Research Original Research| Volume 120, ISSUE 11, P1847-1858, November 2020

Disparities in Access to Healthy Diets: How Food Security and Food Shopping Behaviors Relate to Fruit and Vegetable Intake



      Food shopping behaviors may help determine how local food environments influence fruit and vegetable (F/V) intake, especially among food insecure households.


      To examine whether household food security, food access, and food shopping behaviors are associated with F/V intake among residents of a low-income neighborhood.


      Study design is cross-sectional.


      A simple random sample of 451 adults from a low-income neighborhood in Montreal (Canada) were recruited through telephone interviews in 2014. Final analyses included 417 participants.

      Main outcome measures

      Validated assessment tools were applied to measure F/V intake and to distinguish food secure (FS) from food insecure (FI) participants. Neighborhood food access was calculated according to number of food stores within 0.5 miles of road network buffer of participants’ homes. Self-reported food shopping behaviors included trip frequency, store types, and transport used to reach the 3 most frequented stores. Participants also reported on mobility constraints, use of F/V markets, gardening, and perceived access to healthy food.

      Statistical analyses

      F/V intake was modeled using multivariable linear regression.


      A sample of adults, of whom 21.3% were living in FI households, reported consuming F/V an average of 4.1 times daily. FI participants had a lower intake of F/V (b = −0.69, P = .04), independent of sociodemographics, food access, resource constraints, perceived access to healthy food, and food shopping behaviors. Participants with mobility constraints had lower F/V intake (b = −0.68, P = .02), while gardening was associated with higher F/V intake (b = 0.59, P = .01). Number of supermarkets (b = −0.06, P = .03) and specialty stores (b = 0.10, P = .04) were associated with F/V intake, although the strength of the association was weak.


      For FI households, barriers to food access linked to financial challenges are associated with lower intake of F/V. Studies on food environment should include people’s experience of food access to better understand the numerous barriers to F/V consumption faced by FI households.


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        • Drewnowski A.
        • Specter S.E.
        Poverty and obesity: The role of energy density and energy costs.
        Am J Clin Nutr. 2004; 79: 6-16
        • Peeters A.
        • Blake M.R.C.
        Socioeconomic inequalities in diet quality: From identifying the problem to implementing solutions.
        Curr Nutr Rep. 2016; 5: 150-159
        • Darmon N.
        • Drewnowski A.
        Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: A systematic review and analysis.
        Nutr Rev. 2015; 73: 643-660
        • Darmon N.
        • Drewnowski A.
        Does social class predict diet quality?.
        Am J Clin Nutr. 2008; 87: 1107-1117
        • Black C.
        • Moon G.
        • Baird J.
        Dietary inequalities: What is the evidence for the effect of the neighbourhood food environment?.
        Health Place. 2014; 27: 229-242
        • Statistics Canada
        Household food security by living arrangement.
        (Published February 2020. Accessed February 24, 2020)
        • Cummins S.
        Neighbourhood food environment and diet—Time for improved conceptual models?.
        Prev Med. 2007; 44: 196-197
        • Caspi C.E.
        • Sorensen G.
        • Subramanian S.V.
        • Kawachi I.
        The local food environment and diet: A systematic review.
        Health Place. 2012; 18: 1172-1187
        • Chaix B.
        • Bean K.
        • Daniel M.
        • et al.
        Associations of supermarket characteristics with weight status and body fat: A multilevel analysis of individuals within supermarkets (RECORD study).
        PLoS One. 2012; 7e32908
        • Drewnowski A.
        • Aggarwal A.
        • Hurvitz P.M.
        • Monsivais P.
        • Moudon A.V.
        Obesity and supermarket access: Proximity or price?.
        Am J Public Health. 2012; 102: e74-80
        • LeDoux T.F.
        • Vojnovic I.
        Going outside the neighborhood: The shopping patterns and adaptations of disadvantaged consumers living in the lower eastside neighborhoods of Detroit, Michigan.
        Health Place. 2013; 19: 1-14
        • Hillier A.
        • Cannuscio C.C.
        • Karpyn A.
        • McLaughlin J.
        • Chilton M.
        • Glanz K.
        How far do low-income parents travel to shop for food? Empirical evidence from two urban neighborhoods.
        Urban Geogr. 2011; 32: 712-729
        • Zenk S.N.
        • Odoms-Young A.M.
        • Dallas C.
        • et al.
        “You have to hunt for the fruits, the vegetables”: Environmental barriers and adaptive strategies to acquire food in a low-income African American neighborhood.
        Health Educ Behav. 2011; 38: 282-292
        • Webber C.B.
        • Sobal J.
        • Dollahite J.S.
        Shopping for fruits and vegetables. Food and retail qualities of importance to low-income households at the grocery store.
        Appetite. 2010; 54: 297-303
        • Liese A.D.
        • Bell B.A.
        • Barnes T.L.
        • et al.
        Environmental influences on fruit and vegetable intake: Results from a path analytic model.
        Public Health Nutr. 2014; 17: 2595-2604
        • Cannuscio C.C.
        • Hillier A.
        • Karpyn A.
        • Glanz K.
        The social dynamics of healthy food shopping and store choice in an urban environment.
        Soc Sci Med. 2014; 122: 13-20
        • Zachary D.A.
        • Palmer A.M.
        • Beckham S.W.
        • Surkan P.J.
        A framework for understanding grocery purchasing in a low-income urban environment.
        Qual Health Res. 2013; 23: 665-678
        • Tach L.
        • Amorim M.
        Constrained, convenient, and symbolic consumption: Neighborhood food environments and economic coping strategies among the urban poor.
        J Urban Health. 2015; 92: 815-834
        • Dachner N.
        • Ricciuto L.
        • Kirkpatrick S.I.
        • Tarasuk V.
        Food purchasing and food insecurity among low-income families in Toronto.
        Can J Diet Pract Res. 2010; 71: e50-56
        • Clifton K.J.
        Mobility strategies and food shopping for low-income families.
        J Plan Educ Res. 2016; 23: 402-413
        • Darko J.
        • Eggett D.L.
        • Richards R.
        Shopping behaviors of low-income families during a 1-month period of time.
        J Nutr Educ Behav. 2013; 45: 20-29
        • Sohi I.
        • Bell B.A.
        • Liu J.
        • Battersby S.E.
        • Liese A.D.
        Differences in food environment perceptions and spatial attributes of food shopping between residents of low and high food access areas.
        J Nutr Educ Behav. 2014; 46: 241-249
        • Ma X.
        • Liese A.D.
        • Hibbert J.
        • Bell B.A.
        • Wilcox S.
        • Sharpe P.A.
        The association between food security and store-specific and overall food shopping behaviors.
        J Acad Nutr Diet. 2017; 117: 1931-1940
        • Kaiser M.L.
        • Carr J.K.
        • Fontanella S.
        A tale of two food environments: Differences in food availability and food shopping behaviors between food insecure and food secure households.
        J Hunger Environ Nutr. 2019; 14: 297-317
        • Santé Canada
        Mesure de l’environnement alimentaire au Canada.
        (Published 2013. Accessed May 2019)
        • Wegener J.
        • Hanning R.M.
        Concepts and measures of “alternative” retail food outlets: Considerations for facilitating access to healthy, local food.
        J Hunger Environ Nutr. 2010; 5: 158-173
        • Jilcott Pitts S.B.
        • Wu Q.
        • McGuirt J.T.
        • Crawford T.W.
        • Keyserling T.C.
        • Ammerman A.S.
        Associations between access to farmers’ markets and supermarkets, shopping patterns, fruit and vegetable consumption and health indicators among women of reproductive age in eastern North Carolina, U.S.A.
        Public Health Nutr. 2013; 16: 1944-1952
        • Jilcott Pitts S.B.
        • Wu Q.
        • Demarest C.L.
        • et al.
        Farmers’ market shopping and dietary behaviours among Supplemental Nutrition Assistance Program participants.
        Public Health Nutr. 2015; 18: 2407-2414
        • Gustafson A.
        • Christian J.W.
        • Lewis S.
        • Moore K.
        • Jilcott S.
        Food venue choice, consumer food environment, but not food venue availability within daily travel patterns are associated with dietary intake among adults, Lexington Kentucky 2011.
        Nutr J. 2013; 12: 17
        • Blitstein J.L.
        • Snider J.
        • Evans W.D.
        Perceptions of the food shopping environment are associated with greater consumption of fruits and vegetables.
        Public Health Nutr. 2012; 15: 1124-1129
        • Alaimo K.
        • Packnett E.
        • Miles R.A.
        • Kruger D.J.
        Fruit and vegetable intake among urban community gardeners.
        J Nutr Educ Behav. 2008; 40: 94-101
        • Litt J.S.
        • Soobader M.-J.
        • Turbin M.S.
        • Hale J.W.
        • Buchenau M.
        • Marshall J.A.
        The influence of social involvement, neighborhood aesthetics, and community garden participation on fruit and vegetable consumption.
        Am J Public Health. 2011; 101: 1466-1473
        • Savoie-Roskos M.
        • Durward C.
        • Jeweks M.
        • LeBlanc H.
        Reducing Food insecurity and improving fruit and vegetable intake among farmers’ market incentive program participants.
        J Nutr Educ Behav. 2016; 48: 70-76.e71
        • Huisken A.
        • Orr S.K.
        • Tarasuk V.
        Adults’ food skills and use of gardens are not associated with household food insecurity in Canada.
        Can J Public Health. 2016; 107: 526-532
      1. Tarasuk V, Mitchell A, Dachner N. Household Food Insecurity in Canada, 2014., Published 2016. Accessed May 2019.

        • Bertrand L.
        • Thérien F.
        • Goudreau S.
        • Fournier M.
        Étude sur l’accès aux aliments santé à Montréal. Six ans après la première étude, mêmes disparités?.
        Agence de la santé et des services sociaux de Montréal, Montréal, Canada2013
      2. Carrefour montréalais d'information sociosanitaire, Atlas Santé Montréal: Caractéristiques sociodémographiques de la population.
        (Published 2011. Accessed December 2019)
        • Bertrand L.
        • Goudreau S.
        Étude sur l’accès aux aliments sains à Montréal: Regard sur le territoire du CSSS Lucille-Teasdale.
        (Published 2014. Accessed May 2019)
      3. ASDE Software. [computer program]. Version 2.32: ASDE Survey Sampler, Gatineau, QC, Canada.

      4. Cheng R, Mercille G, Hamelin AM, Apparicio P. Partnering with local organizations to measure food shopping practices and perceptions of food access of Montrealers. Food Environments in Canada: Symposium and Workshop; May 21-23, 2015; Sasfatoon, SK.

        • Government of Canada
        Canadian Community Health Survey, Cycle 2.2, Nutrition (2004): Income-related household food security in Canada.
        (Published 2004. Accessed December 2019)
        • Bickel G.
        • Nord M.
        • Price C.
        • Hamilton W.
        • Cook J.
        Guide to Measuring Household Food Security, Revised 2000.
        US Department of Agriculture, Food and Consumer Service, Office of Analysis and Evaluation, Alexandria, VA2000
      5. PROOF. Household food insecurity in Canada: A guide to measurement and interpretation.
        (Published 2018. Accessed December 2019)
      6. ArcGIS for Desktop. [computer program]. Version 9.3: ESRI Inc, Redlands, CA.

        • McKinnon R.A.
        • Reedy J.
        • Morrissette M.A.
        • Lytle L.A.
        • Yaroch A.L.
        Measures of the food environment: A compilation of the literature, 1990–2007.
        Am J Prev Med. 2009; 36: S124-S133
        • Engler-Stringer R.
        • Le H.
        • Gerrard A.
        • Muhajarine N.
        The community and consumer food environment and children’s diet: A systematic review.
        BMC Public Health. 2014; 14: 522
        • Larsen J.
        • El-Geneidy A.
        • Yasmin F.
        Beyond the quarter mile: Examining travel distances by walking and cycling, Montréal, Canada.
        Can J Urban Res. 2010; 19: 70-88
        • Clary C.M.
        • Kestens Y.
        Field validation of secondary data sources: A novel measure of representativity applied to a Canadian food outlet database.
        Int J Behav Nutr Phys Act. 2013; 10: 77
        • Tabachnick B.G.
        • Fidell L.S.
        Using Multivariate Statistics.
        Allyn and Baco, Boston, MA2007
      7. Economic Research Service (ERS), U.S. Department of Agriculture (USDA). National Household Food Acquisition and Purchase Survey (FoodAPS).
        (Published 2012. Accessed May 2019)
      8. Statistics Canada. Households and the Environment Survey, 2013 (HES).
        (Published 2013. Accessed May 2019)
        • Minaker L.M.
        • Raine K.D.
        • Wild T.C.
        • Nykiforuk C.I.
        • Thompson M.E.
        • Frank L.D.
        Objective food environments and health outcomes.
        Am J Prev Med. 2013; 45: 289-296
        • Gustafson A.A.
        • Sharkey J.
        • Samuel-Hodge C.D.
        • et al.
        Perceived and objective measures of the food store environment and the association with weight and diet among low-income women in North Carolina.
        Public Health Nutr. 2011; 14: 1032-1038
        • Schermel A.
        • Mendoza J.
        • Henson S.
        • et al.
        Canadians’ perceptions of food, diet, and health—a national survey.
        PLoS One. 2014; 9e86000
        • Mujahid M.S.
        • Diez Roux A.V.
        • Morenoff J.D.
        • Raghunathan T.
        Assessing the measurement properties of neighborhood scales: From psychometrics to ecometrics.
        Am J Epidemiol. 2007; 165: 858-867
        • Penchansky R.
        • Thomas J.W.
        The concept of access: Definition and relationship to consumer satisfaction.
        Med Care. 1981; 19: 127-140
        • Traynor M.M.
        • Holowaty P.H.
        • Reid D.J.
        • Gray-Donald K.
        Vegetable and fruit food frequency questionnaire serves as a proxy for quantified intake.
        Can J Public Health. 2006; 97: 286-290
      9. Direction de la santé publique de Montréal. ENQUÊTE TOPO 2012: Guide méthodologique.
        (Published 2012. Accessed January 2019)
      10. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Questionnaire. 2013., Published 2012, Accessed January 2019.

        • National Cancer Institute
        Identifying extreme exposure values.
        (Published 2018. Accessed May 2019)
      11. IBM SPSS Statistics for Macintosh [computer program]. Version 25.0. IBM Corp, Armonk, NY2017
        • Hanson K.L.
        • Connor L.M.
        Food insecurity and dietary quality in US adults and children: A systematic review.
        Am J Clin Nutr. 2014; 100: 684-692
        • Laraia B.A.
        Food insecurity and chronic disease.
        Adv Nutr. 2013; 4: 203-212
        • Morales M.E.
        • Berkowitz S.A.
        The relationship between food insecurity, dietary patterns, and obesity.
        Curr Nutr Rep. 2016; 5: 54-60
        • Rao M.
        • Afshin A.
        • Singh G.
        • Mozaffarian D.
        Do healthier foods and diet patterns cost more than less healthy options? A systematic review and meta-analysis.
        BMJ Open. 2017; 3: e004277
        • Monsivais P.
        • Aggarwal A.
        • Drewnowski A.
        Are socioeconomic disparities in diet quality explained by diet cost?.
        J Epidemiol Community Health. 2012; 66: 530-535
        • Aggarwal A.
        • Monsivais P.
        • Cook A.J.
        • Drewnowski A.
        Does diet cost mediate the relation between socioeconomic position and diet quality?.
        Eur J Clin Nutr. 2011; 65: 1059-1066
        • Zenk S.N.
        • Lachance L.L.
        • Schulz A.J.
        • Mentz G.
        • Kannan S.
        • Ridella W.
        Neighborhood retail food environment and fruit and vegetable intake in a multiethnic urban population.
        Am J Health Promot. 2009; 23: 255-264
        • Morland K.
        • Wing S.
        • Diez Roux A.
        The contextual effect of the local food environment on residents’ diets: The atherosclerosis risk in communities study.
        Am J Public Health. 2002; 92: 1761-1767
        • Bodor J.N.
        • Rose D.
        • Farley T.A.
        • Swalm C.
        • Scott S.K.
        Neighbourhood fruit and vegetable availability and consumption: The role of small food stores in an urban environment.
        Public Health Nutr. 2008; 11: 413-420
        • Rose D.
        • Richards R.
        Food store access and household fruit and vegetable use among participants in the US Food Stamp Program.
        Public Health Nutr. 2004; 7: 1081-1088
        • Thornton L.E.
        • Pearce J.R.
        • Macdonald L.
        • Lamb K.E.
        • Ellaway A.
        Does the choice of neighbourhood supermarket access measure influence associations with individual-level fruit and vegetable consumption? A case study from Glasgow.
        Int J Health Geogr. 2012; 11: 29
        • Ball K.
        • Crawford D.
        • Mishra G.
        Socioeconomic inequalities in women’s fruit and vegetable intakes: A multilevel study.
        Pub Health Nutr. 2006; 9
        • Pearson T.
        • Russell J.
        • Campbell M.J.
        • Barker M.E.
        Do “food deserts” influence fruit and vegetable consumption?—A cross-sectional study.
        Appetite. 2005; 45: 195-197
        • Murakami K.
        • Sasaki S.
        • Takahashi Y.
        • Uenishi K.
        Neighborhood food store availability in relation to food intake in young Japanese women.
        Nutrition. 2009; 25: 640-646
        • Thornton L.E.
        • Crawford D.A.
        • Ball K.
        Neighbourhood-socioeconomic variation in women’s diet: The role of nutrition environments.
        Eur J Clin Nutr. 2010; 64: 1423-1432
        • Boone-Heinonen J.
        • Gordon-Larsen P.
        • Kiefe C.I.
        • Shikany J.M.
        • Lewis C.E.
        • Popkin B.M.
        Fast food restaurants and food stores: Longitudinal associations with diet in young adults: The CARDIA Study.
        Arch Intern Med. 2011; 171: 1162-1170
        • Minaker L.M.
        Retail food environments in Canada: Maximizing the impact of research, policy and practice.
        Can J Public Health. 2016; 107: 5632
        • Hamelin A.-M.
        • Beaudry M.
        • Habicht J.-P.
        La vulnérabilité des ménages à l’insécurité alimentaire.
        Canadian Journal of Development Studies / Revue canadienne d’études du développement. 1998; 19: 277-306
        • Dachner N.
        • Tarasuk V.
        Tackling household food insecurity: An essential goal of a national food policy.
        Canadian Food Studies. 2018; 5: 230-247
        • Kirkpatrick S.I.
        • Tarasuk V.
        Assessing the relevance of neighbourhood characteristics to the household food security of low-income Toronto families.
        Public Health Nutr. 2010; 13: 1139-1148
        • Perez E.
        • Roncarolo F.
        • Potvin L.
        Associations between the local food environment and the severity of food insecurity among new families using community food security interventions in Montreal.
        Can J Public Health. 2017; 108: e49-e55
        • Burns C.
        • Bentley R.
        • Thornton L.
        • Kavanagh A.
        Reduced food access due to a lack of money, inability to lift and lack of access to a car for food shopping: A multilevel study in Melbourne, Victoria.
        Public Health Nutr. 2011; 14: 1017-1023
        • Frongillo E.A.
        • Wolfe W.S.
        • Valois P.
        Understanding the experience of food insecurity by elders suggests ways to improve its measurement.
        J Nutr. 2003; 133: 2762-2769
        • Shim J.E.
        • Kim S.-J.
        • Kim K.
        • Hwang J.-Y.
        Spatial disparity in food environment and household economic resources related to food insecurity in rural Korean households with older adults.
        Nutrients. 2018; 10: 1514
        • Lee J.S.
        • Frongillo Jr., E.A.
        Factors associated with food insecurity among U.S. elderly persons: Importance of functional impairments.
        J Gerontol B Psychol Sci Soc Sci. 2001; 56: S94-S99
        • Giskes K.
        • van Lenthe F.J.
        • Kamphuis C.B.
        • Huisman M.
        • Brug J.
        • Mackenbach J.P.
        Household and food shopping environments: Do they play a role in socioeconomic inequalities in fruit and vegetable consumption? A multilevel study among Dutch adults.
        J Epidemiol Community Health. 2009; 63: 113-120
        • Caspi C.E.
        • Kawachi I.
        • Subramanian S.V.
        • Adamkiewicz G.
        • Sorensen G.
        The relationship between diet and perceived and objective access to supermarkets among low-income housing residents.
        Soc Sci Med. 2012; 75: 1254-1262
        • Griffith D.M.
        • Cornish E.K.
        • McKissic S.A.
        • Dean D.A.
        Differences in perceptions of the food environment between African American men who did and did not consume recommended levels of fruits and vegetables.
        Health Educ Behav. 2016; 43: 648-655
        • Caldwell E.M.
        • Miller Kobayashi M.
        • DuBow W.M.
        • Wytinck S.M.
        Perceived access to fruits and vegetables associated with increased consumption.
        Public Health Nutr. 2009; 12: 1743-1750
        • Inglis V.
        • Ball K.
        • Crawford D.
        Socioeconomic variations in women’s diets: What is the role of perceptions of the local food environment?.
        J Epidemiol Community Health. 2008; 62: 191-197
        • Alber J.M.
        • Green S.H.
        • Glanz K.
        Perceived and observed food environments, eating behaviors, and BMI.
        Am J Prev Med. 2018; 54: 423-429
        • Menezes M.C.d.
        • Diez Roux A.V.
        • Souza Lopes A.C.
        Fruit and vegetable intake: Influence of perceived food environment and self-efficacy.
        Appetite. 2018; 127: 249-256
        • Jilcott Pitts S.B.
        • Gustafson A.
        • Wu Q.
        • et al.
        Farmers’ market use is associated with fruit and vegetable consumption in diverse southern rural communities.
        Nutr J. 2014; 13 (1-1)
        • Minaker L.M.
        • Olstad D.L.
        • Thompson M.E.
        • Raine K.D.
        • Fisher P.
        • Frank L.D.
        Associations between frequency of food shopping at different store types and diet and weight outcomes: Findings from the NEWPATH study.
        Public Health Nutr. 2016; 19: 2268-2277
        • McGuirt J.T.
        • Jilcott Pitts S.B.
        • Gustafson A.
        Association between spatial access to food outlets, frequency of grocery shopping, and objectively-assessed and self-reported fruit and vegetable consumption.
        Nutrients. 2018; 10: 1974
        • Vaughan C.A.
        • Collins R.
        • Ghosh-Dastidar M.
        • Beckman R.
        • Dubowitz T.
        Does where you shop or who you are predict what you eat? The role of stores and individual characteristics in dietary intake.
        Prev Med. 2017; 100: 10-16
        • Aggarwal A.
        • Cook A.J.
        • Jiao J.
        • et al.
        Access to supermarkets and fruit and vegetable consumption.
        Am J Public Health. 2014; 104: 917-923
        • Clary C.
        • Matthews S.A.
        • Kestens Y.
        Between exposure, access and use: Reconsidering foodscape influences on dietary behaviours.
        Health Place. 2017; 44: 1-7


      C. Drisdelle is a graduate from the Département de nutrition, Université de Montréal, Montreal, Quebec, Canada.


      G. Mercille is an assistant professor, Département de nutrition, and the WHO Collaborating Centre on Nutrition Changes and Development, Université de Montréal, Montreal, Quebec, Canada.


      Y. Kestens is an associate professor, Département de médecine sociale et préventive, École de Santé Publique, Université de Montréal, Montreal, Quebec, Canada.


      A.-M. Hamelin is an associate director, 4P Training Program, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.

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