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      Evaluating the Impact of Improving Access on Consumption of Fruits and Vegetables in a Rural Community in Texas: A Modeling Study

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          Purpose: Most residents in rural regions of the United States consume fewer amounts of fruits and vegetables (FVs) compared with their urban counterparts. Difficulties in access to FVs often contribute to different consumption patterns in rural regions, aside from a lack of education or motivation for eating healthy foods. This article uses simulation methods to estimate the relationship between increasing food access and FV consumption levels in a targeted rural community.

          Methods: An agent-based model previously developed to predict individual dietary behaviors was used. We adapted it to a rural community in west Texas following a two-step process. First, we validated the model with observed data. Second, we simulated the impact of increasing access on FV consumption. We estimated model parameters from the 2010 census and other sources.

          Results: We found that decreasing the driving distance to FV outlets would increase FV consumption in the community. For example, a one-mile decrease in driving distance to the nearest FV store could lead to an 8.9% increase in FV consumption; a five-mile decrease in driving distance could lead to a 25% increase in FV consumption in the community. We found that the highest marginal increase in FV consumption was when the driving distance decreased from 3.5 miles to 3 miles.

          Conclusions: Analysis to inform policy alternatives is a challenge in rural settings due to lack of data. This study highlights the potential of simulation modeling to inform and analyze policy alternatives in settings with scarce data. The findings from modeling can be used to evaluate alternative policies in addressing chronic diseases through dietary interventions in rural regions.

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          Most cited references 34

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          Fruit and vegetable intake and risk of major chronic disease.

          Studies of fruit and vegetable consumption in relation to overall health are limited. We evaluated the relationship between fruit and vegetable intake and the incidence of cardiovascular disease and cancer and of deaths from other causes in two prospective cohorts. A total of 71 910 female participants in the Nurses' Health study and 37,725 male participants in the Health Professionals' Follow-up Study who were free of major chronic disease completed baseline semiquantitative food-frequency questionnaires in 1984 and 1986, respectively. Dietary information was updated in 1986, 1990, and 1994 for women and in 1990 and 1994 for men. Participants were followed up for incidence of cardiovascular disease, cancer, or death through May 1998 (women) and January 1998 (men). Multivariable-adjusted relative risks were calculated with Cox proportional hazards analysis. We ascertained 9329 events (1964 cardiovascular, 6584 cancer, and 781 other deaths) in women and 4957 events (1670 cardiovascular diseases, 2500 cancers, and 787 other deaths) in men during follow-up. For men and women combined, participants in the highest quintile of total fruit and vegetable intake had a relative risk for major chronic disease of 0.95 (95% confidence interval [CI] = 0.89 to 1.01) times that of those in the lowest. Total fruit and vegetable intake was inversely associated with risk of cardiovascular disease but not with overall cancer incidence, with relative risk for an increment of five servings daily of 0.88 (95% CI = 0.81 to 0.95) for cardiovascular disease and 1.00 (95% CI = 0.95 to 1.05) for cancer. Of the food groups analyzed, green leafy vegetable intake showed the strongest inverse association with major chronic disease and cardiovascular disease. For an increment of one serving per day of green leafy vegetables, relative risks were 0.95 (95% CI = 0.92 to 0.99) for major chronic disease and 0.89 (95% CI = 0.83 to 0.96) for cardiovascular disease. Increased fruit and vegetable consumption was associated with a modest although not statistically significant reduction in the development of major chronic disease. The benefits appeared to be primarily for cardiovascular disease and not for cancer.
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            Interventions designed to increase adult fruit and vegetable intake can be effective: a systematic review of the literature.

            International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods > or = 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by approximately 0.1-1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.
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              Obesity and supermarket access: proximity or price?

              We examined whether physical proximity to supermarkets or supermarket price was more strongly associated with obesity risk. The Seattle Obesity Study (SOS) collected and geocoded data on home addresses and food shopping destinations for a representative sample of adult residents of King County, Washington. Supermarkets were stratified into 3 price levels based on average cost of the market basket. Sociodemographic and health data were obtained from a telephone survey. Modified Poisson regression was used to test the associations between obesity and supermarket variables. Only 1 in 7 respondents reported shopping at the nearest supermarket. The risk of obesity was not associated with street network distances between home and the nearest supermarket or the supermarket that SOS participants reported as their primary food source. The type of supermarket, by price, was found to be inversely and significantly associated with obesity rates, even after adjusting for individual-level sociodemographic and lifestyle variables, and proximity measures (adjusted relative risk=0.34; 95% confidence interval=0.19, 0.63) Improving physical access to supermarkets may be one strategy to deal with the obesity epidemic; improving economic access to healthy foods is another.

                Author and article information

                Health Equity
                Health Equity
                Health Equity
                Mary Ann Liebert, Inc., publishers (140 Huguenot Street, 3rd FloorNew Rochelle, NY 10801USA )
                25 July 2019
                25 July 2019
                : 3
                : 1
                : 382-389
                [ 1 ]Department of Health Policy and Management, University of Georgia, Athens, Georgia.
                [ 2 ]Computer Science Department, Furman University, Greenville, South Carolina.
                [ 3 ]Center for Health Innovation, the New York Academy of Medicine, New York, New York.
                [ 4 ]Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York.
                [ 5 ]Agricultural and Applied Economics, Texas Tech University, Lubbock, Texas.
                Author notes

                Co-first authors.

                [ * ]Address correspondence to: Janani Rajbhandari-Thapa, PhD, Department of Health Policy and Management, University of Georgia, 205D Wright Hall, Health Sciences Campus, 100 Foster Road, Athens, GA 30602 jrthapa@
                © Nicole D. Katapodis et al. 2019; Published by Mary Ann Liebert, Inc.

                This Open Access article is distributed under the terms of the Creative Commons License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 2, Tables: 1, References: 45, Pages: 8
                Original Article

                chronic diseases, modeling, diet, fruit and vegetables, rural


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