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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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          Associations between access to food stores and adolescent body mass index.

          Environmental factors such as the availability of local-area food stores may be important contributors to the increasing rate of obesity among U.S. adolescents. Repeated cross-sections of individual-level data on adolescents drawn from the Monitoring the Future surveys linked by geocode identifiers to data on food store availability were used to examine associations between adolescent weight and the availability of four types of grocery food stores that include chain supermarkets, nonchain supermarkets, convenience stores, and other grocery stores, holding constant a variety of other individual- and neighborhood-level influences. Increased availability of chain supermarkets was statistically significantly associated with lower adolescent Body Mass Index (BMI) and overweight and that greater availability of convenience stores was statistically significantly associated with higher BMI and overweight. The association between supermarket availability and weight was larger for African-American students compared to white or Hispanic students and larger for students in households in which the mother worked full time. Economic and urban planning land use policies which increase the availability of chain supermarkets may have beneficial effects on youths' weight outcomes.

            Author and article information

            [ 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@
            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
            6657293 10.1089/heq.2018.0090 10.1089/heq.2018.0090
            © 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.

            Figures: 2, Tables: 1, References: 45, Pages: 8
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