Estimating Access to a High Quality Diet for Older Adults in Springfield, Massachusetts

Transcription

1 University f Massachusetts Amherst SchlarWrks@UMass Amherst Masters Theses Dissertatins and Theses 2015 Estimating Access t a High Quality Diet fr Older Adults in Springfield, Massachusetts Nicle M. Ratchfrd University f Massachusetts Amherst Fllw this and additinal wrks at: Recmmended Citatin Ratchfrd, Nicle M., "Estimating Access t a High Quality Diet fr Older Adults in Springfield, Massachusetts" (2015). Masters Theses This Open Access Thesis is brught t yu fr free and pen access by the Dissertatins and Theses at SchlarWrks@UMass Amherst. It has been accepted fr inclusin in Masters Theses by an authrized administratr f SchlarWrks@UMass Amherst. Fr mre infrmatin, please cntact schlarwrks@library.umass.edu.

2 Estimating Access t a High Quality Diet fr Older Adults in Springfield, Massachusetts A Thesis Presented by NICOLE RATCHFORD Submitted t the Graduate Schl f the University f Massachusetts Amherst in partial fulfillment f the requirements fr the degree f MASTER OF SCIENCE September 2015 Nutritin

3 Cpyright by Nicle Ratchfrd 2015 All Rights Reserved

4 ESTIMATING ACCESS TO A HIGH QUALITY DIET FOR OLDER ADULTS IN SPRINGFIELD, MASSACHUSETTS A Thesis Presented by NICOLE RATCHFORD Apprved as t style and cntent by: Lisa M. Try, Chair Alayne G. Rnnenberg, Member Nancy L. Chen, Department Head Nutritin

5 DEDICATION T bth f my lving parents. Wrds can never express hw thankful I am fr yur cntinued guidance, as all f my achievements are nt pssible withut yu. And t Drew. I am s grateful fr yur uncnditinal lve and supprt.

6 ACKNOWLEDGMENTS I wuld like t thank Dr. Lisa M. Try, as she has been an utstanding advisr thrughut my time at the University f Massachusetts. This accmplishment wuld nt have been pssible withut her cntinuus supprt, advice, and feedback. I als want t extend my gratitude t Dr. Alayne Rnnenberg fr her insight n this prject. I am extremely frtunate t have been part f the Nutritin Assessment Lab at UMass, Amherst, and wuld like t thank all f the past and current members fr their help t make my thesis the best pssible. I want t especially thank Bi-sek Hsai and Dminique Deslauriers fr assisting with data cllectin and prviding cnstant supprt fr the current prject. Withut yur help, this prject wuld nt have been pssible. v

7 ABSTRACT ESTIMATING ACCESS TO A HIGH QUALITY DIET FOR OLDER ADULTS IN SPRINGFIELD, MASSACHUSETTS SEPTEMBER 2015 NICOLE M. RATCHFORD, B.S., SPRINGFIELD COLLEGE M.S., UNIVERSITY OF MASSACHUSETTS AMHERST Directed by: Dr. Lisa M. Try Seventy five percent f lder adults are affected by multiple chrnic diseases. Cnsuming a high quality diet cnsisting f fruits, vegetables, whle grains, and lean prtein assists with chrnic disease preventin and management. Healthful fd availability is a majr determinant f individual eating behavirs. The purpse f the current study was t describe the types, variety, and density f fd utlets and t estimate access t a high quality diet fr lder adults in an urban setting. The Cmmunity Nutritin Envirnment Evaluatin Data System (C-NEEDS) survey and restaurant menus were used t determine availability f healthful fd in thirteen neighbrhds in Springfield, Massachusetts. A "Dietary Guidelines fr Americans Adherence Index Fd Envirnment" (DGAIFE) algrithm was created t estimate access t a high quality diet based n the stres and restaurants within the study area. Envirnmental characteristics that are recgnized as facilitatrs r barriers t a high quality diet were added t the DGAIFE algrithm t calculate a "Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics" (DGAIFEC) scre. The DGAIFE and DGAIFEC scre ranges fr all study areas were and , respectively (pssible range 1.00 higher t 5.00 lwer access). Access t a high quality vi

8 diet is within reach but nt equal acrss the thirteen study areas. The findings can be used by Registered Dietitians t guide clients t make healthful fd chices in urban neighbrhds and prvides infrmatin t imprve public health plicy t increase access t healthful fds. vii

9 TABLE OF CONTENTS Page ACKNOWLEDGMENTS...v ABSTRACT... vi LIST OF TABLES... xi LIST OF FIGURES... xii INTRODUCTION... CHAPTER 1. LITERATURE REVIEW...4 Diet-Related Chrnic Disease...4 Multiple Chrnic Cnditins...5 Cardivascular Disease...10 Diabetes...12 Metablic Syndrme...16 Inflammatin...17 Measuring Diet Quality: Individuals...20 Dietary Assessment Methds...20 Dietary Quality...21 Measuring Diet Quality in Older Adults...26 Natinal Cancer Institute Fruit and Vegetable Screener...28 Determinants f Diet Quality...32 Gender-based Differences...32 Sci-ecnmic Impact n Diet Quality...35 Educatin as a Determinant f Diet Quality...37 Lifestyle Impact n Diet Quality...37 Scial Impact n Diet Quality...39 Oral Health and Diet Quality...39 Malnutritin in Older Adults...40 Mini Nutritinal Assessment...41 Nutritin Screening Initiative...42 Dietary Screening Tl FOOD ENVIRONMENT AFFECTS DIET QUALITY...47 viii

10 Intrductin...47 Fd Access...49 Fd Access in Springfield, Massachusetts...51 GFresh Mbile Market...53 Transprtatin...54 Fd Availability...54 Fd Availability Impacts Healthful Fd Cnsumptin...55 Cmmunity Nutritin Envirnment Evaluatin Data System (C-NEEDS): An Instrument t Assess the Fd Envirnment...56 Summary f Current Literature PURPOSE, OBJECTIVES, RESEARCH QUESTIONS AND SIGNIFICANCE OF THE STUDY...59 Research Purpse...59 Objectives...59 Significance METHODS...61 Study Lcatin...61 Study Area Ratinale...61 Justificatin fr using a ne half-mile radius...63 Classifying Fd Outlets...64 Fd Stre Classificatin...64 Traditinal Stres...66 Cnvenience Stres...67 Nn-Traditinal Stres...67 Micrenterprise Stres...67 Restaurant Classificatin...68 Healthy Fd Availability Assessment...69 Fd Stre Assessment...69 Restaurant Assessment...71 Data Cllectin fr Fd Stres and Restaurants...71 ix

11 Envirnmental Assessment...72 Statistical Analysis...74 Fd Stre Scring...77 Restaurant Scring RESULTS...84 Fd utlet Types, Variety, and Density...84 Healthful Fd Availability in Fd Outlets...87 Estimating Access t a High Quality Diet based n Fd Outlets...92 Estimating Access t a High Quality Diet with Key Envirnmental Characteristics DISCUSSION CONCLUSION APPENDICES A: HALF-MILE GOFRESH LOCATIONS, FOOD OUTLETS, AND TIME TO COMPLETE B: FOOD STORE DEFINITIONS (WHITTINGTON, 2013) C: RESTAURANT TYPE DEFINITIONS D: DERIVATION OF THE HEALTHY FOOD AVAILABILITY INDEX FOR GROCERY STORES E: DERIVATION OF THE UNHEALTHY FOOD AVAILABILITY INDEX FOR GROCERY STORES F: COMMUNITY-NUTRITION ENVIRONMENT EVALUATION DATA (C-NEEDS) G: C-NEEDS ADDENDUM H: INTERVIEW GUIDE FOR REGISTERED DIETITIANS REGARDING THE FOOD ENVIRONMENT BIBLIOGRAPHY x

12 LIST OF TABLES Table Page 1: Indices t Measure Diet Quality in Individuals : Dietary Screening Tls t assess Malnutritin in Older Adults : Healthful Fd Availability in Stres Based n the 2010 Dietary Guidelines fr Americans (DGA) fd grups and C-NEEDS : Average Healthful Fd Availability (AHFA) Scring fr Fd Stres : Average Healthful Fd Availability (AHFA) Scring fr Restaurants : Fd utlet Type, Variety, and Density fr each Half-Mile Radius Area : Average Healthful Fd Availability by 2010 DGA fd grup and percentage f Healthful Fd Availability fr each Stre Type based n C-NEEDS : Average number f Healthful Fd Items in Restaurants : Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) fr each Half-Mile Radius Area : Key Envirnmental Characteristics : Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scre fr each Half-Mile Radius Area : Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) scres cmpared t Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scres : USDA Lw Access t Fd Data cmpared t Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) scres and Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scres xi

13 LIST OF FIGURES Figure Page 1: Percentage f adults with tw r mre chrnic cnditins vs (Freid, 2012) : Percentage f adults in the U.S. with tw r mre chrnic cnditins distributed by race (Freid, 2012) Springfield Fd Desert Map (Pineer Valley Planning Cmmissin, 2014) : Classificatin Chart fr Fd Stres (Adapted frm Whittingtn, 2013) Classificatin Chart fr Restaurants Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) Algrithm : Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) Algrithm xii

14 INTRODUCTION Chrnic diseases are the leading causes f death in the United States and cst billins f dllars each year (CDC, Chrnic Disease Overview). Older adults are a vulnerable ppulatin because as individuals live lnger, the chance fr develping a diet-related chrnic cnditin such as cardivascular disease (heart disease, strke), diabetes, metablic syndrme, and inflammatin, may be greater (Drewnwski & Warren-Mears, 2001; Marengni et al., 2011; Cnklin et al., 2013; Wheeler Frd et al., 2013). The prevalence f individuals living with multiple chrnic cnditins is als increasing and affects apprximately 75% f lder adults in the U.S. (Gdman et al., 2014). Lifestyle mdificatins such as cnsuming a high quality diet cnsisting f fruits, vegetables, whle grains, and lean prtein, as well as being physically active are slutins fr preventing and managing chrnic disease. As men and wmen age, basal metablic rate (BMR) decreases. BMR is the rate f energy expenditure at rest t maintain functining f vital rgans. In rder t btain adequate nutrients while decreasing calric intake, it is critical fr lder adults t cnsume fds that are nutrient dense. Fr example, fruits and vegetables are nutrient dense fds as the rati f vitamins and minerals is high relative t ttal calries. There are several ways t assess an individual s diet. Dietary intake can be measured by several dietary assessment methds such as fd recrds, 24-hur dietary recalls, and fd frequency questinnaires. Dietary quality is an assessment f verall dietary intake, specifically in regards t the quality and variety f fds cnsumed in the diet. Diet quality indices typically assess hw well an individual s diet adheres t specific recmmendatins, such as the Dietary Guidelines fr Americans. Dietary screening tls 1

15 have been develped t assess different aspects f diet such as daily fruit and vegetable cnsumptin (e.g., Natinal Cancer Institute s Fruit and Vegetable Screener (Subar et al., 2001)) r nutritin screening and malnutritin (e.g., Mini Nutritin Assessment (Guigz et al., 1994), Nutritin Screening Initiative (Dwyer et al., 1992)). Despite the imprtance f diet n chrnic disease preventin and management, there are many influences n cnsumptin f healthful fds in lder adults including persnal, scial, ecnmic, and envirnmental factrs. Availability f healthful and unhealthful fd is ne f the mst influential determinants f individual eating behavirs and chrnic disease utcmes (Larsn et al., 2009; Wedick et al., 2015; Olendzki et al., 2015). The quantity and quality in which fd is available can impact fd chices and therefre health and verall quality f life (Drewnwski and Specter, 2004; United States Department f Agriculture, 2015). The United States Department f Agriculture's (USDA) Ecnmic Research Service (ERS) defines a fd desert as a census tract with at least 33% f the census tract's ppulatin living mre than ne mile frm a supermarket r large grcery stre. ERS estimates that 23.5 millin peple lived in fd deserts (USDA Agricultural Market Service: Fd Deserts, 2015). Mre than half f the peple living in fd deserts, apprximately 13.5 millin peple, are lw incme individuals, and 11.2 millin live in urban areas (USDA Agricultural Market Service: Fd Deserts, 2015). A 2010 reprt indicated 19.35% and 8.24% f peple had lw access t healthy fds in Massachusetts and Springfield, respectively (USDA ERS Fd Research Atlas, 2010; Pineer Valley Planning Cmmissin, 2014). Similar t indices that quantify diet quality f individuals, fd envirnment tls such as Cmmunity Nutritin Envirnment Evaluatin Data System (C-NEEDS) have 2

16 been develped t assess fd availability within neighbrhds and cmmunities (Olendzki et al., 2015). The fd envirnment tls assess the area's healthful fd availability and if the fd stres and restaurants supprt a high quality diet fr individuals. In 2011, the GFresh prgram was pilted with the gal f prviding access t healthy fd, specifically fresh prduce, at affrdable prices. The GFresh Mbile Market is crdinated by Partners fr a Healthier Cmmunity and verseen by a GFresh leadership team that includes the Directr f Elder Affairs f Springfield, Massachusetts. The purpse f the current study was t describe the types, variety, and density f fd utlets (i.e., fd stres and restaurants, including mbile vendrs) and t estimate access t a high quality diet fr lder adults in an urban setting. Estimating access t a high quality diet fr lder adults was assessed within specific half-mile radius areas relative t the ten cnfirmed 2015 GFresh sites and three ptential future sites lcated thrughut Springfield, Massachusetts. 3

17 CHAPTER 1 LITERATURE REVIEW Diet-Related Chrnic Disease Chrnic diseases such as cardivascular disease and diabetes are the mst cmmn, cstly, and preventable health prblems in the United States (CDC, Chrnic Disease Overview). Diet and exercise are majr mdifiable risk factrs fr many chrnic cnditins and can make a pwerful difference n symptms f chrnic cnditins (CDC, Chrnic Disease Overview). Making lifestyle changes such as imprving diet and increasing exercise are vital in preventin r management f chrnic diseases (Drewnwski & Warren-Mears, 2001; Kant, 2004; Heidemann et al., 2008; Lazaru et al., 2012). Althugh there is n standard definitin fr dietary quality, it is characterized by a diet higher in nutrient dense fds, meaning the fds cnsumed have a high rati f beneficial nutrients relative t the ttal amunt f calries. High dietary quality is assciated with lwer risk and better management f chrnic diseases and inversely assciated with mrtality (Kant, 2004). Fr example, imprvement in dietary quality by cnsuming mre plant based fds such as fruits, vegetables, and whle wheat grains can cntrl diabetes and lwers the pssibility f undiagnsed type II diabetes (Lazaru et al., 2012). Other researchers have bserved that increased cnsumptin f fruits, vegetables, legumes, fish, pultry, and whle grains cmpared t Western dietary patterns high in prcessed meats and ther prcessed and high fat fds were assciated with lwer risk f CVD, bimarkers f inflammatin, crnary heart disease, emergence f type II diabetes, and besity (Heidemann et al., 2008; Lazaru et al., 2012). 4

18 Alng with a balanced diet, physical activity has been widely recgnized as a primary way f preventing and managing chrnic disease (Ewing Garber et al., 2011; CDC, Chrnic Disease Overview). A psitin statement published by The American Cllege f Sprts Medicine regarding quantity and quality f exercise fr healthy adults ntes physical activity decreases the risk f develping crnary heart disease, strke, type II diabetes, and different frms f cancer such as cln and breast cancer (Ewing Garber et al., 2011). Regular exercise lwers bld pressure, imprves insulin sensitivity and bld glucse cntrl, aids in weight management, enhances lipprtein prfile and CHD bimarkers, preserves bne mass and reduces risk f falling in lder adults, and imprves stress levels and mderate depressive disrders (Ewing Garber et al., 2011). Multiple Chrnic Cnditins Much f the literature has fcused n specific chrnic diseases such as cardivascular disease, diabetes, and cancer, but research examining hw multiple cnditins can c-ccur in the same individual is gaining mmentum. A persn living with multiple (tw r mre) chrnic diseases, als knwn as multimrbidity, affects as many as 75% f lder adults in America (Wlff et al., 2002; Gdman et al., 2014). Figure 1 shws the percentage f adults with tw r mre chrnic cnditins in the U.S. ages and 65 and lder. The percentage f adults with multiple chrnic cnditins has increased frm t , and the percentage f lder adults with multiple chrnic cnditins is duble the percentage f adults age (Freid, 2012). Figure 2 shws the percentage f adults with tw r mre chrnic cnditins in the U.S. ages and 65 and lder and prvides percentages amng different races. The percentage f lder adults age 65 and lder in all race grups (Black, White, and 5

19 Hispanic) with multiple chrnic cnditins increased frm t (Freid, 2012). The nine selected chrnic cnditins include hypertensin, heart disease, diabetes, cancer, strke, chrnic brnchitis, emphysema, current asthma, and kidney disease (Freid, 2012). 6

20 Figure 1: Percentage f adults with tw r mre chrnic cnditins vs (Freid, 2012) Figure 2: Percentage f adults in the U.S. with tw r mre chrnic cnditins distributed by race (Freid, 2012) Prevalence f tw r mre f nine selected chrnic cnditins amng adults aged 45 and ver, by age and race and Hispanic rigin: United States, and Age in years Percent SE Percent SE Black nly, nt Hispanic White nly, nt Hispanic Hispanic and ver Black nly, nt Hispanic White nly, nt Hispanic Hispanic NOTE: SE is standard errr SOURCE: CDC/NCHS, Natinal Health Interview Survey Accurately measuring the prevalence f multimrbidity requires a cnsistent definitin, a defined list f diseases cnsidered, and clear infrmatin abut diagnstic methds. Withut clear standards, it is difficult t give patients prper care and can impact utcmes such as quality f life, mrtality, and functining (Valderas et al., 7

21 2009). Clinical research, treatment, and preventin may nt be cnsistent and effective withut a clear way t define and measure the cncept f multimrbidity. Multimrbidity has cnsequences fr all age grups, especially lder adults. Men and wmen with multiple chrnic cnditins tend t have mre rapid decline in their health status as well as a greater risk f disability (Wlff et al., 2002). There is a link between multimrbidity and multiple medicatin use in the lder adult ppulatin. Accrding t NHANES , 76% f lder adults in the U.S. used tw r mre prescriptin medicatins, and 37% used five r mre (Natinal Center fr Health Statistics, 2010). Anther cncern fr physicians and clinicians is arund whether medicatin fr ne cnditin negatively interacts with medicatin fr ther cnditins. There has been questin surrunding the increased number f medicatins fr multiple cnditins and whether they have beneficial r harmful effects n individuals because many clinical trials that evaluate medicatin exclude participants with multiple cnditins. (Wlff et al., 2002; Gdman et al., 2014). Use f multiple medicatins interferes with nutrient absrptin, metablism, and excretin, and als affects the taste f different fds (Drewnwski & Shultz, 2001). If nutrient absrptin is altered and taste f fd is affected by medicatin, individual appetite is ften reduced, leading t nutrient deficiency and under-nutritin. Multimrbidity has large impact n the U.S. health care system because apprximately 80% f Medicare spending is devted t patients with fur r mre multiple chrnic cnditins (Valderas et al., 2009). Medical csts are increasing drastically as the prevalence f multiple chrnic diseases increases (Wlff et al., 2002; Marengni et al., 2011). It is vital fr physicians t prperly diagnse and recgnize 8

22 patients with multiple chrnic cnditins in rder t give prper health attentin, whether it's frm primary care physicians r frm specialists. Wlff et al., fund that per capita Medicare expenditures increased drastically in beneficiaries with chrnic cnditins cmpared t beneficiaries with n chrnic cnditin. On average, $211 in expenditures accunted fr beneficiaries withut a chrnic cnditin cmpared t $13,973 fr beneficiaries with fur r mre chrnic cnditins (2002). Varius disease management prgrams, patient educatin, and therapy are available in rder t help patients manage and prevent chrnic diseases. With a few exceptins, mst treatment fcuses n ne cnditin rather than managing multiple cnditins (Wlff et al., 2002). At this time, literature and data cncerning evidence based care fr patients with multiple chrnic cnditins is nt sufficient (Marengni et al., 2011). A Registered Dietitian (RD) is a fd and nutritin expert wh wrks in treatment and preventin f diseases by giving nutritin cunseling, medical nutritin therapy, and nutritin educatin as part f a multidisciplinary medical team (Academy f Nutritin and Dietetics, 2015). RDs are qualified t give individualized nutritin care accrding t the patient s needs and medical cnditins. Older adults specifically may imprve nutritinal status and quality f life by individualized diet prescriptin (Drner et al., 2010). RDs ften cllabrate with exercise physilgists as they refer patients fr exercise prescriptin as part f disease management (Miedema et al., 2015). An Exercise Physilgist is certified t assess an individual's exercise ability and prescribes apprpriate physical activity t individuals with a range f chrnic cnditins. 9

23 The cmplexity f having multiple cnditins requires medical experts frm varius fields, including RDs. Accrding t Partnership fr Health in Aging Wrkgrup n Interdisciplinary Team Training in Geriatrics, using a RD as part f a multidisciplinary team leads t better health utcmes specifically with cmmn chrnic illness, imprved medicatin adherence, fewer adverse drug interactins, lwer csts, increased patient satisfactin, and better quality care verall (Mntagnini, 2014). Cardivascular Disease Cardivascular disease (CVD) is the number ne cause f death in American adults and is accuntable fr 30% f deaths arund the wrld (Turluki et al., 2009). CVD cncerns the heart and bld vessels and includes health cnditins such as heart attack, strke, and heart failure. Plaque buildup in the walls f the arteries, als knwn as athersclersis, causes difficulty in bld flw. Athersclersis eventually can lead t a bld clt, and ultimately a heart attack r strke. CVD is assciated with ther chrnic cnditins such as hypertensin, diabetes, and metablic syndrme (Turluki et al., 2009; Heidenreich et al., 2011; Lazaru et al., 2012). Accrding t the American Heart Assciatin, apprximately 33 billin dllars are spent n medical csts relating t heart disease, strke, diabetes, and cancer, which are related t cnsuming a pr diet (AHA, 2013). CVD-related medical csts have increased at an average yearly rate f 6% in the past decade, and have als accunted fr a 15% increase in medical spending in the United States. Amng Americans, 83.6 millin have sme frm f CVD, 42.3 millin f wh are adults lder than age 60 (AHA, 2013). Accrding t the American Heart Assciatin, 76.4 millin Americans have been diagnsed with hypertensin, 16.3 millin have crnary heart disease, 5.7 millin have 10

24 heart failure, and 7 millin have experienced a strke (2009). In 2009, the CDC reprted that heart disease was the number ne cause f death in wmen age 65 and lder, fllwed by cancer, and strke (CDC, 2012). Research predicts the prevalence f CVD will increase apprximately ten percent ver the next twenty years based n current preventin and treatment trends (Heidenreich et al., 2011). Dietary habits can influence risk factrs f cardivascular disease like systlic and diastlic bld pressure, lw-density lipprtein (LDL) and high-density lipprtein (HDL) chlesterl, weight gain, and bld glucse levels (Heidemann et al., 2008; Heidenreich et al., 2011). Fcusing n verall dietary quality rather than single fds and nutrients is imprtant in preventin f CVD. Dietary quality is a mdifiable risk factr in preventin and management f CVD, especially in lder adults (Atkins et al., 2014). The Nurses' Health Study fund that diets cnsisting f high intakes f fruits, vegetables, legumes, whle grains, fish, and pultry were assciated with 28% lwer cardivascular mrtality, whereas diets characterized by high saturated fat and refined grain intake were assciated with 22% higher risk f CVD mrtality (Heidemann et al., 2008). Diets cnsisting f high saturated fat and refined grain intake have als been linked t increased risk in develping diabetes and metablic syndrme (van Dam et al., 2002). Regular exercise has been shwn t help prevent and manage CVD and ther risk factrs. The American Cllege f Sprts Medicine suggests a relatinship between psitive health utcmes and physical activity levels. Middle-age and lder adults with better cardirespiratry fitness levels at baseline, and adults wh imprve their 11

25 cardirespiratry fitness levels have lwer risk f CVD and all-cause mrbidity and mrtality (Ewing Garber et al., 2011). Diabetes Diabetes is a majr health cncern that is increasing at a rapid rate. Type 2 diabetes is the mst cmmn type f diabetes and is characterized by the bdy's inability t use insulin prperly, als knwn as insulin resistance (American Diabetes Assciatin). Insulin is a hrmne that allws cells t use bld glucse (sugar) as energy. When the bdy is resistant t insulin, cells d nt receive enugh energy. As a result, glucse remains in the bldstream, increasing bld glucse levels. Chrnic elevatin f high bld sugar is a majr characteristic f diabetes and has negative effects n areas f the bdy such as the heart, bld vessels, kidneys, nerves, and eyes. Lng term cmplicatins include increase risk f develping heart disease r having a strke, neurpathy, ft cmplicatins which can lead t amputatins, kidney failure and dialysis, frequent infectins, and premature death (American Diabetes Assciatin). Althugh diabetes cannt be reversed, bld glucse levels can be managed with a balanced diet and regular exercise (Lazaru et al., 2012). The American Diabetes Assciatin estimated the ecnmic cst f diagnsed diabetes in 2012 t be $245 billin, which "accunts fr mre than 1 in 5 health care dllars in the U.S." (American Diabetes Assciatin, 2013). The cst f diabetes has increased 41% frm 2007, which was an estimate f $174 billin in ecnmic csts. $176 billin f the ttal ges twards direct medical csts including inpatient hspital care, prescriptin medicatins fr cmplicatins, diabetic supplies, rutine physician visits, and residential facility stays (American Diabetes Assciatin, 2013). $69 billin is spent 12

26 n indirect csts f diabetes such as absenteeism and decreased prductivity at wrk fr diabetics wh are emplyed, inability t wrk due t disability, and premature mrtality (American Diabetes Assciatin, 2013). Medical expenses due t diabetes and its cmplicatins are als high fr individuals diagnsed with the cnditin. The American Diabetes Assciatin estimates beneficiaries with diabetes spend apprximately 2.3 times mre in medical expenditures than individuals withut diabetes (American Diabetes Assciatin, 2013). A majrity f the cst fr care in the United States is cvered by the gvernment including Medicare, Medicaid, and military insurance. Private insurance and the uninsured pay the remainder f that cst. Diabetics wh are uninsured have 79% less physician visits and are prescribed 68% less medicatin, but have 55% mre emergency department visits cmpared t diabetics with insurance (American Diabetes Assciatin, 2013). Accrding t the American Diabetes Assciatin, 29.1 millin Americans (adults and children) have diabetes (G et al., 2013). Of the 29.1 millin peple, 21.0 millin peple are diagnsed and 8.1 millin peple are undiagnsed. Men had a slightly higher prevalence than wmen, 15.5 millin vs millin, respectively (CDC, Natinal Diabetes Statistics Reprt: Estimates f Diabetes and Its Burden in the United States, 2014). American Indians/Alaskan Natives have the highest prevalence f diabetes (15.9%), fllwed by Nn- Hispanic blacks (13.2%), Hispanics (12.8%), Asian Americans (9.0%), and nn-hispanic whites (7.6%) (CDC, 2014). Type 2 diabetes accunts fr apprximately 90 t 95 percent f diabetes in the United States. The Centers fr Disease Cntrl and Preventin (CDC) reprted in 2010 that 26.9% f adults age 65 and lder had been diagnsed with diabetes, the highest 13

27 prevalence amng all age grups. In additin, ver 20 millin lder adults are pre diabetic based n fasting glucse results, ral glucse tlerance tests, and hemglbin A1C. The American Diabetes Assciatin reprted in 2012 that the prevalence f diabetes (diagnsed and undiagnsed) amng senirs decreased t 25.9%, apprximately 11.8 millin senirs (American Diabetes Assciatin, 2013). Diabetes affects millins f Americans, but treatment and care varies per individual. There are different areas f care available including bld glucse testing, prescriptin medicatin, physician visits, and lifestyle interventins such as prper diet and exercise. Bld glucse testing is necessary fr mst patients in rder t prperly manage glucse levels. Patients must be aware f the signs f high bld sugar (hyperglycemia) and lw bld sugar (hypglycemia).different medicatins are available t diabetes, but are prescribed depending n individual basis. Patients with Type I diabetes must use insulin because their inability t prduce insulin. Type II diabetics als may use insulin depending n their case. There are abut 20 types f insulin sld in the United States and have different characteristics based n time befre it enters the bldstream, when it's wrking at its maximum capacity, and hw lng it lwers glucse based n a dse (American Diabetes Assciatin, 2013). Oral medicatin is prescribed fr glucse cntrl (antihyperglycemic agents), stimulatin f insulin prductin by the pancreas, increased sensitivity t insulin, imprvement f glucse r insulin after a meal, r imprved absrptin f carbhydrates. Different cmbinatins f ral medicatin may be prescribed as well, depending n the patient. Althugh diabetes cannt be reversed, it can be cntrlled with changes in lifestyle. First, it is imprtant fr an individual with diabetes t test their bld sugar t 14

28 make sure it is within prper range during times f fasting and after a meal. If a health care prvider has prescribed medicatin t help lwer bld sugar, it is imprtant that medicatin is taken as prescribed. Nutritinal therapy and cnsistent exercise are lifestyle factrs that can help manage the cnditin. Eating a prper diet is ne f the key factrs t managing diabetes r preventing pre diabetes frm prgressing. The rle f diet shuld be t help lwer and maintain bld glucse levels at apprpriate levels, as well as achieving r maintaining a healthy weight, and maintaining bld lipid levels (Lazaru et al., 2012). Because carbhydrates prvide the mst glucse in the diet, the amunt and type f carbhydrates have been studied in regards t impact n pstprandial glucse levels and verall glucse cntrl (Wheeler & Pi-Sunyer, 2008). Diabetics are suggested t fllw carbhydrate cunting methds (Kaiser Permanente, 2013) r fllw diabetic exchange diets. Cmplex carbhydrates and carbhydrates f lwer glycemic index raise bld sugar at a mre gradual, steady rate cmpared t simple carbhydrates and high glycemic index carbhydrates which raise bld glucse rapidly (Barclay et al., 2008). Varius diets have been suggested in the literature in rder t cntrl bld glucse levels and ther CVD bimarkers. A study investigating adherence t the Dietary Guidelines fr Americans and the measurement f insulin resistance in the Framingham Heart Study Offspring Chrt fund that participants with higher diet quality scres, measured by Dietary Guidelines fr Americans Adherence Index, had lwer hmestasis mdel assessment f insulin resistance. The results fund were mst significant in wmen (Fgli-Cawley et al., 2007). Diets rich in fruits, vegetables, whle grains, and lw fat dairy were assciated with prtectin against insulin resistant phentypes and a diet 15

29 with refined grains, high fat dairy, baked gds, sda, and candy increased insulinresistant phentypes (Liu et al., 2009). A recent study regarding lw carbhydrate and lw saturated fat diets vs. high-unrefined carbhydrate, lw fat diets in participants with Type II diabetes cncluded bth diets imprved glycemic cntrl and CVD bimarkers ver 24 weeks, and the lw carbhydrate diet imprved antiglycemic medicatin requirements (Tay et al., 2014). New research is cntinually published regarding diet and management f diabetes. The University f Pittsburgh's Diabetes Preventin Prgram was a majr clinical trial that investigated whether either lifestyle changes such as diet and exercise r the ral diabetes medicatin Metfrmin culd prevent r delay type II diabetes in participants with impaired glucse tlerance. Lifestyle interventin included a healthy lw fat, lw calrie diet as well as mderate intensity exercise at least 150 minutes per week. Participants in this grup received a 16 lessn curriculum including diet, exercise, and behavir mdificatin. Average fllw up f participants was 2.8 years fr placeb, Metfrmin, and lifestyle interventin grups. The incidence f diabetes was significantly lwer in the lifestyle interventin grup in the fllw up cmpared t the Metfrmin, therefre mre effective in reducing the incidence (Bray et al., 2002). Metablic Syndrme Metablic Syndrme is a cluster f health prblems which puts individuals at greater risk fr develping ther chrnic diseases such as diabetes and CVD. Metablic syndrme is diagnsed if an individual has three r mre f the fllwing cnditins: abdminal besity, hyperglycemia (fasting glucse 100 mg/dl r greater), elevated triglyceride levels (150 mg/dl r greater), lw HDL chlesterl (less than 40 mg/dl in 16

30 men and less than 50 mg/dl in wmen), hypertensin (Fgli-Cawley et al., 2007). Abut ne in three American adults has metablic syndrme, and is becming an increased health cncern as besity and ther chrnic cnditins have increased amng the American ppulatin. Adherence t the Dietary Guidelines fr Americans, 2010, culd help with management f metablic syndrme, as well as ther chrnic cnditins (Fgli- Cawley et al., 2007, Hsseini-Esfahani et al., 2011). Inflammatin Inflammatin is the bdy's immune respnse t an external stimulus that is nt nrmally prduced r recgnized by the bdy. The gal is t eliminate the cause f cell injury and t begin the repair prcess. White bld cells and ther plasma prteins are part f the immune respnse and g t the site f infectin r damage. Acute inflammatin is an immediate respnse t an infectin, injury, r virus. Chrnic inflammatin is respnse t a lng lasting external stimulus which ften severely damages tissues ver time. Persistent infectin, autimmune disease, and chrnic expsure t txic chemicals r stress are all causes f chrnic inflammatin. Adipse tissue (fat cells) can als be respnsible cntributing t inflammatin. Cmmnly studied bimarkers f inflammatin are Interleukin-6 (IL-6) and C- reactive prtein (CRP) and can be measured thrugh bld samples as a way t measure inflammatin severity. Research has shwn IL-6 and CRP t be mre cmmnly fund in individuals with besity r chrnic diseases such as cancer, CVD, and Type II diabetes (Bansal et al., 2007; Pradhan et al., 2001). Althugh the mechanisms are nt fully understd, inflammatin is cnsidered t be an imprtant linking factr between dietary patterns (such as the Western diet) and disease states such as CVD, diabetes mellitus, and 17

31 cancer. One study cncluded that high levels f plasma CRP were significantly assciated with the risk fr ischemic strke (Everett et al., 2006). Data frm the Wmen's Health Study shwed a link between high baseline levels f IL-6 and CRP and risk f develping Type 2 Diabetes Mellitus (Pradhan et al., 2001). Bansal et al. (2007) fund that wmen with higher baseline levels f high sensitivity-crp suffered mycardial infarctins earlier in life cmpared t wmen with lwer baseline levels and were mre likely t have a fatal event. Reducing inflammatin thrugh diet and physical activity may be beneficial, as research suggests it may decrease the risk f develping chrnic disease related t diet. Higher diet quality has been assciated with lwer levels f inflammatry markers. Nettletn et al. (2006) fund that CRP and IL-6 were inversely assciated with cnsumptin f a diet highly cmprised f fruit, nuts, whle grains, and green leafy vegetables. A recent study by Park et al. (2014) cncluded that CRP cncentratins were negatively crrelated with higher diet quality. Increase fiber intake has been shwn t be assciated with decreased CRP levels (Kantr et al., 2013). A current review summarized eight bservatinal studies frm 2010 thrugh 2013 n assciatin between diet patterns and diet quality scres with inflammatry markers. The authrs cncluded diets rich in fruits and vegetables were assciated with lwer levels f CRP and ther inflammatry markers, while diets high in meat were assciated with higher levels f inflammatry markers (Oude Griep et al., 2013). Sedentary behavir has been linked t increase risk f inflammatin. One study nted significant decrease in CRP levels in wmen after a sixteen week aerbic exercise interventin with n dietary mdificatin (Arikawa et al., 2011). Reed et al. (2010) 18

32 examined the effect f physical activity and calric restrictin n inflammatry markers and cncluded the significant decrease n IL-6 but nt CRP. 19

33 Measuring Diet Quality: Individuals There are multiple ways t measure an individual's diet. An individual's dietary intake is measured by dietary assessment methds. Methds used t assess diet include, but are nt limited t, weighted fd recrds, fd diaries, 24 hur diet recalls, and fd frequency questinnaires (FFQ). There are dietary indices that analyze multiple nutritinal cmpnents, nutrients, and/r fd grups t rate verall diet and dietary quality. Dietary Assessment Methds Diet is ne f the majr cntributrs t verall health. Measuring diet thrugh different dietary assessment tls has been develped t accurately determine dietary intake. Each assessment tl cnsiders types and amunt f fd as well as nutrient intake. The different methds can either dcument what an individual ate n ne r mre days (Fd recrds, 24 hur diet recall), r capture a snapsht f what a persn typically eats during a specific perid f time (fd frequency questinnaire). A fd recrd is a diary f fd a persn eats n ne day r multiple days. An individual keeps recrd f the fd brand, preparatin methd, and the time and lcatin in which they ate. The 24 hur diet recall shuld be dne multiple times t see variatins in a persn's diet n a day t day basis. Typically, at least ne weekday is recrded and ne weekend day. A trained prfessinal will cnduct the recall, s literacy is nt required, but it des require the participant t rely n memry. The FFQ assesses diet intake ver a perid f time, typically a week, mnth, seasn (3 mnths), r a year, by questining hw ften and hw much the participant cnsumes particular fds and beverages in the specified time frame. This is dne by the participant, r it can be interviewer administered. 20

34 Chsing the apprpriate dietary assessment methd and analysis techniques are imprtant t determine the relatinship between dietary intake and chrnic disease in different ppulatins and age grups. Determining dietary patterns (e.g. fd ften cnsumed, meal and snacking habits, eating frequency) is imprtant regarding the relatinship t chrnic disease. Dietary Quality Dietary quality is cnsistent with nutrient density; high dietary quality is characterized by a diet high in fruits, vegetables, lean prtein, whle grains, and lw fat dairy, while lw dietary quality is characterized by fds high in fat (saturated, trans), high sdium, high chlesterl, and added sugar. The purpse f many diet quality indices is t understand whle diet cnsumptin, specifically quality and variety f the diet cnsumed, and the assciatin it has n health utcmes. Often times, dietary quality indices are used t measure hw well an individual's diet adheres t specific requirements, such as the Dietary Guidelines fr Americans (DGA). The DGA was develped with the aim f preventing chrnic disease develpment r prgressin. Having a diet cnsistent with the DGA can prevent chrnic disease frm develping, can imprve chrnic disease state, and can prevent the develpment f ther chrnic cnditins (Wirt, 2009). Dietary Quality Indices The purpse f many f the diet quality indices is t examine an individual's diet as a whle rather than lking at a single nutrient. There are tw different types f scring methds when discussing diet quality indices. First, there are a priri scring methds which is a theretical, scre-based apprach based n current knwledge in the 21

35 field f nutritin (Waijers et al., 2007). A priri scring fcuses n fd and nutrients that are vital t health, and are examined as a cmprehensive measure f diet quality. Diet indices based n the adherence t dietary guidelines such as the Healthy Eating Index (Guenther et al., 2013) and Alternative Healthy Eating Index (McCullugh et al., 2002) are bth examples f a priri scring indices. The a psteriri methd is an empirically derived eating pattern that is data driven using factr r cluster analysis (Meller et al., 2006). These data are cllected based n crrelatins f fd intakes frm a variety f dietary cmpnents (Waijers et al., 2007). Examples f empirically derived eating patterns include "high-fat," "vegetable and fruit," r "Heart Healthy" (Newby & Tucker, 2004). Often time, a priri and a psteriri scring methds have been cmbined t display an assciatin between verall diet and different health utcmes. The Dietary Guidelines fr Americans Adherence Index (DGAI) is a diet quality index develped riginally by Fgli-Cawley et al. (2006). The DGAI was develped based n the 2005 DGA and has since been revised t meet the key fd recmmendatins f the mst recent 2010 DGA (Try & Jacques, 2012). The DGAI , an a priri measurement f diet quality, measures hw well an individual's diet adheres t the recmmendatins set ut by the 2010 DGA. DGAI-2010 is a cntinuus scre and is scred frm 0 (prest diet quality scre) t 100 (highest diet quality scre). The DGAI-2010 scring includes five main fd grups; fruit, vegetable, prtein, grains, and dairy and subgrups f sme fd grups (i.e., vegetable and prtein; described in detail belw). The scre fr each categry is 0-1. One strength f the DGAI is that it penalizes vercnsumptin f energy dense fds if intake is ver the 22

36 recmmended amunt such as cnsuming saturated fat greater than 10% f ttal energy intake (Fgli-Cawley, et al. 2006). The penalty assessed fr vercnsumptin is prprtinal t the amunt cnsumed ver the target range. Anther strength f the DGAI-2010 is pints fr variety amng prtein, fruit, and vegetable intake. Prtein is categrized in three subcategries; seafd, meats and pultry, and eggs, nuts and seeds, and sy prducts. The vegetables subcategries are "dark green," "range/red," "beans and peas," "starchy vegetables," and "ther vegetables." There are studies that use the DGAI-2010 t assess diet quality and the assciatins between different chrnic cnditins. Fgli-Cawley et al. examined the relatinship between diet quality and degree f insulin resistance based n data frm the Framingham Offspring Chrt Study (2007). Participants with the highest quintile categry f DGAI scre had significantly lwer degree f insulin resistance than thse in the lwest quintile after adjusting fr age, sex, and waist circumference (Fgli-Cawley et al., 2007). Liu et al. fund similar results, suggesting the cnsumptin f a diet high in fruit, vegetables, whle grains, and lw fat dairy prtects against insulin resistance (2009). DGAI-2010 is used in many studies t assess relatinships between diet quality and risk f chrnic disease. The Healthy Eating Index (HEI) was develped by the United States Department f Agriculture t determine hw well individual diets were adhering t the Dietary Guidelines fr Americans (DGA). It analyzes fd, beverage, and nutrient intake, as well as balance amng fd grups. The HEI-2010 reflects the 2010 DGA and is cmprised f twelve cmpnents; 9 adequacy and 3 mderatin cmpnents (Guenther et al., 2013). If an individual meets the guideline standard r cnsumes mre than the standard within 23

37 each individual adequacy categry, they receive maximum pints within that particular categry. Fr the mderatin cmpnents, intakes at the standard r belw receive maximum pints within each categry. The HEI is a widely used diet quality index in the United States. The Alternative Healthy Eating Index (AHEI) was develped based n an extensive review f the currently literature and cllabratin with nutritin experts with the gal f identifying nutrients and fds which are assciated with lwer risk f chrnic disease develpment (Chiuve et al., 2012). The AHEI-2010 has been used t assess the assciatin between diet quality and risk f majr chrnic disease and was strngly predictive f crnary heart disease risk and diabetes risk (Chiuve et al., 2012). A study examining diet quality and the assciatin f chrnic disease mrtality risk in pstmenpausal wmen fund that having better diet quality, measured by AHEI-2010, significantly decreased CVD mrtality risk by 18-26% (Gerge et al., 2014). Research shws the rate fr multiple chrnic diseases is lwer in the Mediterranean regin f the wrld, which largely can be related t specific dietary practices and patterns (Fung, et al., 2005). The alternate Mediterranean Diet Scre (amed) was develped t use alng with the FFQ in the United States and is based n the Mediterranean diet scale. There are nine categries, and an individual receives ne pint if they cnsume abve the median fr each f the categries except red meat (belw the median receives a scre f 1). amed scres range frm 0-9, zer being the wrst and nine being the best. Higher amed scres were assciated with lwer inflammatin bimarkers, which suggest a reductin f risk f diseases such as hypertensin, diabetes, and CVD (Fung et al., 2005). Having a better diet quality measured by amed is 24

38 assciated with 18-26% lwer all-cause mrtality and CVD mrtality, as well as a 20-23% lwer risk f cancer in pst menpausal wmen (Gerge et al., 2014). The Dietary Diversity Scre (DDS) was develped t measure dietary variety amng the United States ppulatin frm five fd grups; meat (animal and plant prtein surces), dairy, fruit, vegetables, and grains. Increasing the variety f fds in the diet can ensure adequate intake f the essential nutrients (Kant et al., 1991). A maximum DDS f 5 signifies cnsumptin f fd frm each f the five fd grups listed abve. The DDS has been used t assess ttal diet in relatin t all-cause mrtality. Kant et al (1993) used data frm the first NHANES Epidemilgic Fllw-up Study t relate dietary diversity t all-cause mrtality. 24 hur recalls were cllected frm 10,424 participants ages in rder t determine DDS. 25% f the participants scred less than 4 n the DDS. Increasing incme and educatin were assciated with higher DDS scres in men and wmen, and lwer BMI was assciated with higher DDS in wmen. A large prtin f the participants wh reprted having "little physical activity" had lw DDS. Crude and age-adjusted all-cause mrtality rates were calculated. Relative risk f mrtality was fund t be inversely related t DDS, while increasing mrtality was assciated with decreased DDS in men and wmen; therefre, mitting fd grups was assciated with increased risk f all-cause mrtality (Kant et al., 1993). In an extended study, Kant et al. (1995) examined the relatinship f diet quality assessed by DDS with CVD, cancer, and ther causes (nn-cvd, nn-cancer) f mrtality frm NHANES I Epidemilgic fllw up study. Age adjusted risk f mrtality was inversely related with DDS in men and wmen, except cancer in wmen. This data 25

39 suggests eliminating ne r mre majr fd grup increases the risk f CVD and cancer mrtality (Kant et al., 1995). The Recmmended Fd Scre (RFS) was develped t examine the assciatin f diet quality and mrtality in wmen using data frm the Breast Cancer Detectin Demnstratin Prject. Wmen age 35 t 74 years cmpleted a 62 item fd frequency questinnaire. Using the FFQ, the RFS index was develped. Twenty three fd items frm the FFQ are used fr scring, emphasizing cnsumptin f fruits, vegetables, whle grains, lw-fat dairy, and lean meats r meat alternates. The RFS is calculated by summatin f the 23 items that participants mentined they cnsumed at least nce a week, resulting in a maximum scre f 23. The remaining 39 fd items did nt meet the criteria fr inclusin in the RFS (Kant et al., 2000). The mean RFS in the chrt was 11.4 and participants with higher RFS were typically lder, mre educated, physically active, likely t drink alchl, use supplements, and less likely t currently smke. Wmen wh reprted dietary patterns cnsistent with current guidelines (fruits, vegetables, whle grains, lw fat dairy, lean meat) had lwer risk f mrtality and wmen in the highest RFS quartile had 30% lwer risk f multivariate age-adjusted all cause mrtality cmpared t wmen in the lwest RFS quartile (Kant et al., 2000). Measuring Diet Quality in Older Adults A variety f dietary indices have been used t evaluate the assciatin between diet quality and chrnic disease risk and mrtality, but until recently, n index had been develped specifically fr lder adults. Energy requirements decrease with age due t a decrease in basal metablism and lwer energy expenditure levels. Althugh daily calric 26

40 needs are decreased, prtein, vitamin and mineral intake shuld stay relatively the same thrugh the later stages in life (Kurlaba et al., 2009). The Elderly Dietary Index (EDI) was develped t assess dietary adherence t dietary recmmendatins specifically fr lder men and wmen using a survey in the Mediterranean islands. The fd scring categries f the EDI is based n the specific dietary recmmendatins fr lder adults frm the Mdified Fd Guide Pyramid fr 70+ Adults develped by researchers at Tufts University (Russell et al., 1999). The ten dietary cmpnents used t develp the EDI include cereal, meat and meat prducts, vegetables, fruits, legumes, fish and seafd, dairy prducts, bread (e.g., whle grain, white, and a cmbinatin), alchl, and live il. Cnsumptin f a variety f fds frm different fd grups can help lder adults meet the Recmmended Dietary Allwances fr vitamins, and minerals such as calcium, ptassium, and ther dietary cmpnents which lder adults typically d nt meet such as fiber and prtein (Kurlaba et al., 2009). Each categry had a max scre f fur assigned; deviatin frm the recmmended cnsumptin resulted in a scre less than fur. Ttal EDI scre is derived frm the summatin f each categry which ranges frm Higher scres indicate greater adherence t the dietary recmmendatins (Kurlaba et al., 2009). The develpers f the EDI, Kurlaba et al., (2009) examined whether the EDI is assciated with CVD risk factrs such as diabetes mellitus, besity, hypertensin, and hyperchlesterlemia thrugh a validatin sample f 668 free-living Greek adults 65 years and lder. Individuals were selected if they were free f CVD (mycardial infarctin, strke, and angina), if they did nt fllw a specific diet t cntrl bld pressure, bld glucse, bdy weight, r lipid levels, and if they maintained the same 27

41 dietary habits ver the past decade. Dietary intake was assessed thrugh semi-quantitative fd frequency questinnaire while physical activity was evaluated by self reprted Internatinal Physical Activity Questinnaire fr the elderly. EDI scre was brken int tertiles; 1st (10-28 pints), 2nd (29-31 pints) and 3rd (32-40 pints). Mean EDI scre was Participants in the third tertile had higher educatin level, better financial status, and were less likely t be sedentary cmpared t the participants in the first and secnd tertiles. Third tertile participants were less likely t be bese, hypertensive, and have at least ne risk factr fr CVD cmpared t the rest f the participants. A ne unit increase in EDI scre was assciated with apprximately 10% lwer dds f being bese, hypertensive, and having at least ne CVD risk factr even when adjusting fr age, sex, smking, physical activity, educatin, and living alne. Sensitivity f the EDI was 59% fr besity, 71% fr hypertensin, and 68% fr having at least ne CVD risk factr. Specificity fr EDI was 51% besity, 45% fr hypertensin, and 49% fr having at least ne CVD risk factr (Kurlaba et al., 2009). Therefre, the EDI can be a useful tl when assessing diet quality and risk fr develping CVD in lder adults. Natinal Cancer Institute Fruit and Vegetable Screener Dietary screening tls have been develped t assess dietary intake f different fd cmpnents such as fruit and vegetables. Fruit and vegetable intake are indicatrs f an verall healthy diet. Fruits and vegetables are necessary fr a healthful diet as they prvide essential vitamins and minerals as well as ther health prmting cmpunds. Intake f fruits and vegetables has been studied in relatin t disease risk. A baseline study regarding daily fruit and vegetable intake in the United States reprted an average 28

42 f 3.4 servings cnsumed per day, lwer than the recmmended minimum f five daily servings (Subar et al., 1995). Increasing fruit and vegetable intake t five r mre servings per day has been a cncern in the United States, therefre the Natinal Cancer Institute and Natinal 5 a Day Prgram develped a fruit and vegetable screener as an effrt t track prgress in fruit and vegetable cnsumptin. Using data frm the Natinal Institutes f Health- AARP Diet and Health Study, Thmpsn et al. (2000) tested the perfrmance f the standard fruit and vegetable screener as well as an updated, 16 questin fruit and vegetable screener. Fruit and vegetable intakes using the screener and FFQ were cmpared t the estimated true usual intake using a measurement errr mdel. Median daily servings were underestimated in bth screeners. 29

43 30 Table 1: Indices t Measure Diet Quality in Individuals Name f Index Diet Diversity Scre (DDS) Recmmended Fd Scre (RFS) Value/use f index Descriptin Range f scre (minimummaximum) Measures extent f dietary variety by cnsidering cnsumptin frm all fd grups (crrelates psitively with nutritinal adequacy) Used t evaluate variety f ttal diet and relatin t all cause-mrtality (using NHANESI) Diets that mit several fd grups assciated with increased risk f mrtality Multifactrial measure f verall diet quality derived frm dietary guidelines Assciatin f mrtality frm a prspective chrt study, Breast Cancer Detectin Demnstratin Prject, with diet quality High RFS assciated with decreased risk f mrtality in wmen. Cunts the number f fd grups (dairy, meat, grain, fruit, vegetable) cnsumed daily Based n reprting frm 24 hur recalls Measures the sum f the number f fds recmmended by the dietary guidelines (fruits, vegetables, whle grain, lw fat dairy, lean meat/pultry) Independent f reprted amunts t avid measurement errr. 0-5 (1 pint fr each grup) 0-23 (Calculated using 23 fd items cnsumed at least nce per week; sum f the 23 items) Develper/validatin Kant, A.K., Schatzkin, A., Harris, T.A., Ziegler, R.G., Blck, G. (1993). Dietary diversity and subsequent mrtality in the First Natinal Health and Nutritin Examinatin Survey Epidemilgic Fllw-up Study. The American Jurnal f Clinical Nutritin; 57: Kant, A.K, Schatzkin, A., Graubard, B.I., Schairer, C. (2000). A Prspective Study f Diet Quality and Mrtality in Wmen. Jurnal f the American Medical Assciatin; 283(16):

44 31 Elderly Dietary Index (EDI) Natinal Cancer Institute (NCI) Fruit and vegetable screener Measure the degree f adherence t nutritinal recmmendatins fr lder adults Assess diet quality and health status in lder adults, especially risk fr develping CVD. Develped by NCI and Natinal 5 a Day Prgram Indicatr f usual fruit and vegetable intake per day Track changes in fruit and vegetable cnsumptin Validated in adults ages years ld Measures 10 cmpnents pertaining t cnsumptin and frequency Fruits, vegetables, grains, fish, meat, legumes, live il, alchl, type f bread and dairy. Assessment tl t assess fruit and vegetable intake including 100% juice, green salad, french fries/ptates, vegetables nt including salad and ptates, fruit nt including juices Time frame f cnsumptin based n past mnth (Each categry scre 1-4) Respnse t questinnaire items are: Never, 1-3/mnth, 1-2/week, 3-4/week, 5-6/week, 1/day, 2/day, 3/day, 4/day, 5+/day Kurlaba, G., Plychrnpuls, E., Zampelas, A., Linis, C., Panagitasks, D.B. (2009). Develpment f a Diet Index fr Older Adults and Its Relatin t Cardivascular Disease Risk Factrs: The Elderly Dietary Index. The Jurnal f the American Dietetic Assciatin; 109(6): Subar AF, Thmpsn FE, Kipnis V, Midthune D, Hurwitz P, McNutt S, McIntsh A, Rsenfeld S. (2001). Cmparative Validatin f the Blck, Willett, and Natinal Cancer Institute Fd Frequency Questinnaires: The Eating at America's Table Study. American Jurnal f Epidemilgy: 154:

45 Determinants f Diet Quality A diet f high dietary quality can help with the aging prcess as it may alleviate physilgical and functinal declines, increases the chances f successfully living independently (Payette, 2005), and helps ffset chrnic disease develpment (Irz, 2012). Research has shwn that lder adults eat less healthy partially due t reduced fd and energy intake, decreased vegetable intake and less dietary variety due t diet restrictins, dental prblems, and scial factrs (Arabshahi et al., 2011; Cnklin, 2013). In rder t imprve verall diet in lder adults, we need t understand the determinants f diet quality within this ppulatin. The literature suggests predictrs are different amng lder men and lder wmen (Shatenstein, 2004), but the questin is what leads lder adults t chse specific diet patterns. Different determinants cntributing t diet quality in lder adults studied in the literature include demgraphic and ecnmic factrs, as well as envirnmental, cultural, and psychlgical factrs. Gender-based Differences There are many gender-based differences that are psitive and negative predictrs f diet quality. In a study examining gender differences regarding views n healthy behavirs and cgnitive health, bth men and wmen agreed a healthy diet was vital fr healthy aging (Wu et al., 2009). That study identified barriers t healthy eating, which differed between the tw genders. Wmen said they ften chse quick and cnvenient meals as ppsed t healthier meals when cking fr themselves, as well as difficulty preparing healthy meals as barriers, while men said taste preference, fast-fd, and lack f self cntrl were barriers (Wu et al., 2009). Studies have nted less cncern abut healthy eating amng men, and in married men, healthier diets were a result f 32

46 their wives cking (Wardle et al., 2004; Wu et al., 2009). Older wmen cnsume mre fruits and vegetables cmpared t lder men because they have better nutritin knwledge (Baker and Wardle, 2003). Scidemgraphic, lifestyle, and dietary characteristics in lder adults were examined t understand determinants f diet quality and diversity in a Quebec study (Shatenstein et al., 2004). Results fund different psitive and negative predictrs f usual dietary adequacy between men and wmen age using tw validated diet quality scres; the Dietary Diversity Scre (DDS) and Dietary Adequacy Scre (DAS). Psitive predictrs f usual DDS in men were eating breakfast and eating prepared fds, while negative predictrs f usual DDS were pr scial supprt and use f supplements. Prepared meals were defined as ready-t-eat frzen meals, meals eaten in restaurants, and delivered t the hme (Shatenstein et al., 2004). The DDS scre frm the study is based n Canada's Fd Guide fr Healthy Eating and des nt cnsider added fat, sugars, salt, and nn-nutritive substances in fd (Health Canada, 1992), making this a limitatin regarding prepared fds as a psitive indicatr. Using nutrient supplements, regular smking, and eating tw r fewer meals per day were negative predictrs fr men using DAS index (Shatenstein et al., 2004). Psitive predictrs f usual DDS fr wmen included regular physical activity as ppsed t sedentary behavir and higher educatin levels, while eating cmmercial prepared fds and preferring t be verweight than being deprived favrite fds were negative predictrs. Reprting that fd chices were influenced by health cncerns were psitive determinants f DAS in wmen (Shatenstein et al., 2004). 33

47 Frm the Quebec study, the mst influential predictr f higher DAS in bth men and wmen was eating three meals per day (Shatenstein, 2004), which is nt surprising. Nutrient and energy intakes increase the mre meals an individual cnsumes. Individuals wh tend t skip meals, typically breakfast, ptentially d nt receive enugh energy and nutrients (Lee et al., 1996; Rednd et al., 1997). A study examining the shrt term impact f nutritin educatin and cunseling including cngregate feeding and hme delivered meals fund an increase in number f meals cnsumed per day and eating five r mre serving f fruits and vegetables. As a result, nutritin risk factr scres were significantly imprved in participants as well as nutrient intake (Wunderlich et al., 2011). Baseline determinants f diet quality in lder men and wmen were identified frm the Canadian NuAge study n nutritin and successful aging (Shatenstein et al., 2013). Psitive determinants f diet quality in men were higher educatin, diet knwledge, number f daily meals, and perceived physical health, while negative predictrs were wearing dentures, alchl cnsumptin, and eating regularly in restaurants. Fr wmen, higher educatin, diet knwledge, number f daily meals, and having greater hunger sensatin were psitive predictrs while greater BMI and chewing prblems were negative determinants (Shatenstein et al., 2013). Many f the results align with results frm ther studies. Cnsuming three meals per day cnfirmed results frm 2004 NuAge chrt (Shatenstein et al., 2004). Higher diet quality was suggested t be better in lder adults with better health and nutritin awareness, as well as the amunt f attentin paid t maintaining a healthy diet (Shatenstein, 2004). It is clear frm the research there are gender differences which suggests targeting health prmtin and nutritin educatin t the needs f men and wmen in a different manner. 34

48 Sci-ecnmic Impact n Diet Quality Sci-ecnmic status (SES) and demgraphic factrs have an effect n verall diet quality (Larrieu et al., 2004; Darmn & Drewnwski, 2008; Katsaru et al., 2010). SES determinants frequently studied cnsist f individual and husehld incme, educatin, and ccupatin, while demgraphic factrs include husehld cmpsitin and marital status. SES and demgraphic determinants can better predict verall diet quality cmpared t chrnlgical age (Drewnwski & Shultz, 2001). High nutrient-dense diets, cnsisting f fruits, vegetables, lean meat, fish, and whle grains are assciated with better health but are cnsiderably mre expensive than diets cnsisting f high fat, refined grains, and sugar (Cnklin et al., 2013). Older adults are susceptible t pr diet quality due t changes in ecnmic status. Many lder adults are n a fixed incme due t retirement r unemplyment, which may limit what they are purchasing fr fd. Fd prices, especially fruits, vegetables, fish and lean prtein, have increased ver the years. Sme research suggests that it wuld cst an lder adult half f their weekly budget t supprt a healthy diet, and special therapeutic diets may cst even mre (Cnklin et al., 2013). Fd is ften viewed as a flexible expense fr the lder ppulatin, s lder individuals may limit their spending in this area if necessary as a means t save mney. Many lder adults are affected with ne r mre chrnic cnditin (Wlff et al., 2002; Gdman et al., 2014), which ptentially makes medical csts a pririty ver spending mney n healthier fd. In a Canadian study, health care prviders acknwledged hw fixed incmes in lder adult clients played a significant rle in fd access (Keller et al., 2010). 35

49 A fur-cuntry study, including Finland, Italy, UK, and Sweden, examined SES and demgraphic determinants f diet quality (Irz et al., 2012) using the Diet Quality Index (DQI) develped by Pattersn and clleagues (1994). Results fund lder individuals with better resurce availability in the UK and Finland had prer DQI scres, and n significance amng individuals in Italy and Sweden. Individuals with higher resurces in the cuntries studied cnsume mre saturated fat, chlesterl, and sdium (Irz et al., 2012). The results cntradict many studies which suggest lwer resurce availability t be assciated with lwer diet quality, particularly in the United States (Darmn & Drewnwski, 2008; Katsaru et al., 2010). Preference fr fd was significantly negatively assciated with diet quality, as lder adults allcate mre mney t fd with higher ttal energy, saturated fat, sdium, and chlesterl cntent. Irz et al. described lack f ratinale and cntrl amng the lder ppulatin when making fd chices (2012). Fd chices als may be derived frm habits frmed thrugh an individual's life. The Three City (3C) study identified SES and demgraphic differences in dietary habits amng cmmunity living lder adults in three urban cities in France (Larrieu et al., 2004). Results fund men ate mre meat, fish, cereal/bread/starch, raw vegetables, and legumes, while wmen cnsumed mre raw fruit, cked fruits and vegetables, and cnsumed less alchl. Bth men and wmen in the ldest age grup (85 years ld and up) participants cnsumed less cereals/bread/starch, raw vegetables and legumes. Wmen als cnsumed less fish and meat than men in this age grup (Larrieu et al., 2004). 36

50 Educatin as a Determinant f Diet Quality In the fur-cuntry study, educatin was a significant predictr f diet quality (Irz et al., 2012). Higher educatin level was significantly assciated with higher DQI scres when incme was cntrlled fr. Higher educatin was assciated with higher cnsumptin f fruits and vegetables and lwer cnsumptin f saturated fat in Finland and Sweden. When incme and educatin were cntrlled fr, prfessinal status (retired, self-emplyed, manager, r emplyee) shwed n significant crrelatin t diet quality (Irz et al., 2012). The 3C study examined educatin level as a determinant f diet quality and had a significant assciatin with incme (Larrieu et al., 2004). Cnsumptin f fish, raw fruits and vegetables, cked fruits and vegetables, and quantity f alchl increased with higher educatin level. Eating mre cereal, bread, and starch was assciated with lwer educatin level (Larrieu et al., 2004). A study determined if sciecnmic status amngst eastern Mediterranean lder adults was assciated with diet habits, especially traditinal Mediterranean dietary guidelines. This study cncluded participants with mre years f educatin and higher incme were mre likely t have a healthier diet (Katsaru et al., 2010). Lifestyle Impact n Diet Quality There are varius lifestyle variables examined when discussing determinants f diet quality in lder adults. In a study by Byntn, et al. (2008), educatin level, smking histry, alchl cnsumptin, family histry f cancer, intentinal weight lss, and BMI and bdy fat were examined as determinants f diet quality in verweight and bese, therwise healthy, pstmenpausal wmen. Results fund the strngest, significant 37

51 predictrs f diet quality amng the study ppulatin t be educatin and smking histry. The wmen with sme cllege and wmen wh were frmer smkers had higher diet quality scres cmpared t wmen with a high schl educatin and wmen wh never smked. The researchers suggest individuals wh were frmer smkers have made a cnscius decisin tward a healthier lifestyle by quitting smking, suggesting they may have made imprvements t their diet as well (Byntn, et al., 2008). BMI and percent bdy fat were fund t be mderately assciated with diet quality in verweight and bese, pstmenpausal wmen. Wmen with lwer BMI status and lwer percent bdy fat had higher diet quality scres cmpared t wmen with higher BMI scres (Byntn et al., 2008). Individuals wh are physically active have shwn imprvements diet quality ver time cmpared wh individuals wh are sedentary (Fung et al., 2007; Lee et al., 2007; Arabshahi et al., 2011). Trends in verall diet quality fr crnary heart disease preventin were examined by bserving data derived frm the Minnesta Heart Survey. Participants wh were physically active cmpared t sedentary and were nn smkers had better diet quality scres (Lee et al., 2007). Being physically active and nn smking status were assciated with higher diet quality in a study assessing the assciatin between diet quality and type II diabetes risk in wmen (Fung et al., 2007). A lngitudinal study in Australia fund that individuals wh were physically active had better imprvements in diet quality ver a 15 year perid than individuals wh were sedentary, and wmen wh were nnsmkers had imprvements in diet quality (Arabshahi et al., 2011). A review f literature n behaviral determinants f healthy aging fund smking status and physical activity t be significant determinants. Current 38

52 nn-smkers and individuals wh had previusly quit smking had better health utcmes, as well as participants wh were frequently physically active (Peel et al., 2005). Scial Impact n Diet Quality A Quebec study analyzing hme dwelling lder adults fund that pr scial supprt is a negative predictr in diet quality in lder men (Shatenstein, 2004). Changes in husehld structure and lss f a partner r spuse can impact nutritin status as lneliness and living alne has been cited as a factr leading t inadequate nutrient intakes in lder adults (Payette & Shatenstein, 2005). Older men, especially men 75 years and lder, tend t cnsume a pr diet cmpared t men f the same age living with a spuse (Wardle et al., 2004; Wu et al., 2009). Research n scializatin during meal time has shwn t imprve diet and nutritinal status when eating with family r friends (Drewnwski & Shultz, 2001). Results frm the fur cuntries study in the EU fund that living with a spuse was significantly related t higher diet quality in three f the fur cuntries, as living alne is assciated with making less healthy fd chices (Irz et al., 2012). In the 3C study, participants wh lived alne, cmpared t participants living with a spuse r thers, cnsumed significantly less f all fd grups. Wmen wh lived alne ate especially less meat and raw vegetables (Larrieu et al., 2004). Oral Health and Diet Quality Oral health prblems such as dry muth, wearing dentures, and tth lss, have been assciated with altered nutrient intake and pr diet quality in bth elderly men and wmen due t difficulties chewing and swallwing (Cermak et al., 2003; Quandt et al., 39

53 2011; Savca et al., 2011). Diets are ften changed r altered amng individuals affected ral health difficulties in rder t make chewing and swallwing easier (Quandt et al., 2009). Severe cases f dry muth have been assciated with lwer intake f whle grains but high intakes f fruit. Dry muth has been assciated with avidance f several fds due t perceived swallwing difficulty (Quandt et al, 2011), which may have an impact n variety and types f fd cnsumed. Results examining diet quality and ral health status f lder adults in the rural parts f the United States shwed lder adults wh avided the mst amunts f fds wre dentures and were nt prperly fitted (Quandt et al., 2009). A study by Savca et al. wanted t determine if denture status (n denture use, cmplete, partial) is assciated diet quality. Frequent remval f dentures was assciated with lwer diet quality and mre fds avided, and severe tth lss had the highest negative impact n diet quality and fd avidance (Savca et al., 2011). Avidance f certain fds because f dry muth, denture usage, and tth lss can result in lwer nutrient intakes and affects diet quality (Cermak et al., 2003; Savca et al., 2011). Malnutritin in Older Adults Older adults are at a greater risk fr develping nutritin deficiencies if they have ne r mre chrnic cnditin, as well as if they are chrnic medicatin users because f the increased risk f fd and drug interactins (Guigz et al., 1994; Drewnwski & Shultz, 2001). Natural physilgical and psychlgical changes that develp in the aging prcess can als cntribute t nutritin deficiency (Guigz et al., 1994; Brwnie et al., 2006). Physilgic changes assciated with aging include sensry impairment, specifically taste and smell, ral health prblems, altered energy requirements, muscle lss, and decreased physical activity (Brwnie et al., 2006). Older adults typically d nt 40

54 meet the recmmendatins fr necessary vitamins and minerals. 75% f lder men and wmen fail t meet Recmmended Dietary Allwance fr nutrients such as flate, vitamin E, and zinc. Less than ten percent f lder men and wmen are meeting the recmmendatins fr calcium (Drewnwski, 2001). Malnutritin in the elderly is assciated with increased mrbidity and mrtality, decreased immunity, decreased physical and cgnitive functin, and increase risk f bne fractures (Guigz, 2006). Detectin f pr nutritin status at an early stage is vital in beginning nutritinal therapy t reduce the prgressin f any f the negative health risks (Cereda et al., 2008). The prevalence f malnutritin in hspitalized r institutinalized elderly is 30-60% (Guigz, 2006). It is imprtant that malnutritin risk is determined as sn as pssible t avid further prgressin f under nutritin, and t lessen the negative effects it has n health. Nutritin assessment tls have been develped t identify individuals at risk r wh are malnurished. Mini Nutritinal Assessment The Mini Nutritinal Assessment (MNA) is a validated nutritin assessment tl fr patients 65 years and lder (Rubenstein, 2001). This simple, reliable, quick, and nninvasive assessment tl has been supprted by hundreds f publicatins and has been used as part f a standard evaluatin f elderly patients within hspitals, nursing hmes, and ther clinical settings t assess the nutritin risk in patients (Guigz et al., 1996; Guigz et al., 2006). Three studies frm France, United States, and Switzerland cnsisting f mre than 600 subjects have validated this tl (Guigz et al., 1996; Guigz et al., 2006). The MNA was designed t be a reliable scale, have clearly defined threshlds, be cmpatible with skills f the assessr, have minimal bias by the assessr, 41

55 be a lw cst tl, and be acceptable by patients (Guigz, 2006). It was validated using tw principles; the first being clinical status f the patient determined by a trained physician with nutritin expertise, and a cmprehensive nutritin assessment (Guigz, 2006). The cmprehensive nutritin assessment n the MNA cnsists f 18 questins separated in t fur categries: anthrpmetric assessment (height, weight, arm and calf circumference, and weight lss), general state (residential status, psychlgical, mbility, medicatin, and skin ulcers), dietary assessment (number f meals, fd cmpsitin and fluid intake, independent feeding), and self-assessment (subjective t health and nutritin) (Bastiaanse, 2012). The ttal/maximum scre is 30 pints; 24 pints is categrized well-nurished, 17 t 23.5 pints signifies risk f malnutritin, and a scre f 17 pints r less indicate malnutritin (Guigz et al., 1996). Sme limitatins t the MNA tl is that it takes t lng t cmplete in a health care setting, and des nt cnsider tube feeding nutritin. Nutritin Screening Initiative The U.S Natinal Nutritin Screening Initiative (NSI) DETERMINE yur health checklist was designed t prmte regular nutritin screening in a quick, cst effective manner (White et al., 1992; Mitchell, 2002). The purpse f the tl is t identify individuals with a greater risk f malnutritin based n the categries related t disease, eating prly, tth lss/muth pain, ecnmic hardship, reduced scial cntact, multiple medicines, invluntary weight lss/gain, needs assistance in self care, and being an elder abve age 80 (White et al., 1992). 42

56 Dietary Screening Tl The Dietary Screening Tl (DST) is a simple questinnaire fr detecting nutritinal risk in lder adults (Bailey et al., 2009). Fur 24 hur dietary recalls including dietary supplement use were used in the riginal crss sectinal study fr dietary assessment. Tw dietary quality indices were calculated using the 24 hur dietary recall data. One index examined micrnutrient intake using Mean Adequacy Rati (MAR) and the ther index used was the Healthy Eating Index 2005 (HEI-2005) (Bailey et al., 2007; Bailey et al., 2009). MAR calculated nutrient adequacy ratis fr 12 vitamins and minerals based n the participants reprted intake divided by the Recmmended Dietary Allwance (RDA), Dietary Reference Intake (DRI), r Adequate Intake (AI) when the RDA wasn't established. In the develpment f the DST, tw dietary patterns were derived frm principal cmpnent analysis, including a nutrient dense dietary pattern and lw nutrientdense pattern. The nutrient dense dietary pattern was related t higher MAR, lwer dietary fat intake, and higher intakes f mega 3 fatty acids, fiber, and prtein. Nutrient density was als significantly crrelated with higher HDL-chlesterl, lwer triglycerides, and a favrable lipid prfile (Bailey et al., 2007). The less nutrient-dense pattern was assciated with lw intakes f micrnutrients, fiber, prtein, higher intakes f added sugar, as well as lw levels f serum vitamin B12 (Bailey et al., 2007). In ttal, 24 questins are included n the DST questinnaire. Nineteen items were chsen that represented tw dietary patterns. Five additinal questins were added t the DST t cllectin infrmatin n added fat and sugar. HEI-2005 scring was used as a guide fr each f the dietary cmpnent categries (e.g., fruits and vegetables). Fds 43

57 assciated with a healthier dietary pattern were mre pints fr higher cnsumptin. The 5 yes r n questins were 1 pint each. The DST classifies nutritinal risk at three levels; at risk, pssible risk, and nt at risk. The results f the study cncluded that DST scres were related t nutrient intakes and bimarkers f nutritinal status. At risk grups reprted significantly lwer prtein intakes, higher ttal and saturated fat intakes, as well as lw levels f serum vitamin B12, flate, and cartenids cmpared t the pssible risk and nt at risk grups. The nt-atnutritinal risk grup had higher MAR and HEI scres, higher intake f dietary fiber, alng with higher lycpene, beta cartene, and lwer hmcysteine and methylmalnic acid cncentratins (Bailey et al., 2009). All three grups had significantly different intakes f fruits and vegetables (Bailey et al., 2009). Nutritinal risk calculated frm the DST was cmpared t a nutritinal risk variable cmpsed f inadequate dietary intakes frm the 24 hur dietary recalls. A cntingency table was calculated with thse classified at risk and nt at risk by the DST and dietary recalls. The cmparisn reprted 83% sensitivity, 75% specificity, 79% accuracy level, and a psitive predictive value f 75%, therefre the researchers cncluded the DST can help detect nutritinal risk in lder adults (Bailey et al., 2009). 44

58 45 Table 2: Dietary Screening Tls t assess Malnutritin in Older Adults Name f tl Value/use f index Descriptin Range f scre (minimummaximum) MNA (Mini Nutritin Assessment) NSI (Nutritin Screening Initiative) Validated fr adults 65+ in evaluating risk f under nutritin Identify peple wh are malnurished, at risk, r wh wuld benefit frm early nutritin interventin "Gld standard" nutritin assessment tl Predictive f mrtality Crrelated t functinal capacity Crrelated t nutritinal intake (macr/micr) Nutritin screening checklist fr malnutritin which is quick, cst effective. NSI identifies patients age 80+ Public awareness and educatin tl (nt a diagnstic device) Identify greater risk patients 18 questins; questins fall int ne f fur categries; Anthrpmetric (BMI, weight lss, etc), Glbal assessment (medicatins, psychlgical impairment, mbility, etc), Shrt diet assessment (number f meals per day, variety amng fd grups, etc), Subjective assessment (self perceptin f health, nutritin) Statements n questinnaire related t Disease, Eating prly, Tth lss/muth pain, Ecnmic hardship, Reduced scial cntact, Multiple medicines, Invluntary weight lss/gain, Needs assistance in self care, Elder years abve age 80. Maximum 30 pints 24 pints is categrized wellnurished pints risk f malnutritin <17 malnurished Circle yes and crrespnding scre if the statement applies t patient Fr each yes answer, scre the number fr that questin Develper/validatin Guigz, Y., Vellas, B., Garry, P.J. (1994). Mini Nutritin Assessment: A Practical Assessment tl Fr Grading the Nutritinal State f Elderly Patients. Facts and Research in Gerntlgy; Supplement 2: Dwyer, J.T., Ham, R.J., Lipschitz, D.A., Psner, B.M., Wellman, N.S., White, J.V. (1992). Nutritin Screening Initiative: develpment and implementatin f the public awareness checklist and

59 46 Diet Screening Tl (DST) Rapid screening f verall dietary intakes in lder adults Adults defined as being at nutritinal risk had significantly lwer indicatrs f diet quality (using HEI and Mean Adequacy rati) Older adults at nutritinal risk had significantly lwer intake f prtein, mst micrnutrients, fruits, vegetables, and dietary fiber Self administered 0-2: Gd nutritin status 3-5: mderate risk >6: high nutritinal risk 24 diet questins structured in categries similar t HEI-2005; pints alltted t each similar t HEI-2005 Whle fruit/juice categry with three subcategries (ttal 15 pints) Vegetable cmpnent, 2 subcategries (ttal 15 pints) Ttal and whle grains, 3 subcategries (ttal 15 pints) Lean prtein, 2 subcategries (ttal 10 pints) Added fats, sugars, sweets, 10 subcategries (ttal 25 pints) Dairy, 2 subcategries (ttal 10 pints) Prcessed meats, 2 subcategries (ttal 10 pints) +5 pints fr use f a dietary supplement Add scres frm each fd grup categry DST scres <60: "at risk" DST scre 60-75: "pssible risk" DST scre >75: "nt at risk" screening tls. Jurnal f the American Dietetic Assciatin; 9(2): 163 Bailey, RL., Mitchell, DC., Miller CK., Still, CD., Jensen, GL., Tucker, KL., Smiciklas-Wright H. (2007). A Dietary Screening Questinnaire Identifies Dietary Patterns in Older Adults. The Jurnal f Nutritin; 137,

60 CHAPTER 2 FOOD ENVIRONMENT AFFECTS DIET QUALITY Intrductin Neighbrhd differences in regards t fd access and availability may be an imprtant influence n the relatinship between dietary patterns and chrnic disease risk (Mrland et al., 2002; Liese et al., 2007; Larsn et al., 2009; Wedick et al., 2015). Neighbrhds characterized by lw incme, high unemplyment rates, husehlds withut vehicles, and high ppulatin density have been assciated with pr dietary behavirs (Liese et al., 2007), while neighbrhds with greater access t healthy fds is assciated with lwer prevalence f chrnic cnditins (Wedick et al., 2015). Engaging in healthy lifestyle behavirs such as cnsuming a high diet quality and physical activity are likely a reflectin f access t a fd and physical activity resurces (Meyer et al., 2015). Neighbrhd fd availability has been regarded as a primary determinant f dietary behavir (Rse & Richards, 2004) therefre evaluating the fd envirnment and the availability f nutrient-dense fd in a specific neighbrhd may ffer insight int eating patterns and behavirs. Nutrient dense fds are primarily available in supermarkets and grcery stres with a large variety f fd (Wedick et al., 2015). Previus research has fund that adults living in areas with relatively mre supermarkets and less cnvenience stres and Fast Fd utlets were mre likely t cnsume a higher quality diet due t the availability f mre vegetables, fruits, whle grains, and lean prtein surces (Rse & Richards, 2004; Bdr et al., 2008; Larsn et al., 2009; Wedick et al., 2015). 47

61 Understanding the neighbrhd envirnment in terms f physical activity resurces is als imprtant in determining pssible slutins t imprving lifestyle (Meyer et al., 2015). Neighbrhds with mre parks and exercise facilities may increase the engagement f physical activity such as walking, running, and biking, fr example, frm lder adults living in the cmmunity (Berke et al., 2007). Previus research suggests that lder adults wh live mre active lifestyles cmpared t sedentary lives are mre likely t cnsume a diet f higher dietary quality (Shatenstein et al., 2004; Peel et al., 2005; Lee et al., 2007; Fung et al., 2007; Arabshahi et al., 2011). A recent study examined the lngitudinal assciatins between envirnmental factrs and lifestyle (dietary behavir and physical activity) and health (BMI and hmestasis mdel assessment f insulin resistance [HOMA-IR]) (Meyer et al., 2015). Neighbrhds were characterized by cmpsitin features such as rad cnnectivity, presence f parks and physical activity facilities, and fd resurces (cnvenience stres, natural fd stres, specialty markets, supermarkets, grcery stres, Fast Fd restaurants, fd stands/cafeterias, and nn-fast Fd restaurants). Meyer and clleagues fund neighbrhd clusters were significantly assciated with verall diet quality measures, but there were n significant assciatins with Fast Fd intake r physical activity measures (2015). In lw ppulatin density neighbrhds (i.e., neighbrhds with less than 1,750 peple per square kilmeter), diet quality was psitively assciated with diversity in the fd envirnment and physical activity resurces. In high ppulatin density neighbrhds (i.e., > 1,750 peple per square kilmeter), diet quality was psitively assciated with a fd envirnment with mre specialty markets and natural fd stres, less cnvenience stres, and mre 48

62 physical activity resurces. There were incnsistent assciatins with BMI and HOMA- IR amng different neighbrhd clusters (Meyer et al., 2015). Examining healthful fd availability in neighbrhds may give better insight t the facilitatrs and barriers t individual health prmting behavirs, such as healthful fd intake. Fd Access The United States Department f Agriculture (USDA) identifies lw-incme and lw-access census tracts using fur measures f lw access. In the first (riginal) fd desert lcatr, lw access was defined as having a census tract with "at least 500 persns and/r at least 33% f the census tract's ppulatin live mre than ne mile frm a supermarket r large grcery stre (10 miles, in the case f rural areas)" (United States Department f Agriculture [USDA], 2015). Data frm 2010 indicated that in urban areas, apprximately 70% f peple lived within ne mile f a supermarket and in rural areas, apprximately 90% f peple lived within 10 miles f a supermarket (Ver Pleg et al., 2012). Accrding t the USDA ERS (2009), " Updating the riginal 1- and 10-mile lwaccess measure shws that an estimated 18.3 millin peple in these lw-incme and lw-access census tracts were far frm a supermarket in 2010." In subsequent years, the USDA added three additinal measures f fd access based n the distance t a supermarket. One measure applies a half-mile demarcatin in urban areas and a 10 mile distance in rural areas. Using the half-mile measure, an estimated 52.5 millin peple, r 17% f the U.S. ppulatin, have lw access t a supermarket (USDA ERS, 2009). 49

63 The USDA uses distance t the nearest supermarket as a measure f access and categrizes tracts int high, medium, r lw access depending n the type f access (walking and driving access). Walking access measures a range f distances fr which it is feasible fr individuals t walk t a supermarket. Walking access fr an area is cnsidered t be "high access" if a supermarket is within a half-mile, "medium" if a supermarket is between a half-mile and ne mile, and "lw access" if the nearest supermarket is mre than ne mile away (USDA ERS, 2009). The USDA has been the head rganizatin t identify fd deserts within the United States. Data frm the USDA's Ecnmic Research Service (ERS) cncluded that 23.5 millin peple live in areas with limited fd access areas, r fd deserts. Mre than half f thse peple, apprximately 13.5 millin, are classified as lw-incme individuals (USDA, 2015). The State Indictr Reprt n Fruits and Vegetables measures the percentage f census tracts natinwide and by state that have at least ne healthier fd retailer (at least ne supermarket, supercenter, larger grcery stre, warehuse club, r fruit and vegetable specialty stre) lcated within the tract r within a half-mile bundary (State Indicatr Reprt, 2013). The State Indicatr Reprt n Fruits and Vegetables referenced the USDA Access t Affrdable and Nutritius Fd: Measuring and Understanding Fd Deserts and Their Cnsequences reprt fr their ratinale in chsing a half-mile bundary (USDA, 2009). The State Indicatr Reprt n Fruits and Vegetables shwed that in 2011, nly 68.6% f Massachusetts census tracts had at least ne healthier fd retailer (i.e. larger grcery stres, supermarkets, supercenters, warehuse clubs, and fruit and vegetable 50

64 specialty fd stres) within the census tract r within a half-mile f the tract bundary, cmpared t the U.S natinal average 69.5% (State Indicatr Reprt, 2013). Fd Access in Springfield, Massachusetts The Fd Access Research Atlas shws that mre than half f Springfield, Massachusetts census tracts are cnsidered fd deserts, having a significant lw-incme ppulatin grcery stre access at mre than a half mile away (in mst cases mre than 1 mile away) (USDA ERS-Fd Research Atlas, 2010). Access t fd within a neighbrhd impacts individual health utcmes. Studies have shwn assciatins between greater access t healthful fds with better dietary quality and lwer prevalence f chrnic disease (Wedick et al., 2015). The Springfield Data Atlas by Neighbrhd reprt indicated the percentage f peple in 2010 with lw access t healthy fds within Massachusetts and within Springfield (Pineer Valley Planning Cmmissin, 2014). In all, 19.35% f peple in Massachusetts have lw access t healthy fd, cmpared t 8.24% f Springfield's ppulatin. Access t fd is nt the same acrss Springfield neighbrhds. Figure 3 shws the percentage f peple in Springfield with lw access t healthy fd. Residents f the East Frest Park (32.57%), Pine Pint (25.71%), and Sixteen Acres (16.34%) neighbrhds have limited access t healthful fd ptins due f lack f supermarkets within prximity t the neighbrhd and limited access t transprtatin. Residents f the Bay (6.1%) and Suth End (0.0%) neighbrhds, fr example, live within clser prximity t supermarkets and have higher reprted rates f vehicle wnership (USDA ERS-Fd Research Atlas, 2010; Pineer Valley Planning Cmmissin, 2014). 51

65 Figure 3 Springfield Fd Desert Map (Pineer Valley Planning Cmmissin, 2014) 52

66 GFresh Mbile Market Intrducing farmers markets and mbile prduce markets int the cmmunity is a public health strategy t imprve fruit and vegetable cnsumptin within neighbrhds where supermarkets are limited and small grcery stres and/r cnvenience stres sell limited prduce (CDC Fruit and Vegetable Guide, 2011). The GFresh Mbile Market is crdinated by Partners fr a Healthier Cmmunity (PHC) and is verseen by a GFresh leadership team that includes the Directr f Elder Affairs f Springfield, Massachusetts. The GFresh missin is t increase access t fruits and vegetables t Springfield residents, specifically underserved ppulatins including lder adults (Live Well Springfield, 2015). GFresh btains fruits and vegetables frm lcal farms, and accepts SNAP and EBT benefits. The GFresh truck brings fresh fruits and vegetables t lcatins thrughut Springfield ver three weekdays and ne weekend day frm July t 53

67 Octber. The lcatins where the GFresh trucks stp include, but are nt limited t, the Springfield City Hall, subsidized husing cmplexes, senir centers, and cmmunity centers. Transprtatin Absence r lack f transprtatin that is reliable can hinder an individual's ability t access healthy fd. Owning a vehicle is a vital individual level determinant f access t healthy fd and adequate nutritin (Tlzman et al., 2014). Having inadequate access t a car results in peple having t rely n public transprtatin and multiple bus rutes, arranging rides with family r relatives, and/r walking. In 2009, the USDA reprted data n time use and travel mde t grcery stres. They cncluded peple living in lwincme areas with limited access spent significantly lnger traveling t a grcery stre cmpared t the natinal average (19.5 minutes in lw incme areas cmpared t 15 minutes natinal average) (USDA, 2009). Fd Availability Fd availability is the physical presence f fd utlets such as fd stres and restaurants. Availability f healthful fd refers t fd being physically present within stres and restaurants, at farmers markets, and in schls and the wrkplace (Bickel et al., 2000). High quality fd refers t fd in fresh cnditin that is nt spiled, cntaminated, r harmful. Affrdability f fd means it is priced lw enugh that it can be purchased and cnsumed regularly by the cnsumer (Bickel et al., 2000). The quantity and quality in which fd is available t peple can impact fd chices and therefre health and verall quality f life (Drewnwski and Specter, 2004; Liese et al., 2007; USDA, 2015). 54

68 Fd Availability Impacts Healthful Fd Cnsumptin Healthful fd availability may have an impact n dietary cnsumptin, and therefre the risk f develping besity and diet-related chrnic disease (Mrland et al., 2002; Liese et al., 2007; Larsn et al., 2009; Wedick et al., 2015). Diets high in fruits and vegetables and lw in sdium and saturated fat are assciated with lwer risk f develping besity and diet-related chrnic disease (Larsn et al., 2009; Wedick et al., 2015). The current recmmendatin is t cnsume at least tw servings f fruit and three servings f vegetables per day, but the majrity f the United States ppulatin is nt reaching the daily recmmendatin (CDC Healthy Peple Targets, 2013). Pr dietary patterns have been assciated with lw area ppulatin density (rural areas), neighbrhd deprivatin, and minrity cmpsitin within the neighbrhd (Larsn et al., 2009). The lcal fd envirnment has an impact n an individual s ability t purchase nutrient dense fd. Fd deserts are areas withut a supermarket (USDA, 2015), and therefre limit healthful fd availability. Supermarkets are knwn t have the mst variety f high dietary quality fds at the lwest cst cmpared t retail and cnvenience fd stres (Larsn et al., 2009). Many neighbrhds d nt have supermarkets within clse range, leaving peple t have t travel far distances t get t the supermarket r t rely n smaller stres within the area fr fd. The cnsequence f lw supermarket access is that residents are mre expsed t energy dense fds frm cnvenience stres and Fast Fd restaurants (Drewnwski and Specter, 2004). A recent study cncluded that living clser t a healthy fd stre was assciated with greater cnsumptin f dietary fiber and fruits and vegetables and that peple wh lived further 55

69 away frm healthful fd stres reprted less dietary fiber cnsumptin (Wedick et al., 2015). Fd quality, pricing, prmtin and prprtin f healthy t unhealthy fd in neighbrhd stres all had an impact n fd purchasing and therefre fd cnsumptin (Olendzki et al., 2015). Research strngly suggests the relatinship between availability f healthful fd and eating behavirs. A study by Larsn, et al (2009) suggested a psitive relatinship between healthful fd availability and eating behavirs, stating that withut nearby availability t healthful fd, individuals had a mre difficult time meeting dietary recmmendatins. Increasing the availability f fresh vegetable variety in lcal fd stres increased vegetable cnsumptin in study based in New Orleans (Bdr et al., 2008). A study analyzing the distributin f fd stres and retailers by neighbrhd financial status and racial segregatin determined pr and minrity neighbrhds did nt have equal access t healthy fd chices. The majrity f fd retailers within pr and minrity neighbrhds were gas statins and cnvenience stres, which d nt ffer healthy fd items. The authrs als cncluded that individuals wh shpped in such neighbrhds spent up t 37% mre mney fr grceries within the lcal fd utlets cmpared t cnsumers wh shp at supermarkets because f the differences in fd cst (Mrland et al, 2002). Cmmunity Nutritin Envirnment Evaluatin Data System (C-NEEDS): An Instrument t Assess the Fd Envirnment Survey instruments have been develped t examine fd availability within a fd envirnment. Cmmunity Nutritin Envirnment Evaluatin Data System (C- 56

70 NEEDS) is a validated instrument develped by Olendzki and clleagues (2015) that identifies fd availability, quality, and nutrient cntent f healthful and less healthful fd ptins within neighbrhds and cmmunities. C-NEEDS was develped t assess the fd envirnment in the Nrtheast regin f the U.S., and was riginally used in Central Massachusetts (Olendzki et al., 2015). C-NEEDS data cllectin aligns with the dietary cmpnents f the Dietary Guidelines fr Americans, which specifically highlights the imprtance f cnsuming high nutrient/lw calrie fds such as vegetables, fruits, and whle grains, which are high in fiber, as well as lw saturated fat cnsumptin. C-NEEDS was adapted frm the Nutritin Envirnment Measures Survey in Stres (NEMS-S) (Glanz et al., 2007). Key mdificatins includes: 1. reginally available fd t the Nrtheast; 2. additin f canned and frzen fd, which is imprtant t lw incme and rural ppulatins; 3. additin f fd cmmn t Latin/Hispanic ppulatin; 4. further assessment f fds with beneficial r detrimental nutrients in regards t cardivascular health and weight such as saturated fat cmpared t unsaturated fats, and the inclusin f micrnutrients and fiber; 5. additin f a survey t be specifically used at Farmer's Markets, whlesale, discunt, and superstres in the areas. Olendzki and clleagues (2015) generated Healthy Fd Availability Index (HFAI) and Unhealthy Fd Availability Index (UFAI) scres fr each stre based n data cllected frm C-NEEDS. HFAI scres range frm 0-33 pints; a higher scre indicates greater availability, variety, and quality f healthy fd. UFAI scre range frm 0-29 pints (0 being the best scre, 29 the wrst). UFAI scres were calculated based n each fd grups lack f nutrients such as refined grains and high sugar, saturated, and 57

71 trans-fat cmpsitins. Scring algrithms are listed in Appendix D and E (Olendzki et al., 2015). NEMS-S is a cmmnly used prtcl t cllect data abut availability, price, and quality f healthy and regular fd ptins within retail fd stres (Glanz et al., 2007). Within the survey are ten fd indicatr categries based n fd prducts that cntribute the mst fat and calries t the American diet, and fds that are mst recmmended fr healthy eating (Glanz et al., 2007). NEMS-S measures the availability, price, and quality f the ten different types f fds within a specific stre (fresh fruit, fresh vegetables, milk, grund beef, ht dgs, frzen dinners, baked gds, beverages (sda/juice), whle grain bread, and baked chips (Glanz et al., 2007). Summary f Current Literature The effect f the fd envirnment n behavirs and verall health f individuals is a primary reasn fr studying the fd envirnment. Understanding the differences in healthful fd availability in neighbrhds is necessary t develp public health plicy and interventins t lessen health inequalities. Access t certain fd utlets such as supermarkets can reduce prevalence f chrnic disease while access t ther utlets such as cnvenience stres and Fast Fd restaurants may increase the risk f chrnic disease due t the energy dense fd availability. 58

72 CHAPTER 3 PURPOSE, OBJECTIVES, RESEARCH QUESTIONS AND SIGNIFICANCE OF THE STUDY Research Purpse The purpse f the current study is t describe the types, variety, and density f fd utlets (i.e., fd stres and restaurants, including mbile vendrs) and t estimate access t a high quality diet fr lder adults in an urban setting. Objectives Objective 1: T determine the types, variety, and density f fd utlets within half-mile radius areas in an urban setting. Objective 2: T estimate access t a high quality diet fr lder adults within halfmile radius areas in an urban setting based n the types, variety and density f fd utlets. Objective 3: T estimate access t a high quality diet fr lder adults within halfmile radius areas in an urban setting based n a cmbinatin f the type, variety, and density f fd utlets plus key envirnmental characteristics (e.g., public transprtatin) that are knwn t act as facilitatrs r barriers f access t a high quality diet fr lder adults. Research Questins Questin 1: What are the types, variety, and density f fd utlets (i.e., fd stres and restaurants, including mbile vendrs) lcated within half-mile radius areas in an urban setting? Questin 2: T what extent des knwing the types, variety, and density f fd 59

73 utlets within a half-mile radius help t estimate access t a high quality diet fr lder adults living in an urban setting? Questin 3: T what extent des cmbining key envirnmental characteristics that are knwn t facilitate access t a high quality diet fr lder adults with the types, variety, and density f fd utlets within a half-mile radius imprve estimates f access t a high quality diet fr lder adults living in urban areas? Significance Older adults are at increased risk f develping a chrnic disease. Lifestyle mdificatins such as cnsuming a high quality diet cnsisting f fruits, vegetables, whle grains, and lean prtein is widely recgnized slutins fr preventing and managing chrnic disease. The current study cntributes t the literature in that it lays the fundatin t estimate access t healthful fds in urban settings that may be used by multiple stakehlders such as Registered Dietitians t guide individuals in making healthful fd chices in urban neighbrhds and cmmunity rganizatins t facilitate envirnmental changes t imprve access t healthful fds in urban settings. 60

74 CHAPTER 4 METHODS Study Lcatin The study was cnducted in Springfield, Massachusetts. Springfield is lcated in Western Massachusetts and is apprximately 33.2 square miles. It is the third largest city in Massachusetts, and is divided int seventeen distinct neighbrhds (Pineer Valley Planning Cmmissin, 2014). Springfield has a diverse ppulatin f apprximately 153,703 residents cnsisting f 38.8% Hispanic r Latin, 36.7% nn-hispanic White, 22.3% Black r African American, 2.4% Asian (1.2% Vietnamese), 0.6% American Indian and Alaska Native, 0.1% Native Hawaiian and Other Pacific Islander, and 4.7% frm Tw r Mre Races (1.5% White and Black r African American; 1.0% White and Sme Other Race) (United States Census Bureau: State and Cunty Quick Facts, 2010). During the study perid, the median husehld incme in Springfield was $34,311 and the unemplyment rate was 8.0% (United States Census Bureau: State and Cunty Quick Facts, 2010). Accrding t the USDA Fd Access Research Atlas, mre than half f Springfield census tracts are cnsidered fd deserts, meaning grcery stre access is ne half mile away, and in many cases mre than ne mile away frm a significant prtin f the ppulatin (USDA ERS-Fd Research Atlas, 2010). Study Area Ratinale The study areas were determined with cmmunity partners, Partners fr a Healthier Cmmunity (PHC) and Elder Affairs, City f Springfield, and were chsen t 61

75 increase the understanding f access t healthful fds within ne half-mile frm the GFresh Mbile Market lcatins. Prir t data cllectin, the addresses f the ten cnfirmed 2015 GFresh sites and three ptential future sites were established by cnsulting PHC, and the GFresh leadership team including the Directr f Elder Affairs f Springfield, Massachusetts. A list f fd stres and restaurants within the half-mile radius f each GFresh site was generated prir t data cllectin using the nline tl Ggle Maps. Ggle Maps is a free, web-based prgram that is easily accessible t the public. By typing in a specific address, the names and lcatins f fd stres and restaurants within the specified area appear n the map. The address f each GFresh site was entered int Ggle Maps. The lcatin f a GFresh site was marked n the map by a red pin lcatin marker. Ggle Maps autmatically identifies stres and restaurants near the selected GFresh lcatin with a blue shpping bag lg (fd stres), and an range frk and knife lg (restaurants). Measuring the distance arund the address was cmpleted by right clicking n the lcatin marker, selecting "measure distance", and then by selecting an area n the map. A path line measuring the distance between the starting pint and end pint was shwn, and the line was adjusted until it reached the distance f 2,640 feet (ne-half mile). The distance was shwn n the line and belw the bx where the address was typed. Once the half-mile path line frm start pint t end pint was established, the "zm-in" feature in the right hand crner was used t examine the individual streets within the half-mile radius in rder t find stres and restaurants. The half-mile endpint marker was dragged 62

76 and adjusted arund the circumference f the GFresh lcatin in rder t capture the stres and restaurants in each f the study areas. Once the list f stres and restaurants was generated based n the infrmatin frm Ggle Maps, surveyrs did a transect walk f each GFresh half-mile radius area t evaluate the fd available within stres and restaurants. Additinal stres and restaurants that were lcated while walking the area but were nt listed n Ggle Maps were evaluated if the stre r restaurant was within the half-mile radius f the GFresh site. Stres and restaurants listed by Ggle Maps but were clsed were nted n the Master list (Appendix A). Justificatin fr using a ne half-mile radius Establishing the distance f a ne half-mile radius was chsen because it is cnsistent with the USDA half-mile lw access definitin fr an urban area (USDA ERS, 2009), the State Indictr Reprt n Fruits and Vegetables (State Indicatr Reprt, 2013), and it prvided a cnsistent unit f measure amng the neighbrhds included in the current study. The GFresh Mbile Market sites are lcated in different neighbrhds within Springfield. We decided t use a half-mile radius because nt all f the Springfield neighbrhds are f equal size. Fr example, Springfield's Suth End neighbrhd is smaller (0.448 square miles) cmpared t Sixteen Acres (7.927 square miles) (City-Data, 2013). Having a cnsistent half-mile radius made the study areas in each neighbrhd mre cmparable. Six f the 13 GFresh sites are lcated within ne f the smaller neighbrhds (less than 1 square mile), and seven f the 13 GFresh sites are in larger neighbrhds (greater than square miles). A half-mile radius is a cnsistent 63

77 measure arund each f the GFresh sites regardless f the size f the neighbrhd, makes each study area cmparable, and is a mre walkable distance. Classifying Fd Outlets Fd utlets were defined as fd stres and restaurants, including mbile vendrs. Fd Stre Classificatin A classificatin chart was develped (Whittingtn, 2013) and adapted fr the current study t categrize each f the stre types (see Figure 4). Appendix B defines each f the stre types. Each stre surveyed in the current study was classified based n the services prvided (Appendix B). Fd stres were defined as stres that sell at least ne canned, frzen, r fresh prduce prduct. This definitin was mdified frm the C-NEEDS definitin (Olendzki et al., 2015), which defined a fd stre as a stre selling at least ne item f fresh prduce year rund. Fr the purpse f the current study, it is imprtant t include canned and frzen prduce because f the similarities in nutrient cntent with fresh prduce. All stres selling canned, frzen, r fresh fruits and vegetables were assessed using C-NEEDS t determine the availability f healthful fd ptins. The amunt f healthful fd available in stres varies by stre type. Supermarkets r large grcery stres usually have a variety fresh, frzen, and/r canned fruits and vegetables, while smaller grcery and cnvenience stres ften times stck little t n fruits and/r vegetables (Mrland et al., 2002; Glanz et al., 2007; Sharkey et al., 2010). Each fd stre surveyed in the current study was classified accrding t the definitins f several studies (Appendix B) (Mrland et al., 2002; Liese et al., 2007). 64

78 65 Figure 4: Classificatin Chart fr Fd Stres (Adapted frm Whittingtn, 2013)

79 Traditinal Stres Traditinal fd stres included supermarkets, grcery stres, and specialty markets. Supermarkets were defined as crprate chain stres that are large in size (>20,000 square feet), prvide a full line f grceries, meat, and prduce, and have at least 2 millin dllars in annual sales. Supermarkets carry apprximately 15,000 items and usually ffer a deli and a bakery (Mrland et al., 2002; Leibtag, 2005). Grcery stres were defined as smaller, nn-crprate wned stres, with sales belw ne millin dllars per year (Mrland et al., 2002). Specialty markets were defined as stres that sell a single fd categry r a stre that specializes in ethnic/internatinal fd (Leibtag, 2005). Specialty stres can be similar t grcery stres because they are smaller in size, are nt identified as chain stres, and are primarily engaged in selling a general line f fd (i.e., fruits, vegetables, prepared meats, fish, and pultry) (Mrland et al., 2002), therefre they were classified as a traditinal fd stre. Fr example, Springfield's Suth End neighbrhd, which was nce heavily ppulated by Italian immigrants wh pened restaurants and fd stres in the late 1800 s thrugh the mid twentieth century (Suth End Business Assciatin), currently has many specialty markets prviding Italian fd staples. Other specialty markets that were surveyed in the current study included an African specialty market. The African market was cnsidered a specialty market because they sld African-specific fds such as specialty nuts, plantains, seafd, and herbs and spices which are nt typically fund in ther fd stres. 66

80 Cnvenience Stres The cnvenience stre classificatin included cnvenience stres and gas statin cnvenience stres. Cnvenience stres were defined as stres with limited selectin and variety f fds, primarily carrying bread, milk, and snack fd items (Sharkey et al., 2010; Whittingtn, 2013). The stres at gas statins typically resemble a cnvenience stre because they prvide a limited selectin and variety f fd. Therefre, stres at gas statins were classified as cnvenience stres (Sharkey et al., 2010; Whittingtn, 2013). Nn-Traditinal Stres Nn-traditinal fd stres included dllar stres and pharmacies (Sharkey et al., 2010). Dllar Stres are small variety stres which sell general merchandise and fd prducts at a very lw price (Leibtag, 2005; Sharkey et al., 2010; Whittingtn, 2013). A pharmacy, typically part f a natinal chain, is a retail shp where medicine and ther items are sld in additin t limited fd items (Sharkey et al., 2010; Whittingtn, 2013). Micrenterprise Stres Micrenterprise retailers include small prduce businesses, farmers' markets, and mbile vendrs (Whittingtn, 2013). Small prduce businesses are small grcery stres that mainly sell fruits and vegetables (Whittingtn, 2013). Farmers Markets are defined as "recurrent rganizatins at fixed lcatins where vendrs sell farm prducts and ther gds" (Gerge et al., 2011). Mbile vendrs cnsist f carts, trucks, and radside stands which sell fd. Mbile vendrs are cnsidered a type f fd stre and restaurant, and are classified based n what they sell. Mbile vendrs such as mbile prduce markets, which sell fresh prduce fr purchase, wuld be classified as a fd stre (Tester et al., 2010). 67

81 Restaurant Classificatin Each restaurant surveyed in the current study was classified accrding t the services prvided. A classificatin chart was develped t categrize each f the restaurants (see Figure 5). Appendix C defines each type f restaurant accrding t the C- NEEDS Restaurant evaluatin manual (Olendzki et al., 2012). Figure 5 Classificatin Chart fr Restaurants Sit Dwn Fast Casual Fast Fd Mbile Vendr Sit-Dwn Restaurants were defined as a restaurant which ffers table service with wait staff wh takes a persn s rder at the table. Fast casual restaurants are similar t Fast Fd restaurants but typically have higher quality fd with less frzen and prcessed ingredients. Fast casual restaurants typically d nt ffer full table service; custmers generally rder and pay at the cunter, and fd is brught t the table t eat in the restaurant r taken with the cstumer t eat elsewhere. T be classified as Fast Fd, restaurants had t meet ne r mre f the fllwing criteria: part f a Fast Fd chain r franchise, lcated in fd curt and/r limited t take-ut nly. Mbile vendrs that were classified as restaurants cnsisted f fd trucks, trailers, and wagns that "generally prepare and/r sell fd items and beverages in the street r ther public places using a push-cart, bicycle r van" (Valdez et al., 2012). 68

82 Healthy Fd Availability Assessment Fd Stre Assessment C-NEEDS was selected as the measurement tl t assess fd availability in the Springfield fd envirnment (Appendix F). The C-NEEDS instrument was riginally used and validated in Wrcester, Massachusetts, by Olendzki and clleagues (2015), includes reginally available ppular fds in the Nrtheast regin f the United States, and captures many f the key dietary cmpnents f the 2010 USDA Dietary Guidelines fr Americans (USDA and HHS Dietary Guidelines fr Americans, 2010) (Olendzki et al., 2015; Wedick et al., 2015). Nt all f the DGA fd grups were included n C-NEEDS, therefre, an addendum (Appendix G) was added t include three fd categries: 1) variety f cking ils (e.g., live, vegetable, canla, crn il); 2) fish (i.e., fresh, frzen, canned, and jarred); and 3) prtein alternatives (e.g., tfu, edamame, and sy). Aligning C- NEEDS with the 2010 Dietary Guidelines fr Americans helps C-NEEDS t be mre cmparable t the diet quality indices which assess diet quality f individuals. Surveyrs cllabrated with the C-NEEDS tl develpers frm The University f Massachusetts Medical Schl in Wrcester, Massachusetts ( Surveyrs were trained by the C-NEEDS tl develpers n quality assurance f data cllectin including survey cmpleteness and quality. Surveyrs cmpleted a pretest in a fd stre utside f the study regin prir t cllecting data t ensure reliability between the three surveyrs. Data cllected during the pretest was cmpared and differences were discussed amng the surveyrs t find a cmmn, acceptable 69

83 classificatin fr any fds that were discrdantly classified between. During data cllectin, each surveyr was assigned t and familiar with a specific sectin f the C- NEEDS survey and cmpleted the same sectin f the survey fr every stre t ensure cnsistency. All sectins f the C-NEEDS survey were cmpleted, and if an item n the survey was unavailable, the surveyr indicated it was nt available by circling "N". Althugh the time spent cllecting data in each stre varied based n the size f the stre and the amunt and variety f fd available, the average time spent cllecting data with 2-3 surveyrs in each stre was fifteen minutes. Stres that had less fd and less variety f fd, such as gas statin cnvenience stres, wuld take apprximately five minutes with three surveyrs. A larger stre with mre fd and variety f fd such as a grcery stre r supermarket wuld take up t twenty minutes because they generally had mre f the fd items listed n C-NEEDS. The walking distance between stres was different in each neighbrhd and the ttal amunt f stres in each neighbrhd was mixed, therefre the time t cmplete data cllectin in each neighbrhd varied. By using Ggle Maps, a brief assessment f the area can be cmpleted by lking at the number f stre and restaurants lgs, main rad r highway presence, r if the lcatin is primarily residential r a business district. Residential areas typically had fewer fd stres, but tk lnger t walk the halfmile radius because stres were lcated n side streets instead f the majrity f stres being lcated alng ne main rad. Ttal time cnducting surveys in residential areas was less than business areas, but walking time was higher. The large, verlapping lcatins in the Suth End and Metr Center neighbrhds in Dwntwn Springfield required 70

84 apprximately tw t three hurs n fur separate trips t cmplete C-NEEDS due t the higher number f stres. Appendix A includes the apprximate time spent in each f the study areas during data cllectin. Restaurant Assessment The C-NEEDS-Restaurant and Other Eating Places (C-NEEDS-R) tl was selected as the measurement tl t assess fd availability in restaurants. The C- NEEDS-R instrument was riginally used in Wrcester, Massachusetts, by Olendzki and clleagues (2015). C-NEEDS-R includes three sectins; an Internet/Online evaluatin, a Site Visit, and a Menu and Nutritin Assessment (Olendzki et al., 2012). Fr purpses f the current study, nly Questin 3 n the Site Visit frm was cmpleted t determine type f service and was used t classify the type f restaurant. The excluded C-NEEDS-R items did nt assess healthful fd availability. Data Cllectin fr Fd Stres and Restaurants Over ne mnth perid, between April 15 and May 21, 2015, we apprached all f the fd utlets in the study areas. We cmpleted a C-NEEDS survey fr every stre that we received cnsent frm by a stre manager. If the surveyrs were denied by a manager/wner r if there was a language barrier, a survey was nt cmpleted fr the stre (n=4). Surveyrs btained a menu frm each restaurant, r if the restaurant did nt have a menu available, the menu was retrieved frm the restaurant's website. Data cllectin was cmpleted Mnday thrugh Friday between the hurs f 9:30AM and 5:30 P.M. 71

85 In ttal we cmpleted surveys fr 43 fd stres lcated in the thirteen study areas including ne supermarket, five grcery stres, 15 cnvenience stres, 12 gas statin cnvenience stres, fur pharmacies, ne dllar stre, fur specialty markets, and ne small prduce business with the C-NEEDS survey. Nne f the study areas had a Farmers Market in peratin during the time the survey was cnducted. We surveyed 52 restaurants including 23 sit dwn, 14 fast casual, 14 fast fd restaurants and ne fd truck. Appendix A lists the stres and restaurants lcated within their respective half-mile radius area(s). Envirnmental Assessment Identificatin f key envirnmental characteristics which act as facilitatrs r barriers t healthful fd access was cmpleted. Envirnmental characteristics including availability f public transprtatin, availability f sidewalks, presence f a majr intersectin and/r highways, walkability f the area, the quality f fresh prduce in stres, and absence f fd utlets were studied. Assessing public transprtatin availability was determined by Ggle Maps (blue bus icn n the map) and by cnsulting the Pineer Valley Transit Authrity website. Sidewalk availability was determined during transect walks. The quality f fresh prduce sld in stres was determined when the C-NEEDS assessment was cmpleted in each stre. Majr intersectins and highways were cnsidered because they can hinder the ability t access fd if an individual can nly access the fd by walking t utlets (Blck et al., 2004). Majr intersectins and highway presence were determined thrugh Ggle maps and during the transect walk. 72

86 Alng with the assessment f sidewalk availability, assessment f the half-mile radius area walkability was needed. The cmpany Walk Scre creates a walkability scre fr any address by analyzing hundreds f walking rutes t nearby amenities including stres and restaurants. Pints are given based n the distance t amenities in varius categries. Amenities within 0.25 miles (apprximately a five minute walk) are given maximum pints and 0 pints are given after a 30 minute walk. The scre als factrs in ppulatin density within the census tract in which the address is lcated and rad metrics such as blck length and intersectin density. Data surces used t calculate scres include Ggle and the U.S. Census (Walk Scre, 2015). Scres range 0-100; walk scres between 0-50 indicate car dependent areas, indicate smewhat walkable areas, are very walkable areas, and means n car is required fr the area (Walk Scre, 2015). Quality f fruits and vegetables was determined fr fresh prduce nly and was described as acceptable r unacceptable. The quality rating was based n the majrity (50%) f the prduce. Acceptable quality was defined as "peak cnditin, tp quality, gd clr, fresh, firm, and clean," and unacceptable quality was defined as being "bruised, ld lking, mushy, dry, verripe, dark sunken spts in irregular patches r cracked r brken surfaces, signs f shriveling, mld r excessive sftening" (Olendzki et al., 2012). Every half-mile radius area was evaluated based n whether r nt they had fd utlets available. Absence f fd utlets was cnsidered a barrier t fd access. 73

87 Statistical Analysis A ttal f 95 fd utlets were evaluated in the current study. Stres were excluded if there were n canned, frzen, r fresh fruits and vegetables fr sale (n=4). Restaurants were excluded if there was n menu available nline r fr take away (n=2), r if the menu was in anther language r gave minimal descriptin abut fd preparatin (n=2). Objective 1: T determine the types, variety, and density f fd utlets within half-mile radius areas in an urban setting. We cunted the number f different stre types (e.g., supermarkets, grcery, specialty markets, cnvenience stres, gas statin cnvenience stres, dllar stres, pharmacies, and small prduce businesses) and restaurant types (e.g., sit dwn, fast casual, Fast Fd, and fd trucks). Knwing the types f utlets available in a specific area can help estimate access t a high quality diet because healthful fd availability varies by stre type (Mrland et al., 2002; Glanz et al., 2007; Sharkey et al., 2010). We determined the variety f fd utlets within a half-mile radius by summing the number f different types f stres, the number f different types f restaurants, and the number f different stre types plus the number f different restaurant types in a specific half-mile radius area. We calculated the density f healthful fd availability within each half-mile radius area as a rati f the number f healthful fd utlets divided by the ttal number f fd utlets within the half-mile radius area. Fd utlets were classified as healthful and unhealthful based n the average healthful fd availability fund in stres which is described belw. 74

88 Each fd utlet type was given an "Average Healthful Fd Availability" (AHFA) scre based n the amunt f healthful fd items available. In rder t assign an AHFA scre t each fd utlet type, the average number f healthful fd items available within each stre type and restaurant type was determined by C-NEEDS and menu evaluatin. We als used the 2010 DGA and DGAI-2010 Fd Intake sub scre t categrize healthful fd items fr bth stres and restaurants. The Fd Intake sub scre cntains 11 Fd Grup categries, tw Variety categries, and ne Empty calrie categry. Table 3 illustrates the healthful fd items reflected n C-NEEDS and their respective 2010 DGA fd grup. Healthful fd items in restaurants were als categrized int their 2010 DGA fd grups. 75

89 Table 3: Healthful Fd Availability in Stres Based n the 2010 Dietary Guidelines fr Americans (DGA) fd grups and C-NEEDS. C-NEEDS fd items Fd grup Categry (Give ne pint fr each fd item available in the stre) Apples, bananas, cantalupe, grapes, navel ranges, peaches, berries, raisins, watermeln, pears, avcad, any canned fruit in 100% juice, frzen berries (n sugar 1. Fruits added), frzen mixed fruit (n sugar added), 100% (Max pints: 15) range juice. Brccli (fresh, frzen, frzen with cheese), spinach 2. Dark green vegetables (fresh, frzen, frzen with cheese), Green leaf lettuce (Max pints: 7) such as rmaine. 3. Red, range vegetables Tmates and carrts (fresh, frzen, and canned). (Max pints: 4) 4. Legumes Kidney beans, black beans, chickpeas, edemame. (Max pints: 4) 5. Other vegetables Green beans (frzen, canned), pepper, celery, cabbage, (Max pints: 8) cauliflwer, cucumbers, mixed vegetables (frzen). 6. Starchy vegetables (Max pints: 5) 7. Whle grains (Max pints: 5) 8. Milk and milk prducts (Max pints: 11) 9. Seafd (Max pints: 3) 10. Meat, pultry (Max pints: 4) 11. Nuts, seeds, sy (Max pints: 4) 12. Fruit and vegetable variety (Max pints: 43) 13. Prtein variety (Max pints: 15) 14. Empty Calries (Added Sugar) (Max pints: 1) Ttal healthful fd availability Canned crn, canned peas, frzen crn, frzen crn with butter, frzen green peas. 100% whle-wheat bread, whle-grain cereals (plain cheeris and tasted at cereal with <7g sugar and 5g Fiber), whle grain spaghetti, and brwn rice. Skim milk, 1% milk, fat free frzen ygurt, nn fat plain ygurt, reduced fat plain ygurt, nn fat flavred ygurt, reduced fat flavred ygurt, fat free cttage cheese, reduced fat cttage cheese, fat free cheddar cheese, reduced fat cheddar cheese. Canned, fresh, frzen. Lean ht dgs, lean grund beef, grund chicken (lean), and grund turkey extra lean. Almnds unsalted, almnds salted, peanuts unsalted, peanuts salted. Fruit categry, all vegetable categries, and legumes cmbined. Seafd, meat, pultry, nuts, seeds, sy, and legumes cmbined. Sugar Sweetened Beverages (juice, sda, ice tea, sprts drinks, energy drinks): Reverse scring 1 pt fr n sugar sweetened beverages available; 0.5 pints if the stre had 1-3 available; 0 pints if the stre had 4+ sugar sweetened beverages available. 129 ttal healthful fd items 76

90 Fd Stre Scring A ttal f 129 healthful fd items were included n C-NEEDS. Each f the healthy items n C-NEEDS was assigned t its apprpriate 2010 DGA fd grup categry. A pint was given fr each healthful fd item available within the stre. A maximum scre fr each fd grup was calculated based n the ttal number f C- NEEDS fd items in that categry. Fr example, C-NEEDS cllects infrmatin n 15 varieties f fruits, therefre the maximum scre fr the fruit fd grup wuld be 15. Stres were gruped tgether by type t calculate an AHFA scre. Scring fr each stre type was as fllws. The average availability fr every sub scre (e.g., fd grup, variety categry, and empty calrie categry) was calculated. Then, the average scre f every sub scre was added tgether t get a ttal scre. The ttal scre was divided by 129 t calculate the percentage f healthful fd available. An AHFA scre was assigned t each stre type based n the percentage f healthful fd available. AHFA scring ranges frm 0-7. A scre f zer signifies n healthful fd items were available in the stre and 7 signifies nearly all healthful fd items were available in the stre (85% r mre). Fr the current study, a scre f 4 r higher was cnsidered a healthful fd utlet r "facilitatr". Fd stre scring is summarized in Table 4. 77

91 Table 4: Average Healthful Fd Availability (AHFA) Scring fr Fd Stres Percentage f healthful fd AHFA available Scre % % % % % % % 1 N healthful fd items available 0 Restaurant Scring We evaluated every restaurant menu, specifically lking fr fd items included in the 2010 DGA and DGAI-2010 Fd Intake sub scre categries. We cmbined all vegetable categries (dark green vegetables, red/range, starchy, and ther vegetables) int ne general vegetable categry. Healthful fd items n were assigned t their apprpriate 2010 DGA sub scre categry (e.g., fd grup categry, variety categry, r empty calrie categry) if they met the criteria. If a menu described fd items and/r preparatin methds in a different language, the restaurant was excluded frm the study. If fd preparatin was nt described n the menu fr the fd item, the fd item was nt cunted. If fds were part f a dish but nt the main fd item, it was nt cunted. An example f a fd item that wuld nt cunt wuld be vegetables that were part f a casserle. Decisins n fd 78

92 inclusin were based n C-NEEDS (Olendzki et al., 2012) and NEMS ratinale (Glanz et al., 2007). Fruits were cnsidered if they were sld alne as a fruit salad r as a side f fruit. Fruit tppings n salads, pizza, r breakfast items were nt included. Any fruit with added sugar described in the preparatin methd was nt included. Vegetables were nly cnsidered if they were steamed, biled, baked, r grilled. If the menu descriptin described vegetables in a cream sauce, sautéed in butter, r fried, they were nt included. Vegetables at Chinese restaurants were nt cnsidered as a healthful fd item unless they were listed n the menu under the "healthy ptins" categry, which nted that the vegetables were steamed with n il/sauce. Salads were cnsidered vegetables nly if the menu specified that the lettuce was rmaine, kale, field greens, mixed greens, r arugula. Salads made with iceberg lettuce were nt included. Legumes were cunted if they were the main fd item f the dish and did nt have any added fat such as cream r butter. Milk and ygurt were cnsidered if the menu specified that it was 1% milk, lw fat, r nn-fat. Whle grain items such as 100% whle wheat bread and wraps, brwn rice, and atmeal were included. Fr seafd, meat, and pultry, nly menu items specifying that they were grilled, baked, rasted r briled were cnsidered. If they were fried r part f a dish with a cream sauce r butter, they were nt included. T be cnsistent with fd stre data cllectin, we did nt cllect infrmatin abut eggs. Restaurants were gruped tgether by type in rder t calculate an AHFA scre. The average availability f every sub scre was calculated. Then, the sum f the averages was calculated t get a ttal number f healthful fd available. One pint was subtracted 79

93 frm the ttal scre if the majrity f beverages sld were sugar sweetened. Similar t fd stres, AHFA scres ranged frm 0-7. A minimum scre f zer signified n healthful fd was available and a maximum scre f 7 signified mre than 60 menu items were classified as healthful. An AHFA scre f 4 r higher was cnsidered a "healthful fd utlet." Scring cutffs are summarized in Table 5. Table 5: Average Healthful Fd Availability (AHFA) Scring fr Restaurants Average number f healthful fd AHFA items available within restaurants Scre > N healthful fd items available 0 Objective 2: T estimate access t a high quality diet fr lder adults within halfmile radius areas in an urban setting based n the types, variety and density f fd utlets. A Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) algrithm was created t estimate access t a high quality diet fr each f the half-mile radius areas. DGAIFE scres were based n scres f the fd utlet types and the ttal number f healthful fd utlets available within the half-mile radius areas (Figure 6). 80

94 Based n the AHFA scres fr each fd utlet type, a sum f scres fr each stre type within the half-mile radius plus the sum f scres fr each restaurant type within the half-mile radius were added tgether. The added sums were divided by the sum f the facilitatrs (healthful fd utlets) within the half-radius. DGAIFE scres range frm A scre f 1.00 signifies that 100% f the fd utlets within the half-mile radius area are cnsidered healthful. A high DGAIFE scre (5.00) means fewer healthful fd utlets were available within the half-mile radius, reflecting lw access t a high quality diet, while a lwer scre, clse t 1.00, means higher availability f healthful fd utlets within the half-mile radius and reflects higher access t a high quality diet. If there were n healthful fd utlets within a half-mile radius, the area received the wrse pssible scre f 0.00, and if there were n fd utlets within a halfmile radius area, a scre was nt cmpleted (N/A). Figure 6 shws the algrithm equatin based n eight fd stres types and fur restaurants types. Figure 6 Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) Algrithm Objective 3: T estimate access t a high quality diet fr lder adults within halfmile radius areas in an urban setting based n a cmbinatin f the type, variety, and density f fd utlets plus key envirnmental characteristics (e.g., public transprtatin) that are knwn t act as facilitatrs r barriers f access t a high quality diet fr lder adults. 81

95 A Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) algrithm was created. Using the riginal DGAIFE algrithm that estimates access t a high quality diet based n the type, variety, and density f fd utlets within a half-mile radius, we included key envirnmental characteristics including public transprtatin access, sidewalk availability, presence f majr intersectins and highways, Walk Scre, quality f fresh prduce in sld in stres, and absence f fd utlets t estimate access t a high quality diet. Envirnmental characteristics were given pints based n if it was a facilitatr r barrier t healthful fd access. Public transprtatin availability within half-mile radius areas was +1 pint and sidewalk availability within the majrity f the half-mile radius area was given +1 pint. Presence f a majr intersectin(s) and/r highways within a half-mile radius areas can hinder the ability t walk t purchase fd, therefre -1 pint was given t areas with a majr intersectin r highway. If the study area received a Walk Scre ranging frm , +1 pint was given, while study areas with Walk Scres ranging frm received zer pints, and less than 50 received -1 pint. Acceptable quality f prduce sld in the majrity (50%) f stres within the half-mile radius area was +1 pint. If there were n fd utlets lcated within a half-mile radius area, the area received -1 pint. DGAIFEC scres range frm A scre f 1.00 signifies that 100% f the fd utlets within the half-mile radius area are cnsidered healthful. A DGAIFEC clse t 5.00 means less healthful fd utlets and less envirnmental facilitatrs available within the half-mile radius, reflecting lw access t healthful fd. A lwer DGAIFEC scre, clse t 1.00, means mre healthful fd utlets and envirnmental 82

96 facilitatrs were available within the half-mile radius, reflecting higher access t a high quality diet. If there were n fd utlets within a half-mile radius area, a scre was nt cmpleted (N/A), reflecting n access t a high quality diet. Figure 7 shws the algrithm based n eight fd stres types, fur restaurants types, and six key envirnmental characteristics which culd be facilitatrs r barriers t healthful fd access. T calculate a DGAIFEC scre fr each half-mile radius, the sum f scres fr fd utlet types plus the sum f scres fr envirnmental factrs (facilitatrs and barriers) was divided by the sum f scres f healthful fd utlets plus the sum f scres f envirnmental facilitatrs. Figure 7: Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) Algrithm 83

97 CHAPTER 5 RESULTS Fd utlet Types, Variety, and Density A ttal f 87 fd utlets were included in the analysis fr the current study (39 stres, 48 restaurants). Stre types included ne supermarket, five grcery stres, ne specialty market, 15 cnvenience stres, 11 gas statin cnvenience stres, ne dllar stre, fur pharmacies, and ne small prduce business. Restaurant types included 22 sit dwn restaurants, 12 fast casual restaurants, 13 Fast Fd restaurants and ne fd truck. On average, there were five fd utlet varieties amng the 13 half-mile radius areas. Tw f the study areas lcated in Springfield's Metr Center had a maximum f nine varieties f fd utlets, while ne study area lcated in Springfield's Sixteen Acres neighbrhd had zer varieties f fd utlets. The fd utlet type, variety, and density fr each half-mile radius area studied is summarized in Table 6. The average healthful fd utlet density scre fr the half-mile radius areas was In all, 38% f the study areas had a density scre f r higher. Only 15% f study areas had a density scre f r higher, all f which were lcated in Springfield's Metr Center neighbrhd. Three f the 13 half-mile radius areas had n healthful fd utlets; therefre, their density scres were One f the 13 half-mile radius areas, a ptential future GFresh site lcated in Springfield's Sixteen Acres neighbrhd, was unable t be calculated because there were n fd utlets. 84

98 85 Table 6: Fd utlet Type, Variety, and Density fr each Half-Mile Radius Area GFresh Half- mile Radius Area 1. Gentile Apartments 31 utlets ttal 2. Caring Health Center 28 utlets ttal 3. Curt Square 31 utlets ttal 4. Saab Curt 17 utlets ttal 5. Linden Twers 6 utlets ttal 6. Baystate Place 8 utlets ttal Types f Fd Stres (Blded stre types are cnsidered "healthful") 1 Small Prduce Business 2 Grcery Stres 5 Cnvenience Stres 3 Gas Statin Cnvenience Stres 4 Specialty Markets 2 Grcery 2 Cnvenience Stres 4 Specialty Markets 1 Gas Statin Cnvenience Stres 1 Pharmacy 1 Grcery 2 Cnvenience Stres 1 Gas Statin Cnvenience Stres 4 Specialty Markets 1 Pharmacy 1 Grcery 3 Cnvenience Stres 2 Gas Statin Cnvenience Stres 4 Cnvenience Stres 2 Gas Statin Cnvenience Stres 5 Cnvenience Stres 2 Gas Statin Cnvenience Stres Types f Restaurants (Blded restaurant types are cnsidered "healthful") 8 Sit Dwn 3 Fast Casual 5 Fast Fd Variety f Fd Outlets 5 varieties f fd stres 3 varieties f restaurants 8 ttal fd utlet varieties 9 Sit Dwn 5 varieties f 4 Fast Casual fd stres 4 Fast Fd 4 varieties f 1 Fd Truck restaurants 9 ttal fd utlet varieties 11 Sit Dwn 5 varieties f 7 Fast Casual fd stres 3 Fast Fd 4 varieties f 1 Fd Truck restaurants 9 ttal fd utlet varieties 6 Sit Dwn 3 varieties f 4 Fast Casual fd stres 1 Fast Fd 3 varieties f restaurants 6 ttal fd utlet varieties Nne 2 varieties f fd stres 2 ttal fd utlet varieties 1 Fast Fd 2 varieties f fd stres 1 variety f restaurants 3 ttal fd utlet varieties Density (Healthful stres+ restaurants/ ttal utlets) (3+11)/ (2+13)/ (1+18)/ (1+10)/

99 86 7. Independence Huse 1 utlet ttal Nne 1 Fast Fd 1 variety f restaurants 1 ttal fd utlet varieties Cld Cncepcin Cmmunity Center 12 utlets ttal 9. Springfield Technical Cmmunity Cllege (STCC) 11 utlets ttal 10. East Springfield Public Library 14 utlets ttal 11. Rbinsn Gardens 6 utlets ttal 12. Clnial Estates 0 stres, 0 restaurants 13. Outing Park Apartments cmmunity ffices Suth End 29 utlets ttal 1 Supermarket 1 Gas Statin Cnvenience Stre 2 Pharmacies 1 Dllar Stre 1 Sit Dwn 2 Fast Casual 4 Fast Fd 4 varieties f fd stres 3 varieties f restaurants 7 ttal fd utlet varieties (1+3)/ Grcery 1 Fast Casual 4 varieties f (3+1)/11 1 Cnvenience Stre 3 Fast Fd fd stres 2 Gas Statin Cnvenience Stres 2 varieties f restaurants Pharmacy 6 ttal fd utlet varieties 1 Cnvenience Stre 3 Sit Dwn 2 varieties f 8/14 1 Gas Statin Cnvenience 5 Fast Casual fd stres Stre 3 Fast Fd 3 varieties f restaurants 7 ttal fd utlet varieties 2 Cnvenience Stres 3 Sit Dwn 2 varieties f 3/6 1 Gas Statin Cnvenience fd stres Stre 1 variety f restaurants 3 ttal fd utlet varieties Nne Nne N/A N/A 1 Small Prduce Business 2 Grcery Stres 5 Cnvenience Stres 4 Gas Statin Cnvenience Stres 4 Specialty Markets 7 Sit Dwn 1 Fast Casual 5 Fast Fd 5 varieties f fd stres 3 varieties f restaurants 8 ttal fd utlet varieties (3+8)/

100 Healthful Fd Availability in Fd Outlets A maximum f 129 healthful fd items were cllected frm C-NEEDS. Based n the AHFA scring, supermarkets scred a 7, grcery stres and small prduce businesses scred a 4, cnvenience stres and dllar stres scred a 3, and gas statin cnvenience stres, pharmacies, and specialty markets scred a 2. Table 7 summarizes the average availability f healthful fd in fd stres based n the 2010 DGA fd grups. The supermarket evaluated in the current study sld a majrity f the healthful fd items included n C-NEEDS. The fd grups that did nt meet 100% f the C- NEEDS criteria based n the 2010 DGA sub scres were milk (64%), lean meat/pultry (75%), and empty calries. The supermarket did nt meet the "healthful" criteria fr empty calries because a large selectin f sugar sweetened beverages were sld. Althugh supermarkets ffered the mst healthful fd ptins cmpared t any ther stre type, they als ffered a large quantity f unhealthful fd items. On average, grcery stres sld abut half f the healthful fd items included n C-NEEDS (47%). Grcery stres were cnsidered t be healthful fd utlets because they typically sld a majrity f the seafd (60%), fruits and vegetables (53%), and nuts, seeds, sy prducts (50%) included n C-NEEDS. Lean meat and pultry were generally nt sld in grcery stres, as they were nly fund 10% f the time. The nly specialty market that sld fruits and vegetables was the African market, where 17% f the C-NEEDS items were sld in the stre, and nly 14% f the items available were fruits and vegetables. A majrity f the seafd n C-NEEDS was sld at the market (67%). Specialty markets were nt cnsidered t be healthful fd utlets. 87

101 Cnvenience stres were nt cnsidered t be healthful fd utlets, but sld a prtin f the healthful fd items included n C-NEEDS (25%). Legumes were fund mre than any ther healthful fd item (65%), fllwed by nuts, seeds, and sy prducts (40%). On average, nly 27% f the fruits and vegetables and 8% f lean meat and pultry items cllected n C-NEEDS were fund in cnvenience stres. Gas statin cnvenience stres were nt cnsidered healthful fd utlets, as they prvided 19% f the healthful fd items n C-NEEDS. Nuts, seeds, and sy fds included n C-NEEDS were fund the mst ften (68%) in gas statin cnvenience stres, fllwed by whle grains (28%). 16% f the fruits and vegetables and 8% f lean meat and pultry items were available in gas statin cnvenience stres. The ne dllar stre examined in the study sld 25% f healthful fd items n C- NEEDS and sld 100% f the nuts, seeds, and sy prducts. 19% f the fruits and vegetables were sld and n dark green vegetables were available. Lean meat and pultry were als unavailable t purchase. Dllar stres were nt cnsidered a healthful fd utlet. On average, pharmacies sld 20% f the healthful fd items n C-NEEDS, but were nt cnsidered healthful fd utlets. Nuts, seeds, and sy items were available mre than any f the ther healthful fd items (95%), fllwed by whle grains (46%). 13% f the fruit and vegetables were sld at pharmacies, but n dark green r red/range vegetables were available. The small prduce business was cnsidered a healthful fd utlet and cntained almst half f the items n C-NEEDS (48%). The large varieties f prduce available in the stre were fresh, but n canned r frzen items were available, which explains why 88

102 nly 56% f the fruits and vegetables cllected frm C-NEEDS were available. 100% f the nuts, seeds, and sy prducts were available in the stre. 20% f the whle grain prducts included n C-NEEDS were available. Seafd, lean meat, and pultry were nt available t purchase at the small prduce business stre. A deli with prepared fd items was lcated in the stre but analysis f the prepared fd was nt cmpleted. 89

103 82 Table 7: Average Healthful Fd Availability by 2010 DGA fd grup and percentage f Healthful Fd Availability fr each Stre Type based n C-NEEDS Fd grup categry Ma x S Avg % G Av g % C Avg % Cgas Avg % Phar m Avg. % D Avg % SP B Avg % S M Av g Fruits % 7 47% % % % 3 20% 11 73% 1 7% Dark green % % % 0.3 4% 0.0 0% 0 0% 3 43% 0 0% vegetables Red, range % % % % 0.0 0% 1 25% 2 50% 1 25% vegetables Legumes % 3 75% % % 0.3 8% 1 25% 3 75% 2 50% Other vegetables % 5 63% % % % 1 13% 5 63% 2 25% Starchy vegetables % % % % % 2 40% 0 0% 0 0% Whle grains % % % % % 2 40% 1 20% 1 20% Milk and milk % % % % % 1 9% 2 18% 0 0% prducts Seafd % % % % % 2 67% 0 0% 2 67% Meat, pultry, eggs % % 0.3 8% 0.3 8% 0.3 8% 0 0% 0 0% 0 0% Nuts, seeds, sy % 2 50% % % % % % % Fruit and veg % 23 53% % % % 8 19% 24 56% 6 14% variety Prtein variety % % % % 5 33% 7 47% 7 47% 5 33% Empty Calries 1 0 0% % 0.0 0% 0 0% 0 0% 0 0% 0 0% % Ttal % f healthful fd 95% 47 available % % 19% 20% 25 % Max= Maximum scre fr each fd grup categry based n C-NEEDS Pharm= Pharmacy S=Supermarket D= Dllar Stre G=Grcery SPB= Small Prduce Business C=Cnvenience SM= Specialty Market Cgas=Gas statin cnvenience stres 48 % 17 % %

104 Based n the AHFA scring fr restaurant types, fast casual restaurants scred a 5 and sit dwn restaurants scred a 4; therefre, they were bth cnsidered healthful fd utlets. Fast Fd restaurants and fd trucks scred a 2 and were nt cnsidered t be healthful fd utlets. The average number f healthful fd items available at each restaurant was 40.0 (sit dwn), 42.7 (fast casual), 19.4 (Fast Fd), and 17.0 (fd trucks). One fd truck was included in the study, and it nly had six fd items t evaluate. On average, sit dwn restaurants had the highest ffering f legumes (0.91 menu items), whle grains (0.95 menu items), seafd (6.5 menu items), and prtein variety (12.4 menu items). Fast casual restaurants had the highest average fr vegetables (9.3 menu items), lean meat/pultry (9.1 menu items), and fruit and vegetable variety (9.8 menu items). Fast Fd restaurants n average had the mst fruit (0.8 menu items) and lw-fat milk (1.1 menu items) ptins available. The fd truck scred the highest in the empty calries categry because sft drinks r sweetened beverages were nt ffered. Table 8 summarizes the average number f healthful fd items in each restaurant type. 91

105 Table 8: Average number f Healthful Fd Items in Restaurants Fd Categry Sit Dwn Fast Casual Fast Fd Fd Truck Fruit (Nt as a tpping r part f a dish; fruit cup, side f fruit) * Vegetables (Nn fried, n fat added; include salad if it's nt iceberg lettuce) Legumes (Kidney beans, black beans, chickpeas, edemame, lentils) * Whle grains 100% whle-wheat bread, brwn rice, atmeal * Milk (All milks, ygurts; nn-fat r lwfat/1%) * Nuts, seeds, sy 0.00* 0.00* 0.00* 0.00* Seafd (Grilled, baked, steamed, n fat added) * Meat, pultry (Grilled, baked, rasted, briled, n fat added) Fruit and veg. variety Prtein variety Empty Calries 0.00* * 1.00 Ttal Ttal after empty calrie deductin/additin *Nt available Estimating Access t a High Quality Diet based n Fd Outlets The average DGAIFE scre was Half-mile radius areas that had zer fd utlets (n=1) r zer healthful fd utlets (n=3) were nt included in the average. Adding a scre f 0.00 wuld falsely lwer the DGAIFE average t be clser t a perfect scre f Fur f the half-mile radius lcatins were nt included. The best reprted 92

106 DGAIFE scre was lcated in Springfield's Suth End Neighbrhd (1.53). The wrst scre was lcated in Springfield's Pine Pint neighbrhd (2.25). A detailed summary f each half-mile radius lcatin and their DGAIFE scre is given in Table 9. Table 9: Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) fr each Half-Mile Radius Area GFresh Half-Mile Radius Areas Neighbrhd DGAIFE Gentile Apartments Suth End 1.53 Caring Health Center Metr Center 2.00 Curt Square Metr Center 2.00 Saab Curt Metr Center 1.54 Linden Twers Liberty Heights 0.00* Baystate Place Liberty Heights 0.00* Independence Huse Pine Pint 0.00* Cld Cncepcin Cmmunity Center Sixteen Acres 1.56 Springfield Technical Cmmunity Cllege McKnight 2.00 East Springfield Library East Springfield 1.78 Rbinsn Gardens Pine Pint 2.25 Clnial Estates Sixteen Acres - - Outing Park Apartments Cmmunity Offices Suth End 1.53 Average DGAIFE scre 1.80 DGAIFE Scres range frm ; 1.00 =100% fd utlets within the half-mile radius are healthful, 5.00=less healthful fd utlets available * N healthful fd stres available in the half-mile radius area - - N fd utlets available in the half-mile radius area; a DGAIFE scre was nt calculated Estimating Access t a High Quality Diet with Key Envirnmental Characteristics Table 10 defines the key envirnmental characteristics analyzed fr the current study. All half-mile radius areas had at least ne bus rute and sidewalks. Sixty nine percent f the study areas cntained a majr intersectin r highway. Presence f a majr intersectin r highway culd affect shppers ability t walk t fd utlets because having t crss a busy rad may nt be appealing, especially fr lder 93

107 adults. Interstate-91 (I-91) runs alngside Springfield's dwntwn area (Suth End and Metr Center) and parts f Liberty Heights. I-91 was lcated in five f the 13 half-mile radius areas. Interstate 291 (I-291) is lcated in fur f the half-mile radius areas. I-291 runs directly thrugh the middle f Springfield's Metr Center and Liberty Heights neighbrhds, which culd bstruct residents' ability t walk t fd utlets. Massachusetts State highways Rute 20 and 20A are majr highways bth lcated in Springfield's Metr Center, Liberty Heights, and East Springfield neighbrhds. If residents were t walk t fd utlets, they wuld have t crss the busy highway, which may nt be favrable. The Sixteen Acres neighbrhd did nt have a majr highway, but ne f the half-mile radius areas within Sixteen Acres did have a majr intersectin with heavy traffic, making it a challenge t walk t fd utlets. The nly Springfield neighbrhds in the study that were nt affected by a majr intersectin r highway were the Pine Pint and McKnight neighbrhds, where three f the 13 half-mile radius areas were lcated. Frty six percent f the study areas scred 70 r greater n Walk Scre, meaning the area was "very walkable" (Walk Scre, 2015). Only ne half-mile radius area scred 90 r higher, indicating n car is required t access nearby amenities. The lwest scring areas were lcated in Springfield's Sixteen Acres and Pine Pint neighbrhds. Tw f the 13 half-mile radius areas were cnsidered t be areas that were "car dependent" in rder t access nearby amenities (Walk Scre, 2015). Sixty seven percent f the fd stres evaluated sld fresh prduce. Only tw f the stres that sld fresh fruits and vegetables had unacceptable quality prduce, while the ther 26 stres prvided acceptable quality prduce. The tw stres that had 94

108 unacceptable quality prduce were stres lcated in areas f verlap, therefre many half-mile radius areas were affected by unacceptable quality prduce. One study area did nt have any fd utlets present, therefre a DGAIFEC scre was nt cmpleted which reflects n access t healthful fds. Table 10 summarizes the half-mile radius areas and the key envirnmental characteristics. 95

109 96 Table 10: Key Envirnmental Characteristics GFresh Half-mile Radius Area Public Transprtatin Available? (Bus rutes) 1. Gentile Apartments Yes (G1, G2, G5, X92) 2. Caring Health Center Yes (G1, G2, G5, X92) 3. Curt Square Yes (G1, G2, G5 X92) 4. Saab Curt Yes (G2, G3, P21) 5. Linden Twers Yes (G2, G3, P21) 6. Baystate Place Yes (B4, G1, G2, P20, P21) 7. Independence Huse Yes (B7, X92) 8. Cld Cncepcin Yes Cmmunity Center (B17, R27) 9. Springfield Technical Cmmunity Cllege (STCC) 10. East Springfield Public Library 11. Rbinsn Gardens Yes (B6) 12. Clnial Estates Yes (B17) 13. Outing Park Apartments cmmunity ffices Suth End Yes (B6, B7, B17, G3, X90) Yes (G2) Yes (G1, G2, X92) Sidewalk Availability Majr Intersectins r Highways Walk Scre (Walk Scre, 2015) % Stres with Acceptable Quality Prduce Yes I % N Yes I % N Yes I % N Yes Rute 20, 20A, I- 291 Yes Rute 20, 20A, I- 291 Yes Rute 20, 20A, I- 291, I % N 62 50% N 71 75% N Yes Nne 34 N/A N Yes Intersectin at Parker and Wilbraham % N Yes Nne % N Yes Rute 20, 20A and % N I-291 Yes Nne % N Yes Nne 20 N/A Yes Yes I % N Absence f Fd utlet

110 The average DGAIFEC scre was The ne study area that did nt have any fd utlets was nt included in the average because adding a scre f 0.00 wuld falsely lwer the DGAIFEC average t be clser t There were three half-mile radius areas that were riginally nt included in DGAIFE scring because all f the areas had n healthful fd utlets, but they were included in DGAIFEC scring because they had envirnmental characteristics which imprved healthful fd access. The DGAIFEC scres fr each f the study areas are summarized in Table 11. The best DGAIFEC scre was 1.38 fr three f the half-mile radius areas. Tw areas were lcated in Springfield's Suth End neighbrhd, and the ther in Metr Center. The wrst scre (2.50) was in Springfield's Liberty Heights neighbrhd. All half-mile radius areas that were riginally included in the DGAIFE scring shwed imprvement in DGAIFEC scres (Table 12). The average DGAIFE scre imprved frm 1.80 t a DGAIFEC scre f Alng with presence f healthful fd stres, the presence f envirnmental facilitatrs including public transprtatin and sidewalk availability, acceptable quality prduce, and high Walk Scres, increased access t a high quality diet. 97

111 Table 11: Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scre fr each Half-Mile Radius Area GFresh Half-Mile Radius Areas Neighbrhd DGAIFEC Gentile Apartments Suth End 1.38 Caring Health Center Metr Center 1.71 Curt Square Metr Center 1.71 Saab Curt Metr Center 1.38 Linden Twers Liberty Heights 2.33 Baystate Place Liberty Heights 2.50 Independence Huse Pine Pint 1.50 Cld Cncepcin Cmmunity Center Sixteen Acres 1.42 Springfield Technical Cmmunity Cllege McKnight 1.69 East Springfield Library East Springfield 1.50 Rbinsn Gardens Pine Pint 1.71 Clnial Estates Sixteen Acres - - Outing Park Apartments Cmmunity Offices Suth End 1.38 Average DGAIFEC scre 1.68 DGAIFEC scres range frm ; 1.00 =100% fd utlets within the half-mile radius are healthful, 5.00=less healthful fd utlets available. - - N fd utlets available in the half-mile radius area; a DGAIFEC scre was nt calculated 98

112 Table 12: Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) scres cmpared t Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scres GFresh Half-Mile Radius Areas Neighbrhd DGAIFE DGAIFEC Gentile Apartments Suth End Caring Health Center Metr Center Curt Square Metr Center Saab Curt Metr Center Linden Twers Liberty Heights 0.00* 2.33 Baystate Place Liberty Heights 0.00* 2.50 Independence Huse Pine Pint 0.00* 1.50 Cld Cncepcin Cmmunity Center Sixteen Acres Springfield Technical Cmmunity Cllege McKnight East Springfield Library East Springfield Rbinsn Gardens Pine Pint Clnial Estates Sixteen Acres Outing Park Apartments Cmmunity Offices Suth End DGAIFE Scres range frm ; 1.00 =100% fd utlets within the half-mile radius are healthful, 5.00=less healthful fd utlets available. DGAIFEC scres range frm ; 1.00 =100% fd utlets within the half-mile radius are healthful, 5.00=less healthful fd utlets available. * N healthful fd stres available in the half-mile radius area - - N fd utlets available in the half-mile radius area; a DGAIFE scre was nt calculated Sme f the data cllected in the current study n healthful fd access was cnsistent with the USDA (USDA ERS- Fd Research Atlas, 2010; Pineer Valley Planning Cmmissin, 2014) fd access infrmatin. Cmparisns f USDA percentage f ppulatin with lw access t fd with DGAIFE and DGAIFEC scres are summarized in Table

113 Table 13: USDA Lw Access t Fd Data cmpared t Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) scres and Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scres % f Ppulatin with lw access t Fd (USDA ERS- Fd GFresh Half- Mile Radius Areas Neighbrhd Research Atlas, 2010; Pineer Valley Planning Cmmissin, 2014) DGAIFE DGAIFEC Gentile Apartments Suth End 0.0% Caring Health Center Metr Center 0.0% Curt Square Metr Center 0.0% Saab Curt Metr Center 0.0% Linden Twers Liberty Heights 0.0% Baystate Place Liberty Heights 0.0% Independence Huse Pine Pint 25.7% Cld Cncepcin Cmmunity Center Sixteen Acres 16.4% Springfield Technical Cmmunity Cllege McKnight 0.0% East Springfield Library East Springfield 14.8% Rbinsn Gardens Pine Pint 25.7% Clnial Estates Sixteen Acres 16.4% Outing Park Apartments Cmmunity Offices Suth End 0.0%

114 CHAPTER 6 DISCUSSION The current study described the types, variety, and density f fd utlets fr each half-mile radius area and estimated access t a high quality diet fr lder adults in an urban setting. Dietary Guidelines fr Americans Adherence Index Fd Envirnment (DGAIFE) scres and Dietary Guidelines fr Americans Adherence Index Fd Envirnment plus Envirnmental Characteristics (DGAIFEC) scres were calculated in rder t estimate access t a high quality diet based n the fd utlet types, variety, and density, and key envirnmental characteristics. We fund that estimating access t a high quality diet is pssible in an urban setting and that healthful fd access was nt equal acrss the thirteen study areas. Our findings suggest that knwledge f the types f fd utlets within study areas and the healthful fd available within the utlets is the best indicatr t estimate access a high quality diet. Adding knwn envirnmental facilitatrs t the DGAIFE algrithm did nt substantially imprve estimates f access t a healthful diet. Supermarkets and grcery stres had a high variety f fruits and vegetables, as bth fd stre types met 100% and 53% f the C-NEEDS fruit and vegetable criteria, respectively. Recent studies have als dcumented higher availability f fruits and vegetables in supermarkets and grcery stres, cmpared t ther fd stre types (Liese et al., 2007; Larsn et al., 2009; Sharkey et al., 2010). It shuld be nted that althugh supermarkets and grcery stres had a large quantity and variety f healthful fd, bth stre types prvided a large quantity f unhealthful fd ptins. Olendzki and clleagues (2015) reprted that unhealthy fd availability was highly crrelated with 101

115 healthy fd availability and that stres that ffered a large variety f healthful fds als ffered a large variety f unhealthful fds. Despite the relatively higher amunts f unhealthful fds fund in supermarkets and grcery stres, peple living in areas with supermarkets and/r grcery stres tend t have healthier fd intakes (Rse & Richards, 2004; Mre et al., 2008; Larsn et al., 2009; Wedick et al., 2015). We fund that lder adults in Springfield, MA have higher access t a high quality diet if they live in areas with supermarkets and grcery stres because, n average, these stre types ffered the majrity f healthful fd items recmmended by the 2010 Dietary Guidelines fr Americans. The majrity f the stres (67%) we surveyed in the study area were either cnvenience stres r gas statin cnvenience stres. Cnvenience stres and gas statin cnvenience stres were nt cnsidered healthful fd utlets because they did nt sell a majrity f the healthful items cllected frm C-NEEDS. This finding is cnsistent with ther studies (Larsn et al., 2009; Olendzki et al., 2015). Liese and clleagues (2007) fund that cnvenience stres were likely t sell less healthful versins f any given fd item such as lw fiber bread (white bread) with few r n healthful alternatives such as whle wheat bread. Lw availability f fruits and vegetables was als reprted (Liese et al., 2007). Sharkey et al., fund that cnvenience stres prvided less fruits and vegetables cmpared t supermarkets and grcery stres (2010). Althugh cnvenience stre did nt sell a high vlume and variety f fruits and vegetables, all cnvenience stres and gas statin cnvenience stres sld at least ne item f fruit. All cnvenience stres sld at least ne type f canned legume (kidney beans, black beans, and/r chick peas), and the majrity sld at least ne type f canned 102

116 r frzen vegetables. Having at least ne canned, frzen, r fresh fruit, vegetable, and/r legume item increased AHFA scres fr stres. Because each f these stre types had at least ne f the mentined items, they scred higher n AHFA scres, making it seem as thugh they prvided healthful fd even thugh the availability f healthful fd was lw. Many f the cnvenience stres advertised that they accepted WIC, which suggests availability f healthful fds. One recent study examining healthful fd ptins in tw lw-incme, urban cmmunities shwed that availability f healthful fd was higher in stres that were WIC authrized (Hillier et al., 2012).Our findings regarding the fd sld in cnvenience stres are infrmative. While fd shpping in cnvenience stres is nt ideal, individuals can purchase a small variety f healthful items at these fd utlets. Sharkey and clleagues als reprted that dllar stres sld a variety f fruits and vegetables cmpared t cnvenience stres (2010), which was incnsistent with the findings frm the current study. Fruit and vegetable variety at dllar stres was lwer (19%) cmpared t cnvenience stres (27%), but higher than gas statin cnvenience stres (16%) and pharmacies (13%). In ur study, an area mstly ppulated with cnvenience stres, gas statin cnvenience stres, dllar stres, and/r pharmacies, had lwer access t a high quality diet, which has als been fund in recent studies (Larsn et al., 2009; Meyer et al., 2015). The small prduce business in the study scred lwer than expected n the percentage f healthful fd availability based n C-NEEDS. The stre nly sld fresh fruits and vegetables and little f the ther healthful fd included n the survey (lean 103

117 meat, seafd, whle grains), leading t a relatively lw AHFA scre. It shuld be nted that the stre had the mst variety and selectin f fruits and vegetables cmpared t any f the fd utlets in the study, but a majrity f the fresh prduce items sld were nt included n C-NEEDS. The stre did nt sell any canned r frzen items, therefre it culd nt fulfill all f the fruit and vegetable items n C-NEEDS. Althugh estimating access t a high quality diet is pssible based n the stre types within an area, it is recmmended that Registered Dietitians ask their clients further questins abut the fd prvided in the stre r abut the characteristics f the stre. Many stres in the current study had names cntaining the wrd "grcery stre" r "supermarket," but did nt belng int that particular categry based n the items sld in the stre r the size f the stre using the criteria frm the literature (Mrland et al., 2002; Liese et al., 2007). If the stres did nt match the classifying definitin f fd retailers (Appendix B), we reclassified accrdingly. Sit dwn restaurants were cnsidered healthful fd utlets in the current study and scred the highest n whle grains, seafd, and prtein variety. Althugh sit dwn restaurants scred the highest cmpared t ther restaurant types n whle grain availability, the average number f whle grains available was 0.95 servings n a pssible range f servings. Recent studies have als fund whle grain availability in restaurants t be minimal (Kirkpatrick et al., 2014). Sit dwn restaurants had many vegetables available with added fat, hence they were nt included as a healthful fd item. Fast casual restaurants prvided the mst vegetables cmpared t any ther restaurant type, generally in the frm f salads. Salads were nly included in analysis if 104

118 the menu stated that dressing was served n the side. Fast Fd restaurants sld the mst fruit and lw-fat milk prducts cmpared t sit dwn and fast casual restaurants, but in limited quantities. Chain restaurants including McDnalds and Subway have added healthier side ptins such as prepackaged apple slices and 1% milk and ygurt in the past years, which was bserved in the current study. Recent studies analyzing fast fd menus fund cnsistently pr healthful fd ptins (Kirkpatrick et al., 2014). Anther study reprted a psitive assciatin between sit-dwn and fast fd cnsumptin and daily ttal calrie, fat and sugar intake, alng with higher intake f chlesterl and sdium, and lwer intake f fiber, vitamin A, vitamin C, vitamin D, vitamin K, cpper and magnesium (An, 2015). These findings suggest that althugh there are healthful fd ptins available at restaurants, imprvements must be made t restaurant menus including a higher variety f fruits and vegetables and replacing refined grains, sdium, added sugar, chlesterl, and saturated fat with healthier alternatives. Overall, mre restaurants were lcated within the study areas cmpared t fd stres. The majrity f the healthful fd utlets within half-mile radius areas were restaurants in cmparisn t fd stres, which increased the healthful fd density scres in all f the study areas. Althugh sit dwn restaurants and fast casual restaurants were cnsidered healthful fd utlets, there are several menu items that are nt healthful. Recent research has suggested that eating at fast-fd and full-service restaurants (sit dwn and fast casual), was assciated with increases in ttal daily energy intake, ttal fat, saturated fat, chlesterl, and sdium (An, 2015). Meals made at hme cmpared t meals cnsumed at restaurants have been linked t higher dietary quality. 105

119 One recent study analyzed the relatinship between dietary quality and fd surce (e.g., meals made at hme vs. varius different restaurant types) and fund that peple wh ate hme cked meals had a higher dietary quality scre (HEI) than peple wh ate at any type f restaurant (Carlsn & Gerrir, 2006). Even thugh there are healthful ptins available at sit dwn and fast casual restaurants, Registered Dietitians shuld keep in mind when advising patients that there are many unhealthful fd ptins t chse frm at sit dwn and fast casual restaurants. It wuld be beneficial fr the Registered Dietitian t prvide a list f healthful ptins t chse frm at restaurants and ptins t stay away frm that may seem healthy (e.g., fried vegetables). Fr restaurant scring, the ttal number f menu items fr each restaurant was nt cnsidered. The number f healthful fd items in cmparisn t the number f verall menu items was nt calculated. The percentage f healthful fd items available is nt relative frm ne restaurant t the next, which is why a range f healthful fd ptins was cnsidered when classifying a restaurant type as healthful r unhealthful. The empty calries grup is ne f the fd grups fcused n in the 2010 DGA and was included in ur assessment f fd stres and restaurants. Sugar sweetened beverages (e.g., sda, juice, energy drinks) were used as a prxy in the current study t assess empty calries. The Scientific Reprt f the 2015 Dietary Guidelines Advisry Cmmittee: Fd and Nutrient Intakes, and Health: Current Status and Trends reprted that beverages prvide 47% f added sugar intake t the U.S. ppulatin (USDA, 2015). If stres sld mre than half f the sugar sweetened beverages cllected n C-NEEDS, zer pints were allcated t the final healthful fd availability scre. Stres and restaurants were rewarded with 1 pint if they sld nne f the sugar sweetened 106

120 beverages. All f the fd stres sld mre than half f the sugar sweetened beverages cllected n C-NEEDS, and all restaurants ther than the ne fd truck in the current study sld mre than half f the sugar sweetened beverages n C-NEEDS. We fund that half-mile radius areas with a higher variety f fd utlets generally had a higher density scre. A higher variety f fd utlets, specifically healthful fd utlets, reflects higher access t a high quality diet cmpared t an area with less variety f healthful fd utlets. Therefre, if a Registered Dietitian knws the type and variety f fd utlets within the area that a patient live, they can better estimate an individual's access t a high quality diet. Areas with the highest density scres all had at least ne grcery stre. Having this knwledge can make it easier t estimate access t a high quality diet. Grcery stres were cnsidered healthful fd utlets as they prvided clse t half (47%) f the healthful fds frm C-NEEDS. Althugh sme studies have shwn that grcery stres have less variety f healthful fds such as fruits and vegetables in cmparisn t supermarkets (Sharkey et al., 2010), healthful fds were generally available in Springfield grcery stres, but in less quantities and varieties. Fd envirnment scres were calculated fr nine f the 13 lcatins based n the availability f healthful fd utlets. Three f the study areas did nt have any healthful fd utlets (e.g., nly cnvenience stres) and ne study area had zer fd utlets. Larsn et al. (2009) als fund that lw-incme, urban areas have been fund t have pr access t supermarkets and healthful fd and higher access t fd utlets with energy dense fd ptins (Larsn et al., 2009). 107

121 The presence f supermarkets, grcery stres, and small prduce businesses were the best indicatrs f access t a high quality diet because each f the stres had the highest variety f healthful fds. Studies have fund that peple living in areas with supermarkets and grcery stres have higher diet quality scres cmpared t peple living in areas withut supermarkets (Rse & Richards, 2004; Mre et al., 2008; Larsn et al., 2009; Wedick et al., 2015). Once we added key envirnmental characteristics, specifically facilitatrs t healthful fd access, the average DGAIFE scre imprved fr all f the study areas with fd utlets (1.80 t 1.68). A lwer scre, clser t 1.00, signifies better access t a high quality diet as there are mre healthful fd utlets and envirnmental facilitatrs and a higher scre, clser t 5.00, indicates lwer access t a high quality diet as there are less healthful fd utlets and less envirnmental facilitatrs. Several envirnmental characteristics were cnsidered in the current study. Public transprtatin was included in ur analysis as a way t estimate access t a high quality diet because transprtatin limitatins such as nt having a car r n public transprtatin access are barriers t fd access in lder adults (Wlfe et al., 2003; Crabtree et al., 2013; Lucan et al., 2013). One study suggested that adequate public transprtatin was an imprtant envirnmental characteristic because having a high density f fd stres that sell fruits and vegetables did nt matter if transprtatin was nt adequate t access fd stres (Lucan et al., 2013). It shuld be nted that lder adults may nt utilize public transprtatin, even if it is available. One study fund that lder participants did nt use the lcal bus fr shpping because their physical impairments made standing r sitting n buses difficult (Crabtree 108

122 et al., 2013). A recent study reprted that peple living in neighbrhds with subways and trlleys cnsumed less fruits and vegetables, suggesting peple may nt use public transprtatin t access fd (Lucan et al., 2013). Vehicle wnership is an imprtant factr in determining individual access t healthy fd (Tlzman et al., 2014). Infrmatin regarding vehicle wnership frm the U.S. Census American Cmmunity Survey shwed varying rates f ccupied husing units with n vehicles available in each f Springfield's neighbrhds (Springfield Planning and Ecnmic Develpment, 2011). The McKnight neighbrhd had the highest percentage f husing units with n vehicles available (58.9%), fllwed by the Suth End (48.1%), and Metr Center (47.6%) (Springfield Planning and Ecnmic Develpment, 2011). All f the study areas lcated in the McKnight, Suth End, r Metr Center neighbrhds had at least ne grcery stre within the half-mile radius area suggesting healthful fd is within walking distance. A recent study reprted similar findings in that access t all types f fruits and vegetables (fresh, frzen, and canned) was generally better fr residents f lw vehicle wnership neighbrhds cmpared t neighbrhds with higher vehicle wnership, but median distance t a fd stre was still beynd walking distance (Sharkey et al. 2010). Majr intersectins and/r highway presence was included in ur study as a barrier t accessing healthful fd, because it may interfere with the ability t walk t fd utlets if it ran thrugh the study area. It culd be difficult fr an lder adult t crss a busy intersectin in rder t shp fr fd. One study fund that lder adults did nt prefer walking in areas with majr intersectins due t incnvenient crssing pprtunities, inadequate signal times, lng crssing distances acrss multiple lanes. 109

123 Participants nted feeling rushed, and fear f falling when crssing busy streets (Grant et al., 2010). Sidewalk availability was included in the current study because sidewalks may be a facilitatr t accessing healthful fd. A recent study cncluded that lder adults cnsidered bth the presence f sidewalks and crsswalks a pririty when cnsidering factrs that affect walking in their neighbrhds (Hansn et al., 2013). Many studies, hwever, analyze sidewalk presence as part f the built envirnment's assciatin t besity. Few studies examine the relatinship between sidewalk presence and access t a high quality diet fr lder adults. Walk Scre was useful in assessing the walkability f half-mile radius areas, especially because the scres take int cnsideratin the number f amenities available in the area and the ease f walking t them. Ease f walking cnsidered the length f each blck and the amunt f intersectins. A cnsideratin that was nt included in the scre but wuld be useful t include is the elevatin levels r presence f hills in the area. In the study area, ne senir living facility was lcated in ne f the study areas, and if residents were t walk t any fd utlets, they wuld have t walk up a steep hill. It culd be difficult fr lder adults t walk in areas that have steep elevatin r hills, as many lder adults reprt mbility issues and physical capacity as a barrier t accessing healthful fd (Wlfe et al., 2003; Radermacher et al., 2010; Huang et al., 2012). Older adults have cited functinal limitatins as the number ne reasn fr nt being able t access fd (Wlfe et al., 2003; Radermacher et al., 2010; Huang et al., 2012). In ne study examining fd insecurity in New Yrk, lder adults reprted the inability t shp and/r prepare fd as the number ne barrier t accessing healthful 110

124 fd (Wlfe et al., 2003). The authrs suggested imprving fd assistance prgrams as a way fr lder adults t reliably btain healthful fd (Wlfe et al., 2003). Because functinal limitatins ften affect lder adults and their ability t access and prepare fds, understanding the availability f fd assistance prgrams within urban areas can help estimate access t a high quality diet fr lder adults. Anther study assessing the factrs invlved with fd shpping amng lder adults in Brklyn, NY fund that lder adults were mtivated t shp and ck fd despite challenges f mbility and cst (Munz-Plaza et al., 2013). Mst f the adults utilized public transprtatin r walked t grcery stres t btain fd. Participants frequently reprted shpping at least nce per week in rder t purchase fd in small amunts t avid carrying heavy grceries and t avid fd spilage. The findings frm the study suggest that althugh lder adults have functinal limitatins, many are still mtivated t purchase and ck healthful fd fr ptimal health and t maintain a sense f independent (Munz-Plaza et al., 2013). Cst is ften studied when lking at the ptential barriers t healthful fd access (Liese et al., 2007; Tlzman et al., 2014). Cst cncerns have ften been cited as a barrier t accessing healthful fds, especially in lder adults (Wlfe et al., 2003; Radermacher et al., 2010). A study regarding fd insecurity in lder adults living in New Yrk lked at factrs cntributing t fd insecurity in lder adults. One cmmn theme fund in the study was that lder adults were mtivated t cnsume healthful fds such as fruits and vegetables, but the cst was t high fr individuals t purchase these items. Sme lder adults in the study nted that they cmprmised eating mre thrughut the day s that they culd eat healthier, expensive items (Wlfe et al., 2003). 111

125 Cst was nt cnsidered in the study when examining envirnmental characteristics fr tw reasns. Several stres in Springfield, MA did nt list the cst f fd items, the cst was prvided at checkut nly. The C-NEEDS prtcl was t recrd csts nly if labeled n the fd item r crrespnding shelf lcatin. On the C- NEEDS survey, cst f prduce can be reprted in multiple ways including "cst per each," "cst per lb.," and/r "cst per unit." Incnsistent data n cst f fd items lead us nt t cnsider cst f fd as a key envirnmental factr. Hwever, the literature suggests supermarkets have been reprted t sell healthful fds at a lwer cst cmpared t cnvenience stres (Liese et al., 2007; Larsn et al., 2009), therefre it culd be estimated that peple living in the areas withut a supermarket wuld be negatively affected by high cst f healthful fd items. Sme f the data cllected in the current study n healthful fd access was cnsistent with the USDA (USDA ERS- Fd Research Atlas, 2010; Pineer Valley Planning Cmmissin, 2014) fd access infrmatin. Data that was nt cnsistent with USDA lw access data was thught t be incnsistent because nly prtins f the neighbrhd were studied relative t the GFresh sites, rather than the entire neighbrhd. Fr example, the USDA reprted that 16.4% f peple living in Sixteen Acres have lw fd access, but ne f ur study areas lcated within Sixteen Acres had a lw DGAIFEC scre (1.42). The particular area cntained the nly supermarket within the study, had public transprtatin and sidewalks available, and had stres with acceptable quality prduce, all which wuld suggest high access t a high quality diet (Rse & Richards, 2004; Tlzman et al., 2014). Als, lw access refers t the distance t the nearest supermarket (USDA, 2015), but ur study lked at all healthful fd utlets 112

126 instead f just supermarkets, alng with envirnmental characteristics. Sciecnmic variables were cmpared against the DGAIFE and DGAIFEC scres. Infrmatin n median husehld incme and percentage f peple living belw the pverty level was btained fr each f the seven neighbrhds that ur study areas were lcated. The Suth End and Metr Center neighbrhds, which make up Springfield's dwntwn area, had the best DGAIFE and DGAIFEC scres but the ppulatin f bth areas are the prest f the areas studied. As f 2013, the median husehld incme fr the individuals living in Springfield's Suth End and Metr Center are $18,430 and $18,927, respectively (City-Data, 2013). The percentage f peple belw the pverty level is 55% in the Suth End, and 59.3% in Springfield's Metr Center (City-Data, 2013). Althugh bth f the areas mentined had healthful fd utlets, high density scres, and high DGAIFE and DGAIFEC scres, peple living in the area may nt be able t affrd the healthful fd in the area. Tw f the study areas lcated in Liberty Heights and Sixteen Acres were f particular interest. One f the 2015 GFresh Mbile Market sites, lcated within Liberty Heights is at a senir living facility. The half-mile radius area had 0 healthful fd utlets and scred a 0.00 n the DGAIFE. When adding in key envirnmental characteristics, the DGAIFEC scre was Althugh multiple bus rutes and sidewalks were available in the area, majr intersectins and highways were present which can bstruct the ability t walk, and the Walk Scre was 62 (smewhat walkable t amenities). This infrmatin suggests that healthful fd access t the lder adults living at the senir living facility r within the half-mile area is limited and therefre culd be linked t lwer diet quality (Vernez-Mudn et al., 2013). 113

127 One f the 2015 GFresh Mbile Market sites is lcated at a cmmunity center that hsts senir citizen activities and is lcated in Sixteen Acres. There was ne supermarket, ne sit dwn restaurant, and tw fast casual restaurants within the half-mile radius area, a ttal f fur healthful fd utlets. The particular study area's DGAIFE scre was 1.56 and DGAIFEC scre was Althugh the lder adults visiting the cmmunity center may nt necessarily live in the prximity, they have access t a high quality diet when they are in the area. One strength f the current study is that C-NEEDS is a validated fd envirnment tl that was riginally used in central Massachusetts, an area within clse prximity t Springfield, MA. C-NEEDS was able t ffer great insight t the fd available and quality f prduce within fd stres, and cllected data abut reginally and culturally acceptable fd. A few items culd be added t C-NEEDS in rder t align the data cllected t the 2010 Dietary Guidelines fr Americans (DGA). The meat/pultry/eggs fd grup is ne f the fd grups measured in the 2010 DGA and DGAI C-NEEDS was limited in its cllectin f lean meat variety as it nly included grund beef, grund chicken, grund turkey, and fat-free ht dgs. Eggs were nt riginally in the C-NEEDS survey, but were added t the first addendum. After preliminary data cllectin, it was decided t remve eggs frm the addendum because they are a staple fd sld at the majrity f stres. Seafd is anther fd grup categry included in the 2010 DGA, and the C- NEEDS tl did nt include a seafd categry. Seafd was added t the addendum, but the addendum was changed thrughut the study perid. Cllectin f seafd items 114

128 included fresh, frzen and canned seafd, but imprvements culd be made t better capture the types f seafd available within fd stres. The results f the current study may be generalized t ther cities within the Nrtheast regin f the U.S. f similar size and with similar characteristics. It may be difficult t generalize the reprts f this study t cities utside f the Nrtheast U.S., as different types f fds may be available (especially fds cllected n C-NEEDS). Generalizing results t ther cities utside f the U.S. may be difficult, as types f fd sld in fd utlets may differ. Data cllected frm the current study prvides baseline infrmatin which can be useful fr cmmunity partners and can further imprve public health plicy at the lcal level t prvide mre pprtunities t accessing healthful fd items such as fruits and vegetables. Registered Dietitian's can use the infrmatin frm the current study t better assist their clients in making healthful fd chices based n the fd envirnment which they live (see Appendix H fr Interview guide fr Registered Dietitians). Applying the methds f the current study in cities similar t Springfield, MA wuld be useful t see hw Springfield, MA cmpares t ther urban areas in terms f healthful fd availability. Understanding the availability f prgrams fr lder adults in Springfield, MA such as Meals n Wheels wuld help increase knwledge f fd access and healthful fd availability fr lder adults. Cnsidering the perspectives f lder adults regarding healthful fd availability and access, cst, and the ability t adhere t a high quality thrugh fcus grups and questinnaires wuld increase ur understanding f facilitatrs and barriers t a high quality diet fr lder adults. Further studying the assciatin 115

129 between fd utlet type, variety, and density within half-mile radius areas and diet quality thrugh 24 hur dietary recalls wuld prvide insight t the dietary quality f the peple living in Springfield. Integrating individual level data and perspectives can add t the findings f the current study by answering fundamental questins regarding facilitatrs and barriers t healthful fd access within specific urban settings such as Springfield, MA. 116

130 CHAPTER 7 CONCLUSION In cnclusin, the current study fund that access t a high quality diet is within reach, but there are disparities t healthful fd access acrss the thirteen study lcatins. Knwledge f the types f fd utlets within study areas and the healthful fd available within the utlets is the best indicatr t estimate access a high quality diet. Adding knwn envirnmental facilitatrs t the DGAIFE algrithm did nt substantially imprve estimates f access t a healthful diet. Registered Dietitians can use the infrmatin frm the current study t guide clients t make healthful fd chices in urban neighbrhds. It wuld be imprtant fr dietitians t ask clients where they generally btain fd/meals, what types f stres and restaurants are within access, where they generally buy fd, if they have vehicle access and if they are willing t use public transprtatin r walk t fd utlets if they d nt have a vehicle. The findings frm the current study prvide infrmatin t imprve public health plicy t increase access t healthful fd. 117

131 APPENDICES 118

132 119 APPENDIX A HALF-MILE GOFRESH LOCATIONS, FOOD OUTLETS, AND TIME TO COMPLETE 2015 Cnfirmed GFresh Site Gentile Apartments Neighbrhd Suth End Overlap areas (GFresh Sites) Caring Health Center, Curt St. and Outing Park Apartments (Ptential Future site) Stres within the half mile radius f the GFresh Lcatin AC Prduce- SPB Family Dllar- Denied by manager Suth End Supermarket (listed nline as Diaz Supermarket)- G Saratga Mini Mart (listed nline as Saign Mini Market) C City Zne Supermarket- G Hneyland Farm- C Trpical African Market- SMA Mm and Rics Specialty Market (N fruits r vegetables available, nt included in study analysis)- SMI Milan Imprting (N fruits r vegetables available, nt included in study analysis)- SMI Frigs (N fruits r vegetables available, nt included in study analysis)-smi OMI Oriental Grcery stre (clsed/mved t different city) Pride Gas Statin- CGas Restaurants within the half mile radius f the GFresh lcatin McDnalds- FF UNO Pizzeria- SD Plan B Burger Bar- SD Samuels - SD Max's Tavern- SD Subway- FF Dunkin Dnuts- FF H Mei- Nt included in analysis (n menu in stre r nline)- FF Luxe Burger Bar- SD Red Rse Pizzeria-SD Blackjack Steakhuse (Nt listed nline)- SD McCaffrey's Public Huse- FC Crwn Fried Chicken Language barrier, n menu Starbucks- FF Cafe Du Jur- language barrier, n menu Ht Table-FC Palazz Café (Nt listed nline)- FC Nadims Mediterranean Restaurant and Grill/ Cafe Lebann-SD Dynasty-FF Apprximate time t cmplete 4 trips; 10.5 ttal hurs fr Gentile, Caring Health Center, and Curt Square data cllectin

133 120 Caring Health Center Metr Center Gentile, Curt St., and Outing Park Apartments (Ptential Future site) 1 st Stp Cnvenience (Cmpleted survey, nt listed nline) -C Suth Side Mini Mart (Cmpleted survey, nt listed nline)- C FL Rberts at East Clumbus Mbil Gas Statin CGas (N fruits r vegetables available, nt included in study analysis) Brad Street FL Rberts Sunc- CGas Radys Truck Stp (Cmpleted survey, nt listed nline)- CGas Wheelers Market- C Family Dllar- Denied by manager Suth End Supermarket (listed nline as Diaz Supermarket)- G Saratga Mini Mart (listed nline as Saign Mini Market) C City Zne Supermarket- G Hneyland Farm- C Trpical African Market- SMA Mm and Rics Specialty Market (N fruits r vegetables available, nt included in study analysis)- SMI Milan Imprting (N fruits r vegetables available, nt included in study analysis) SMI McDnalds- FF UNO Pizzeria- SD Plan B Burger Bar- SD Samuels - SD Max's Tavern- SD Subway- FF Dunkin Dnuts- FF H Mei- Nt included in analysis (n menu in stre r nline)-ff Luxe Burger Bar- SD Red Rse Pizzeria-SD Blackjack Steakhuse (Nt listed nline)- SD McCaffrey's Public Huse- FC Crwn Fried Chicken Language barrier, n menu Starbucks- FF Cafe Du Jur- language barrier, n menu (see Gentile Apartments, abve)

134 121 Curt Square Metr Center Gentile, Caring Health Center, Saab Curt Outing Park Apartments (Ptential Future site) Frigs (N fruits r vegetables available, nt included in study analysis)- SMI OMI Oriental Grcery stre (clsed/mved t different city) Pride Gas Statin- CGas FL Rberts at East Clumbus Mbil Gas Statin CGas (N fruits r vegetables available, nt included in study analysis) Civic Center Cnvenience - Denied by manager CVS Main Street (Cmpleted survey, nt listed nline)- Pharm City Zne Supermarket- G Hneyland Farm- C Trpical African Market- SMA Mm and Rics Specialty Market (N fruits r vegetables available, nt included in study analysis)- SMI Milan Imprting (N fruits r vegetables available, nt included in study analysis)- SMI Frigs (N fruits r vegetables available, nt included in study analysis)- SMI OMI Oriental Grcery stre (clsed/mved t different city) Ht Table-FC Palazz Café (Nt listed nline)- FC Nadims Mediterranean Restaurant and Grill/ Cafe Lebann-SD City Jake's Cafe- FC Thedres'-SD SUN KIM BOP (Nt listed nline)- FT Dunkin Dnuts- FF H Mei- Nt included in analysis (n menu in stre r nline)- FF Luxe Burger Bar- SD Red Rse Pizzeria-SD Blackjack Steakhuse (Nt listed nline)- SD McCaffrey's Public Huse- FC Crwn Fried Chicken Language barrier, n menu Starbucks- FF Cafe Du Jur- language barrier, n menu Ht Table- FC Palazz Café (Nt listed nline)- FC (see Gentile Apartments, abve)

135 122 Saab Curt Metr Center Baystate Place, Linden Twers, Curt Square, STCC Pride Gas Statin- CGas Civic Center Cnvenience - Denied by manager Dwntwn Cnvenience Stre-C CVS Main Street (Nt listed nline)- Pharm Franklin Supermarket- Language barrier Cife (clsed/nt lcated) Carew Mini Mart (Cmpleted survey, nt listed nline)- C AZ Mart (Citg Gas Statin)- CGas Prspect Variety- C Chestnut Market (Listed as Lily's Market nline)- C Nadims Mediterranean Restaurant and Grill/ Cafe Lebann- SD Student Prince Cafe & The Frt Dining Rm- SD Panjabi Tadka- SD Panda Huse- FF Paramunt Pizza- FC City Jake's Cafe- FC Thedres'- SD SUN KIM BOP (Nt listed nline)- FT Adlf's Ristrante- SD Pineer Valley Brew Pub (clsed) Chef Wayne's Big Mamu- SD Felix's Breakfast & Sandwich- SD Olympic Deli Restaurant- FC 350 Grill Steakhuse- SD Brinquen Crner- Nt included in analysis (fd preparatin nt described/in Spanish)- FC Chef Wayne's Big Mamu- SD Felix's Breakfast & Sandwich- SD Olympic Deli Restaurant- FC 350 Grill Steakhuse- SD Brinquen Crner- Nt included in analysis (fd preparatin nt described/in Spanish)- FC Panjabi Tadka- SD 1 trip; 1.5 ttal hurs (cllecting menus) See Linden Twers/Baysta te Place fr Fd stre cmpletin time belw

136 123 Linden Twers Baystate Place Liberty Height Linden Twers, Saab Curt Independence Huse BP (Gas Statin)- CGas Spring Street Super Grcery and Variety- G Panda Huse- FF Paramunt Pizza- FC City Jake's Cafe- FC Thedres'- SD Adlf's Ristrante- SD Pineer Valley Brew Pub (clsed) Nrth End Pizzeria and Seafd (clsed) Liberty Heights Saab Curt, Cife (clsed/nt lcated) Baystate Place Carew Mini Mart (Cmpleted survey, nt listed nline)- C AZ Mart (Citg Gas Statin)- CGas Prspect Variety- C Chestnut Market (Listed as Lily's Market nline)- C Arianna Cnvenience Stre (Listed as JP Mini Market nline) -C BP (Gas Statin)- CGas Carew Mini Mart McDnalds- FF (Cmpleted survey, nt Nrth End Pizzeria and listed nline)- C Seafd (clsed) Carew Mini Mart (cmpleted survey, nt listed nline)- C AZ Mart (Citg Gas Statin)- CGas Prspect Variety- C Chestnut Market (Listed as Lily's Market nline)- C Arianna Cnvenience Stre (Listed as JP Mini Market nline) -C BP (Gas Statin)- CGas J+J Market & Deli- C Pine Pint Nne Nne Dunkin Dnuts- FF N time in field 2 trips; 5 ttal hurs

137 124 Cld Cncepcin Cmmunity Center Springfield Technical Cmmunity Cllege (STCC) East Springfield Public Library Sixteen Acres Nne Family Dllar- D Pride Gas Statin- CGas Walgreens- Pharm CVS- Pharm Fresh Acres Market- S McKnight Saab Curt CVS Pharmacy - Pht Pharm Highland Farms Gas Statin Cnvenience (Cmpleted survey, nt listed nline)- CGas El Punt Supermarket- G Jumb Supermarket- G Hectrs Mini Mart (Cmpleted survey, nt listed nline) - C Sunc Gas Statin- CGas Spring Street Super Grcery and Variety- G East Springfield Nne Page Cnvenience- C Pride gas statin-cgas Ginger Blssm Chinese Restaurant -SD Wings Over Springfield- FF Dunkin Dnuts- FF Main Garden-FF Pizza Palace- FF Bruns Pizza 16 Acres- FF Parker Pizza- FC MJ's Pizza- FC Pizza Chice-FF Discunt Chinese--FF Burger King-FF 2 Guys Pizzeria- FC Mike s East Side Pub- SD Main Wk Buffet- SD El Mrr Bakery and Restaurant Nt included in analysis (fd preparatin nt described/in Spanish)- FC Palace Pizza- FC Penny s Suthern Style Sul Fd- FC Eat- FC 1 trip: 3 hurs 1 trip; 3.5 hurs 2 trips; 1.5

138 125 Baystate Masn Square Cmmunity Clinic CCMS Saturday Market (GFresh as vendr) *Data was nt cllected fr this site McKnight Nne Stres listed nline Masn Fd Market NSA Supermarket Family Dllar Walgreens Tw & One Grcery CVS Hward Fuel Services gas statin Cabrera Market Rdriguez Family Market and Kitchen Dad s Variety Stre Big D Jamaican Cuisine- Nt included in analysis (n menu in stre r nline)- SD Fitzgerald s Pub and Grill- SD Dunkin Dnuts- FF McDnalds- FF Burger King- FF Negrill Wk King Subway McDnalds El Cidren Antnis Grinders Data nt cllected fr this site Key: S= Supermarket SMA= Specialty Market, African G=Grcery SPB= Small Prduce Business C= Cnvenience stre SD= Sit Dwn restaurant CGas=Gas statin cnvenience stre FC= Fast Casual restaurant Pharm= Pharmacy FF= Fast Fd restaurant D= Dllar Stre FT= Fd Truck SMI= Specialty Market, Italian

139 Ptential Future Sites Rbinsn Gardens Clnial Estates Outing Park Apartments cmmunity ffices Suth End Neighbrhd Overlap areas Stres within the half mile radius f the GFresh Lcatin Restaurants within the half mile radius f the GFresh lcatin Apprximate time t cmplete Pine Pint Nne Geeta Fds Inc./Fd WngWk- SD 1 trip: 1 hur Mart C Napli Restaurant & Shell Gas Statin CGas Pizzeria- SD Tedeschi (Cmpleted survey, nt listed nline) C Skters (Nt listed nline)- SD Sixteen Acres Nne Nne Nne Nne Suth End Caring Health Center, Curt St., Gentile AC Prduce- SPB Family Dllar- Denied by manager Suth End Supermarket (Listed nline as Diaz Supermarket)- G Saratga Mini Mart (Listed nline as Saign Mini Market) C City Zne Supermarket- G Hneyland Farm- C Trpical African Market- SMA Mm and Rics Specialty Market (N fruits r vegetables available, nt included in study analysis)-smi Milan Imprting (N fruits r vegetables available, nt included in study analysis) SMI Frigs- (N fruits r vegetables available, nt included in study analysis) SMI Dynasty- FF McDnalds- FF UNO Pizzeria- SD Plan B Burger Bar- SD Samuels - SD Max's Tavern- SD Subway- FF Dunkin Dnuts- FF H Mei- Nt included in analysis (n menu in stre r nline)- FF Luxe Burger Bar- SD Red Rse Pizzeria-SD Blackjack Steakhuse (Nt listed nline)- SD McCaffrey's Public Huse- FC Crwn Fried Chicken Language barrier, n menu Starbucks- FF (see Gentile Apartments, abve)

140 127 OMI Oriental Grcery stre (clsed/mved t different city) Pride Gas Statin- CGas 1 st Stp Cnvenience (Cmpleted survey, nt listed nline)- C Suth Side Mini Mart (Cmpleted survey, nt listed nline) C FL Rberts at East Clumbus Mbil Gas Statin CGas (N fruits r vegetables available, nt included in study analysis) Brad Street FL Rberts Sunc- CGas Radys Truck Stp (Cmpleted Survey, nt listed nline)- CGas Wheelers Market- C Guananic Market- Language barrier Brad Street Sunc S+S Fd Mart (Citg Statin) (Cmpleted survey, nt listed nline)- CGas Key: S= Supermarket SMA= Specialty Market, African G=Grcery SPB= Small Prduce Business C= Cnvenience stre SD= Sit Dwn restaurant CGas=Gas statin cnvenience stre FC= Fast Casual restaurant Pharm= Pharmacy FF= Fast Fd restaurant D= Dllar Stre FT= Fd Truck SMI= Specialty Market, Italian

141 128 Classificatin Sub- Classificatin Traditinal Supermarket Large, crprate wned chain stres (Mrland 2002) APPENDIX B FOOD STORE DEFINITIONS (WHITTINGTON, 2013) Definitin 2012 NACIS Index 2012 NACIS Definitin Fd Marketing Institute Classificatin Primarily engage in retailing a general line f fd, supermarkets are larger in size (>20,000 sq ft), number f emplyees, and sales vlume. Chain stre identificatin and number f parking spaces were used t distinguish supermarkets frm grcery stres. (Sharkey 2010). A frmat ffering a full line f grceries, meat, and prduce with at least $2 millin in annual sales. These stres typically carry apprximately 15,000 items and frequently ffer a service deli Supermarkets and Other Grcery (except Cnvenience) Stres This industry cmprises establishments generally knwn as supermarkets and grcery stres primarily engaged in retailing a general line f fd, such as canned and frzen fds; fresh fruits and vegetables; and fresh and prepared meats, fish, and pultry. Included in this industry are delicatessen-type establishments primarily engaged in retailing a general line f fd. Cnventinal (vlume greater than $2 millin): A supermarket is a full-line, selfservice grcery stre with annual sales vlume f $2 millin r mre. This definitin applies t individual stres regardless f ttal cmpany size r sales, and therefre includes bth chain and independent lcatins. Trade Dimensins utilizes the trade channel definitin endrsed by FMI (The Fd Marketing Institute) and the leading industry publicatins. FMI is a nnprfit assciatin f 1,500 fd Examples frm the current study Fresh Acres Market

142 129 Traditinal Grcery Stre and a bakery (Leibtag Nv 2005) Traditinal lcal grcery stre that retails nly fd. Smaller nncrpratewned fd stres (Mrland 2002). Primarily engage in retailing a general line f fd, grcery stres are smaller in size, nt identified as a chain stre and have fewer than 100 parking spaces (Sharkey 2010) Supermarkets and Other Grcery (except Cnvenience) Stres This industry cmprises establishments generally knwn as supermarkets and grcery stres primarily engaged in retailing a general line f fd, such as canned and frzen fds; fresh fruits and vegetables; and fresh and prepared meats, fish, and pultry. Included in this industry are delicatessen-type establishments primarily engaged in retailing a general line f fd. retailers and whlesalers, their subsidiaries and custmers. The small crner grcery stre that carries a limited selectin f staples and ther cnvenience gds. These stres generate apprximately $1 millin in business annual Spring Street Super Grcery and Variety, Suth End Supermarket Traditinal Specialty Markets A fd stre primarily engaged in the retail sale f a single fd categry, such as meat and seafd markets, prduce markets and stands, dairy stres, candy and nut stres, and retail bakeries Specialty Fd Stres This industry grup cmprises establishments primarily engaged in retailing specialized lines f fd. Milans, Frigs, Trpical African Market Stres that specialize in a specific fd categry, such as rganic, lcally grwn r prduced, ethnic/internatinal, r health fcused (Leibtag Nv 2005).

143 130 Cnvenience Cnvenience Stre Cnvenience stres r fd marts- primarily engage in retailing a limited line f gds that generally includes milk, bread, sda, and snacks. The cnvenience stre categry als included cnvenience stres with gasline and gasline statins with cnvenience stres (Sharkey 2010) Cnvenience Stres Cnvenience Stres This industry cmprises establishments knwn as cnvenience stres r fd marts (except thse with fuel pumps) primarily engaged in retailing a limited line f gds that generally includes milk, bread, sda, and snacks. Hneyland Farms, Chestnut Market Cnvenience Nn- Traditinal Gas Statin Cnvenience Stres Dllar Stre A retailer with a gas pump A small variety stre that sells general merchandise and, increasingly, fd prducts. These stres ffer a wide assrtment f basic husehld gds at very lw prices. Limited price general merchandise value stres (Sharkey 2010) Cnvenience Stres with Gas Statins All Other General Merchandise Stres This industry cmprises establishments engaged in retailing autmtive fuels (e.g., diesel fuel, gashl, gasline) in cmbinatin with cnvenience stre r fd mart items. These establishments retail a general line f new merchandise, such as apparel, autmtive parts, dry gds, hardware, grceries, huse wares r hme furnishings, and ther lines in limited amunts, with nne f the lines predminating. A small stre frmat that traditinally sld staples and knickknacks, but nw sales f fd and cnsumable items at aggressive price pints accunt fr at least 20%, and up t 66%, f their vlume BP, Mbil, Pride Family Dllar A limited assrtment stre that sells a

144 131 Nn- Traditinal Micrenterprise Pharmacy Small Prduce Business, Farmer s Market, r Mbile Vendr variety f general merchandise and, increasingly, fd prducts. These stres ffer a wide assrtment f basic husehld gds at very lw prices (Leibtag Nv 2005) A retail shp where medicine and ther items are sld. Pharmacies and drug stres that were part f natinal chains (Sharkey 2010) Small grcery stres that mainly sell fruits and vegetables. Farmer's Markets r Mbile vendrs sell fresh prduce fr purchase (Tester et al., 2010) Pharmacies and Drug Stres Fruit and Vegetable Markets This industry cmprises establishments knwn as pharmacies and drug stres engaged in retailing prescriptin r nnprescriptin drugs and medicines. This industry cmprises establishments primarily engaged in retailing fresh fruits and vegetables. A prescriptinbased drug stre that generates 20% r mre f its ttal sales frm cnsumables, general merchandise, and seasnal items. CVS, Walgreens AC Prduce Whittingtn, References: Mrland, K., Wing, S., Rux, A.D., Ple, C. (2002) Neighbrhd Characteristics Assciated with the Lcatin f Fd Stres and Fd Service Places. Am J Prev Med 22(1). Sharkey, J., Hrel, S., Dean, W. (2010). Neighbrhd deprivatin, vehicle wnership, and ptential spatial access t a variety f fruits and vegetables in a large rural area in Texas Internatinal Jurnal f Health Gegraphics, 9:26

145 132 Leibtag, E.S. (2005) Where Yu Shp Matters: Stre Frmats Drive Variatin in Retail Fd Prices. Amber Waves Nvember, Fd Marketing Institute. Supermarket Facts. Accessed 2015 June 2 Nrth American Industry Classificatin System

146 APPENDIX C RESTAURANT TYPE DEFINITIONS Restaurant type Definitin Sit-dwn Offers table service with wait staff wh takes a persn s rder at the table. Fast Casual Higher quality fd with (less frzen and prcessed ingredients) cmpared t Fast Fd restaurants Fast Fd Mbile Vendrs Des nt ffer full table service Custmers generally rder and pay at the cunter, and fd is brught t the table t eat in the restaurant r taken with the cstumer t eat elsewhere Must meet ne f the fllwing criteria: Part f a Fast Fd chain r franchise (e.g. McDnalds) Lcated in a fd curt Limited t take-ut nly Fd trucks, trailers, and wagns that prepare and/r sell fd items and beverages in the street r ther public places 133

147 APPENDIX D DERIVATION OF THE HEALTHY FOOD AVAILABILITY INDEX FOR GROCERY STORES Fd (pints) Pint allcatin: Descriptin Subgrups (pints) Fresh fruits (0-3) 1 pint: 1-5 kinds 2 pints: 6-8 kinds 3 pints: 9+ kinds Fresh prduce (0-6) Fresh vegetables (0-3) 1 pint: 1-5 kinds 2 pints: 6-9 kinds 3 pints: 10+ kinds Frzen fruit (0-1) 1 pint: available Frzen prduce (0-3) Frzen vegetables (0-2) 1 pint: 1-3 kinds 2 pints: 4+ kinds Canned beans (0-1) 1 pint: available Canned beans (0-1) Lean grund beef (0-2) 1 pint: available Prtein (0-7) 1 pint: mre than ne variety Grund turkey/chicken (0-4) 1 pint: lean grund turkey available 1 pint: regular grund turkey available 1 pint: grund chicken available 1 pint: grund chicken/turkey cmb available Fat-free ht dg (0-1) Lw-fat frzen dinner (0-2) Lw-fat baked gds (0-2) Baked chips (0-3) Beverages (0-2) Whle grain bread (0-2) 1 pint: available 1 pint: 1-3 varieties 2 pints: 4-6+ varieties 1 pint: 1-3 varieties 2 pints: 4-6+ varieties 1 pint: baked chips available 1 pint: mre than 1 variety f lw fat ptat chips 1 pint: mre than 1 variety f lw fat trtilla chips 1 pint: diet sda available 1 pint: 100% range juice available 1 pint: available 1 pint: mre than 1 variety Lw-fat dairy (0-3) Skim/1% milk 1 pint: available 1 pint: ccupy at least 50% f shelf space Ice Cream 1 pint: nnfat/reduced fat available Ttal pints fr HFAI 0-33 Frzen dinners (0-2) Snacks (0-5) Beverages (0-2) Breads/cereals (0-4) Dairy (0-3) (Olendzki et al., 2015) 134

148 APPENDIX E DERIVATION OF THE UNHEALTHY FOOD AVAILABILITY INDEX FOR GROCERY STORES Fd (pints) Pint allcatin: Descriptin Subgrups (pints) Grund beef (0-2) 2 pints: regular (80% lean r less) available Prtein (0-4) Ht dgs (0-2) 2 pints: Oscar Meyer (r similar 12 g fat) available Baked gds (0-9) 2 pints: regular muffin available Snacks (0-13) 2 pints: plain bagel available 2 pints: any variety f ready-t-eat cake 1 pint: 1-3 varieties f regular baked gds 2 pints: 4-5 varieties f regular baked gds 3 pints: 6+ varieties f regular baked gds Chips (0-4) 2 pints: regular ptat chips available 2 pints: regular trtilla chips available Beverages (0-2) 2 pints: "juice drink" available Breads (0-2) 2 pints: white bread available Breads/cereals (0-4) Cereals (0-2) 2 pints: sweetened cereals available Milk (0-4) 2 pints: whle milk available Dairy (0-6) 2 pints: whle/2% mre than 50% f shelf space Ice cream (0-2) 2 pints: full-fat ice cream available Ttal pints fr unhealthy fd availability index 0-29 (Olendzki et al., 2015) 135

149 APPENDIX F COMMUNITY-NUTRITION ENVIRONMENT EVALUATION DATA (C- NEEDS) Healthier Chices fr Better and Lnger Life Cmmunity-Nutritin Envirnment Evaluatin Data Health Gegraphy Lab, Preventive and Behaviral Medicine 55 Lake Avenue Nrth, Wrcester, MA Cntact: Wenjun Li, PhD ( ) Barbara Olendzki, RD ( ) Stre ID: Business Name: Street Address: Twn / City: Telephne: Surveyr ID: Date (MM/DD/YY): / / Time (MM: HH): Start : End: : # f surveyrs: Stre type: Grcery Cnvenience Whlesale Super stre (Target, Wal-Mart) Discunt Stre Fruit/Veggie Market Farmer s Market Other Membership required: Yes N Card needed fr discunt: Yes N Des the stre have a nutritin scring system (NuVal, Guiding Star, ANDI): Yes N If Yes, list : Cmments: 136