June 2019 Issue

CPE Monthly: Food Deserts — Understanding Inequity, Seeking Solutions
By Lindsay Ganong, MS, RDN, and Alison Harmon, PhD, RD
Today’s Dietitian
Vol. 21, No. 6, P. 40

Suggested CDR Learning Codes: 3020, 4010, 4070
Suggested CDR Performance Indicators: 3.3.5, 8.2.1, 12.1.1, 12.2.1
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Food insecurity is a lack of consistent, dependable, culturally appropriate food for healthful, active living.1 A food desert is defined as the general unavailability of healthful food in socially disadvantaged and/or economically depressed geographic areas.2 Food deserts are associated with poverty. In the United States, people of color and indigenous peoples are particularly at risk of a lack of access to healthful foods and disproportionately live in food deserts.3

Additional terms associated with food insecurity can help dietetics professionals better understand the food environment and the specific challenges for individuals and families (see Figure 1).

For example, an increased concentration of foods of low nutrient density has been labeled a “food swamp.”4 Similarly, a “food mirage” is a neighborhood with seemingly adequate full-service grocery stores that have a variety of foods, but in which the components of a healthful diet are unaffordable or the grocery store may be culturally or socially unacceptable to some neighborhood residents.5,6 The food mirage concept can help RDs understand and explore equitable food access.

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Food deserts, swamps, and mirages are all examples of food environments contributing to food insecurity. Contrarily, food security is defined as having consistent, dependable access to enough nutritious and culturally acceptable food for active, healthful living, acquired in socially acceptable ways.7 In 2016, 12.3% of households (42 million individuals) in the United States were food insecure,8 and, in a 2009 report to Congress, the USDA Economic Research Service found that about 23.5 million US residents are living in food deserts.9

This continuing education course seeks to improve dietitians’ understanding of food deserts as a concept and a reality in both urban and rural settings. Better understanding of food deserts and their implications for health will support growing competence in counseling clients while being conscious of their food access. This course also explores the roles for RDs in addressing problems created by food deserts, including as educators, innovators, and advocates.

Food deserts represent a specific kind of food insecurity by compounding experiences of individual economic, social, or physical disparity. The characteristics of food deserts and consequent coping strategies of individuals differ depending on whether the environment is rural or urban.

Urban Food Deserts
Urban food environments can include all three types of food disparities (mirages, deserts, and swamps). Deserts can exist in any urban environment where there’s poor access to food. For example, black families in Philadelphia food deserts experience high cost and low variety in corner stores. They report unfair pricing in stores in the neighborhood, lack of safety in reaching stores after dark, lack of transportation to supermarkets outside of the neighborhood, limited income, and a desire to purchase foods from “middle class” establishments (supermarkets) instead of corner stores. Residents are willing to pay more for certain food items in stores in middle class neighborhoods, a phenomenon associated with “symbolic consumption.” They may not be willing to shop at the closest highest-class supermarkets because they feel socially excluded from these stores. One interviewee stated, “So you have to go where you can get in, where you fit, so I go all the way to 56th and Market.”10

Rural Food Deserts
In rural food deserts, food prices are higher than in urban food deserts, especially for foods of higher nutritional value. Higher food prices can impede healthful eating.11 However, in rural Kentucky, the most expensive foods were of medium or high nutritional quality and the most nutritious foods were less expensive.12 Rural Montana residents reported high-cost, low-quality produce in a focus group. Participants also lacked adequate means of public and private transportation, with older adults being additionally challenged by physical immobility.13

Women in 14 focus groups in Illinois’ seven most rural counties experienced a food desert with fewer stores, less in-store food variety, and fewer organizational, community, and public strategies addressing food deserts than in urban areas. The greatest barriers to accessing healthful foods mentioned in the study included low in-store access, individual preference for convenience foods, decreased access to transportation, low-quality in-store produce, and low frequency of grocery trips farther away from rural homes.14

Health Implications of Food Deserts
The hunger that exists in US food deserts can be a source of pain, light-headedness, and anxiety; it impedes physical development and lowers academic achievement; it’s implicated in chronic disease and mental disorders, has a paradoxical relationship with BMI, and comes with consequences for overall quality of life.7

Food Insecurity and Chronic Disease
It’s difficult to afford nutritious foods on a limited budget, exacerbating chronic disease risk for low-income populations. In particular, food insecurity has been associated with diabetes mellitus and cardiovascular risk factors such as hypertension and hyperlipidemia.15 Low-income and minority populations suffer most from high food costs, low-quality foods, and limited access to fresh food, which also is related to overweight and obesity.16

Individuals who are food insecure often rely on low-cost, energy-dense but nutrient-poor foods to satisfy hunger.8 The least expensive forms of food energy are foods in the categories of fats, grains, and other carbohydrates. Conversely, fruits and vegetables are the most expensive in terms of calories, while meat, poultry, and fish are the most expensive per serving.17

Shopping at convenience stores is associated with circumstances including poorer diet; being younger, male, and less educated; and using Supplemental Nutrition Assistance Program (SNAP) benefits.18

Food Insecurity–Obesity Paradox
The observed relationship between food insecurity and obesity seems paradoxical because food insecurity suggests poor access to food, while obesity typically is associated with overconsumption. The food insecurity–obesity paradox is most readily observed in adult women, in whom the prevalence of overweight is positively associated with moderate food insecurity.19 Hypotheses for the relationship include the low cost of energy-dense foods and lower-quality diets, and poor intake of fruits and vegetables. Food-insecure individuals can become preoccupied with food, experience depression and additional stress related to uncertainty about food, and have limitations regarding physical activity. Alternating periods of food restriction and binge eating when food is plentiful results in metabolic changes, increased storage of body fat, and decreased lean muscle mass. Refeeding after a period of involuntary food restriction leads to quicker weight gain.20 Food assistance is associated with a feast-famine cycle, in which benefits are distributed at the beginning of the month but don’t last four weeks. During the first two or three weeks, food may be plentiful, but the last week is marked by food insufficiency in food-insecure households.21 Binge eating and nighttime eating among children in food-insecure households also has been observed.22

Food Deserts and Obesity Status
The relationship between living in food deserts and one’s BMI isn’t entirely clear, particularly in urban food deserts. In one study, residents who had to travel farther to shop for food experienced higher rates of obesity. However, prices are a better predictor of obesity than is distance to the store. Shopping in higher-priced stores is associated with lower likelihood of obesity. Different kinds of stores market food differently, and stores with lower prices are more likely to feature less healthful foods more prominently.23 Residents of urban food deserts who have means to travel farther to shop can gain access to more healthful food selections.24

The number of supermarkets in a locale is negatively associated with obesity status.25 Shorter distance to health food stores has been associated with greater improvements in consumption of fiber and fruits and vegetables.26 In addition, food deserts have been characterized as lacking safe places to be physically active and having fewer amenities that support physical activity such as public parks.27

The relationship between childhood obesity and living in food deserts may warrant special attention from food and nutrition professionals, noting that childhood obesity is a significant expense for society—about $14 billion in direct medical expenses annually. Changes in the retail environment can produce changes in obesity rates. An increasing number of convenience stores in a food environment is positively related to obesity rates among preschool-age children in low-income families. As the number of grocery stores and supercenters increases, obesity rates decrease. The use of SNAP benefits also has been associated with increased childhood obesity, potentially related to the food insecurity–obesity paradox described earlier.28

To summarize, poor access to fresh foods combined with the accessibility of convenience foods can contribute to poor diets and health outcomes, including obesity. The circumstances surrounding food insecurity, which are exacerbated in food deserts, can contribute to obesity and chronic disease, particularly when dependence on food assistance results in alternating periods of overeating and hunger.

Assessment of Food Deserts
The USDA Economic Research Service offers the Food Environment Atlas, a tool for identifying food deserts.29 The atlas provides county- or region-level data related to food choice, food availability, food accessibility, diet-related disease rates, local food, and the food and activity environment. The geographic parameters of the map are defined by census tract and county lines rather than neighborhood.1 The atlas doesn’t measure food quality and acceptability in food outlets, so more information is needed to create a complete picture of food availability in a neighborhood or rural community.

It’s beneficial to use a food systems approach when assessing food access in a community. The food system consists of production, transformation, distribution, access, and consumption sectors and is influenced by policy, economics, education, technology, and social trends.30 Assessment techniques help practitioners elucidate the relationships between food system sectors, influencers, and outcomes that contribute to or ameliorate the food desert. For instance, an urban food desert typically contains similar low-nutrient density foods in each corner store. Limited food selection is an outcome of the food distributors available to small store owners in a given area.31 Food selection in corner stores is influenced by supply-and-demand economics and the nutrition knowledge and skills (education) of customers.32 Therefore, food desert solutions often focus on food marketing, food and nutrition education, and interventions engaging corner store owners and their distributors. Social and economic influencers also affect where residents of food deserts shop.24 A food systems approach also would include a strong community engagement element to find solutions that work best for food desert residents who may not find it useful to have a full-service grocery in the neighborhood.33

The data show a decreased prevalence of health-related resources and food outlets as the concentration of minorities increases in an area, including blacks and, to a lesser extent, Latino and Asian immigrants. In addition to socioeconomic disadvantages, lack of health resources compounds challenges in the food desert environment. Lack of food stores in neighborhoods of color is related to organizational flight—the movement of businesses due to the effects of poverty or racial makeup of a community.34 Assessments must measure resources for all people and disaggregate data to show disparities in resource distribution to address the inequity.35 It’s important to know who’s living in a food desert to understand the story of how the food desert developed and whose responsibility it is to create more just food environments.

Importantly, when the food system outcomes or external influencers damage the human or natural resource foundation of the food system, the impacts are felt throughout the food system. In an equitable food system, all racial and ethnic groups would have equal access to foods. By viewing the food system through a food justice lens, one can understand the historic events that continue to influence the food system in which demographics contribute to inequitable food access and drastic health disparities. Racism continues to segregate people of color and prevent access to land and water that once fed people a more healthful diet than what’s available in today’s food swamps and food deserts where disenfranchised people disproportionately live.36

Authors use a wide variety of measurements to characterize community and consumer food environments.37 For example, authors have considered household income, access to transportation, quality of food sold in available food outlets, and proximity to food outlets.2 Figure 2 describes additional questions and indicators for assessment using a food system and justice lens. For example, we also can consider the time of day, month, or year that food and funds are available; the social, cultural, and safety barriers to accessing food; the cultural acceptability of available food; and knowledge and skills of the consumer for building a healthful diet pattern with food that’s available and affordable. Other dynamic factors, including policy, education, marketing, and economics, influence the consumer food environment. Considering these assessment criteria and observing trends enables us to characterize the community food environment and consider who has the power and responsibility to create change.

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In 2015, the City of Baltimore defined a food desert as “an area where the distance to a supermarket or supermarket alternative is more than 1/4 mile, the median household income is at or below 185% of the federal poverty level, more than 30% of households have no vehicle available, and the average Healthy Food Availability Index score for all food stores is low.” Using the definition, the city identified four measurement criteria: residents’ proximity to food outlets, ability to afford food, access to transportation, and availability of healthful foods.38

Interventions and Strategies for Addressing Disparate Food Access
Strategies to overcome food access and quality issues related to food deserts target multiple levels of the social-ecological model of health behaviors. Following are examples of interventions at the individual, organizational, community, and public policy levels.

Individual and Interpersonal Strategies
Individuals and families cope with limited food access in urban spaces by purchasing food items from a variety of stores if they have transportation (eg, public, car) and shopping at corner stores in the neighborhood. Families also use food pantries, takeout restaurants, and other families’ and friends’ food resources, including food assistance benefits at the end of the month; when it’s available, residents buy fresh food at the farmers’ market.10

In rural Illinois, individuals and families rely on sharing and preserving food from gardens, food pantries, and food waste recovery programs, or periodically travel to more populated areas to access healthful foods.14 Older adults in rural Montana have reported a reluctance to use community food programs, and participants express appreciation for the local food pantry, although it’s underutilized. They also mention using sources of wild food (eg, berries, apples, and hunted foods such as deer, elk, and fish), home gardens, freezing, fermenting, canning foods, and sharing among friends. Older adult populations in rural food deserts may require special consideration in planning for rural food desert solutions, including policy and environmental changes. They are more likely to live in isolation, are less mobile, have health issues specific to older adulthood, have preferences for more traditional foods, and may have negative attitudes about public assistance.13

Federal nutrition programs such as SNAP Education (SNAP-Ed) and the Expanded Food and Nutrition Education Program offer direct nutrition education to individuals and families in poverty. Series of nutrition classes aim to improve participants’ knowledge of food and nutrition and teach cooking skills, modern food safety practices, stretching the food dollar, physical activity, and cooking healthful meals with SNAP benefit dollars. All education derives from the Dietary Guidelines for Americans and the Physical Activity Guidelines. Since 2015, SNAP-Ed also has been working toward research-tested policy, systems, and environment change in communities for obesity prevention. The food pantry assessment and Farm to School efforts discussed below are examples of policy and food environment change in the SNAP-Ed Toolkit. Community strategies such as the Healthy Corner Stores Initiative also acknowledge the joint need for individual food and nutrition education and multilevel interventions to policies, systems, and the social and physical environment.39

Organizational Strategies
Efforts to improve the food environment by offering high-quality foods at food banks or pantries are examples of organization-level intervention. The Healthy Food Pantry Assessment Project from Washington State University provides food pantries an assessment tool with which to evaluate the prominence of foods available in comparison with the recommendations of the Dietary Guidelines for Americans. The tool also can be used to evaluate the safety of the food pantry environment and the dignity afforded to food pantry clients.40

Low-income students eat a significant number of their meals each week at school. The Riverside Unified School District in Riverside, California, includes many low-income neighborhoods that have poor access to supermarkets. The district school meals program provides a farmers’ market salad bar comprising 50% to 100% local foods each day. The school also participates in a harvest of the month program, teacher training, monthly educational newsletters for schools that outline physical activities and garden activities, as well as monthly family newsletters with healthful eating tips, recipes, and tips for purchasing, storing, and serving featured produce. As a result of the school’s farm-to-school programs, children living in a food desert have greater access to fruits and vegetables, while at the community level an institutional buyer was supporting local producers. A National Farm to School Network “how-to guide” contains a logic model that shows all of the players in the school organization and the community that made the farmers’ market salad bar possible.41

In Brooklyn Park, Maryland, four organizations partner to improve access to high-quality foods for families living in food deserts. SNAP-Ed participates in a partnership with the USDA Summer Food Service Program (SFSP) by sending mobile trucks and vans to summer lunch sites and attracting families to an 11-week farmers’ market at the middle school. Families may purchase fresh foods and receive fresh food promotional dollars to encourage them to purchase healthful fruits and vegetables with SNAP benefits, and participants younger than age 18 receive a free meal from the SFSP run by the county public school. SNAP-Ed provides recipes for produce available and fruit and vegetable samples to address individual knowledge, and the County Health Department funds a marketing and outreach campaign to increase demand for farmers’ market foods and awareness of the weekly market. The fourth partner, the farmers’ market association, arranges a community-supported agriculture (CSA) program with the four partner agency employees. Farmers sell an 11-week $20 CSA bag to employees. Employees pledge money at the beginning of the season to invest in the farm enterprise and share the risks and benefits of a growing season with the farmer. Each week, employees pick up bags that contain in-season farm produce worth $20. The CSA bags make it worth the farmers’ time to attend the school farmers’ market in a low-income area. A separate grant-funded $7.50 CSA bag for families at one of the elementary SFSPs provides families and children with consistent local produce throughout the summer. Additional external partners have joined the farmers’ market to provide story time, summer reading, health booths, games, and prizes.42

Community Strategies
The literature suggests that access to healthful foods may improve client selections at a store. Community strategies can focus on city or neighborhood planning with a food system lens, increasing the presence of healthful food outlets, healthful corner stores, or mobile markets, and even providing virtual supermarkets to decrease transportation barriers.

Engler-Stringer and colleagues suggest that increasing access to healthful foods in a neighborhood where planning is viewed through a food system lens may increase purchasing and consumption of healthful foods. Community planners included very low-resource individuals and a disproportionately high percentage of indigenous residents in Saskatoon, Saskatchewan, Canada, in eight years of planning to address food insecurity in a food desert. The study intervention broke transportation and low food quality barriers by building a 4,900-ft2 membership model/cooperative grocery to increase access to healthful foods. Results of door-to-door surveys showed high acceptance of the store by neighborhood residents.43

In a 2012 systematic review of retail food interventions, Gittelsohn and colleagues found that combined approaches addressing individual consumer behaviors (such as nutrition education at the point of purchase) as well as the retail small-store food environment (such as store layout) improved access to more healthful foods, and, in some studies, increased consumption of more healthful foods. Stores that implemented interventions to accept federal food benefits (eg, SNAP, WIC) or offer price promotions (eg, coupons, vouchers, discounts) experienced greater demand for more healthful foods. The review also suggests policies to encourage partnership throughout the food system sectors to increase affordability and availability of more healthful foods in small stores.44

A 2014 case study collected experiences about healthful corner store initiatives in Baltimore; Minneapolis; Burlington, North Carolina; and Philadelphia.32 In Burlington, Latino grocery store owners were trained to increase fruit and vegetable variety. A competitive food marketing campaign promoted fruit and vegetable sales. In Philadelphia, the project brought 18,000 new healthful products, including fruits, vegetables, and whole grain items, to corner stores. Interestingly, the Philadelphia project was led by the Food Trust as part of its School Nutrition Policy Initiative to address the food environment for children who either eat at school or buy food from corner stores. Interventions need to balance stocking healthful foods and efforts to increase demands for healthful foods, and store owners must maintain profit margins to continue with the program. Philadelphia has adequate formative evidence of the success of corner store initiatives such that the city created policies to certify corner stores to ensure affordable, acceptable, and adequate access to the foods that constitute a healthful diet.

Mobile food markets have been proposed as a long-term solution to address limited access to fresh foods while creating markets for local producers, promoting equity in access to fresh food, and offering nutrition education interventions at mobile market sites. The presence of a mobile market has been correlated with increased fruit and vegetable consumption. Challenges of mobile markets include financial sustainability, difficulty communicating the purpose of the project to the communities they serve, marketing schedule and location, quality and variety of produce, and lack of awareness of the mobile market mission.16

In a nationwide survey of mobile market managers, Ramirez and colleagues found that mobile markets can bring produce to the people most successfully when the community is involved in all aspects of the mobile market operations and planning, including setting prices, location of trucks, and schedule. Mobile market operators should partner with a trusted community organization to offer produce directly to consumers at a location residents already visit. In addition, social marketing campaigns for mobile markets should include nutrition education to increase the perceived benefit of produce purchases and should reach residents on their most preferred channel of communication, including websites and social media platforms accessible by phone. In Ramirez and colleagues’ study, mobile markets lacked adequate community engagement to support a financially viable operation. These results suggest a future strategy of extending the healthful corner store initiative by working with small food retailers to stock and appropriately store and market fresh produce in areas with limited access to high-quality produce rather than to attempt the high-input, low-output task of directly marketing produce to low-income minority residents of food deserts.45

The forcible removal of indigenous people from their homelands and/or their confinement in often remote or marginal reservations contributed to the erosion of traditional foodways for this population. Geographic separation of racial minorities has contributed to modern food deserts in both urban and rural environments. A University of Arkansas Intertribal Food Systems Report describes 40 tribe-led projects related to the reclamation of food sovereignty and projects that have sought to improve food security.46 Projects focus on the understanding of food as medicine, youth development, and economic development in tribal communities, among other themes. Native American households tend to share food, food benefits, and food knowledge, and tribes aim to foster traditional food knowledge and increase intergenerational sharing of knowledge with tribal leaders.

Public Policy Strategies
Policy recommendations at various levels of food system intervention typically fall into categories including food and nutrition assistance, consumer knowledge, attitudes and behaviors, health food retail and availability, and food production.47 Specific policy recommendations might pertain to fruit and vegetable farm workers receiving fair wages and working conditions; access to reliable and affordable transportation; a sufficient number of small markets and grocery stores with diverse health food options; reducing barriers to rural farmers’ markets and sources of local foods such as farm stands, food cards, produce trucks, including infrastructure to support farmers coming to market; systems that bring foods directly to consumers; and support to farmers to provide safe, affordable, and healthful foods.

Food policy councils often form to address community issues related to access to quality food, providing recommendations directly to policy makers. For example, in Prince George’s County, Maryland, where 43% of residents live in food deserts, a Food Equity Council formed in 2014 to provide policy recommendations for meeting rural residents’ food needs.48 Policies supported local food ventures, expanded nutrition education, and increased access to affordable foods, including healthful mobile vending. In 2017, County Council candidates were asked to respond to a 2018 Food Policy Platform created by the Food Equity Council and participate in a conversation about ensuring food access and availability for all county residents.

According to Myers and colleagues, food retailers may not be attracted to some “food deserts,” and public health approaches that focus on revitalizing supermarkets alone are inadequate solutions to reverse the poor public health trends occurring in food deserts. However, good food should be a public service of the government. The foundation of a new public food infrastructure lies in government food stores, similar to a military commissary or a state-run alcohol store, to make healthful foods affordable in urban neighborhoods with low access.49

Implications for Practice and the RD’s Role
The RD’s role in addressing problems created by food deserts includes being educators, innovators, and advocates. An important first step lies in understanding the characteristics of food deserts, swamps, and mirages and the strategies used to cope with these varying food environments. Providing diet counseling or nutrition education for clients entails understanding the food environment, such that assistance can be provided in the context of one’s limited food access. In communities, RDs can be important members of professional teams seeking to make connections among producers, food distributors, and food-insecure families and neighborhoods through creative planning and projects. Developing food system linkages through community gardens, mobile markets, neighborhood stores, community kitchens, and community-supported farms is well within the scope of dietetics practice. Finally, RDs can work toward systemic change by first understanding opportunities and barriers and then by being effective advocates for policies that improve access to food through a strong food safety net and through normal market-driven channels that serve to strengthen community food systems.

— Lindsay Ganong, MS, RDN, is food service director at Polson School District in Polson, Montana.

— Alison Harmon, PhD, RD, is dean of the College of Education, Health and Human Development at Montana State University.

Learning Objectives

After completing this continuing education course, nutrition professionals should be better able to:
1. Define terms and understand concepts associated with food deserts and food insecurity.
2. Identify and evaluate vulnerable clients and neighborhoods at risk of food insecurity and understand the health implications and specific challenges.
3. Apply information and intervention strategies related to food deserts in public health and private practice settings.
4. Assess ways nutrition professionals can lead efforts in community food system building that improve food security for all.

CPE Monthly Examination

1. What is the definition of “food desert”?
a. A food environment in which proximal sources of food are insufficient, transportation is unavailable, and income is limited
b. An urban food environment with a limited number of grocery stores
c. A rural food system in which food supplies are limited to convenience stores
d. A food environment with abundant low-quality and ultraprocessed foods and where high-quality foods are less available

2. What is the definition of “food mirage”?
a. A food environment without reliable and safe water supplies
b. A food environment where high-quality foods are unavailable, usually due to costs or social barriers
c. An urban food environment with an abundance of fast food outlets
d. A food environment characterized by inconsistent or culturally inappropriate food access

3. What is the definition of “food swamp”?
a. Inadequate access to fresh produce
b. Areas where food production is difficult due to wet soils
c. A food environment without reliable and safe water supplies
d. A food environment with an abundance of low-quality and ultraprocessed foods and where high-quality foods are less available

4. Which of the following is a strategy to address food deserts at the individual level?
a. Sharing food with family or friends
b. A food pantry environment intervention
c. A summer school farmers’ market with subsidized community supported agriculture bags for elementary school families
d. A farmers’ market salad bar at a Title I school district.

5. Which of the following is an example of a policy-level strategy to address food deserts?
a. Providing a mobile food market after normal working hours
b. Creating a food equity council to provide recommendations to city council members
c. Providing food and nutrition classes for individuals
d. Creating a summer elder camp for teaching indigenous foodways

6. Symbolic consumption is a response to which type of food environment disparity in the socio-ecological context?
a. A food mirage
b. A food desert
c. A food swamp
d. A food-insecure community

7. Poor diets have been associated with which of the following?
a. Being older
b. Being female
c. Being more educated
d. Supplemental Nutrition Assistance Program eligibility

8. What is one way in which urban and rural food deserts differ?
a. The distance required to travel to the nearest healthful food outlet
b. Income levels of residents
c. Residents’ access to transportation
d. Access to high-quality foods

9. Which of the following would be a good first step for RDs who want to address food insecurity in their communities?
a. Providing standard diet counseling regardless of a client’s food access
b. Developing food system linkages that connect consumers and producers
c. Understanding the characteristics of food deserts, swamps, and mirages
d. Advocating for public policies that address food insecurity

10. Which of the following is a component of the food insecurity–obesity paradox?
a. People with limited income routinely overconsume calories.
b. Those who are food insecure have high intakes of fresh produce.
c. Low-quality and ultraprocessed foods tend to be less affordable.
d. In food-insecure households, there are alternating periods of food restriction and binge eating due to the availability of food dollars/food benefits.

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