying on Blackness as part of its core marketing constructs.

I'm assuming that it follows from what you've been saying that the African American community has disproportionately been targeted with the marketing of these foods. Is that true of children within that community?

Research shows that in terms of fast food marketing at the point of purchase. There's more - display advertising for example at restaurants that are in Black communities. And then there's also been research to show, not in terms of the outlets themselves, but in terms of TV programming that there tends to be more commercials for fast food and other unhealthy foods during shows that are targeting Black youth.

How much of the patterning of the fast food restaurants is due to income or due to the amount of fast food consumption in these areas with many restaurants?

Almost none of it really. It's not income and it's not the amount of fast food that people are consuming. In fact, one of the main studies that led me to start researching this book, because I was coming to it from public health where there was a lot of research around the disproportionality of fast food restaurants. We actually did a study in New York City, some colleagues and we published it in 2009, where we looked at how fast food was distributed across New York City's five boroughs. And restaurant density, we found, was due almost entirely to racial demographics. There's very little contribution from