Evidence

Evidence

Evidence supporting the health benefits of access to Healthy Food


Evidence suggests there are a range of factors that contribute to the built food environment and its impact on encouraging healthy eating behaviours. 


A considerable body of literature exists relating to the association between the community food environment and diet quality (such as through purchasing and consumption behaviours); the association between the community food environment and obesity; and the association between neighbourhood characteristics (i.e. disadvantage) and the food environment. 


Scope of evidence


Studies predominantly from Australia, UK and USA, have shown that the density of, and proximity to, food outlets has an influence on food purchasing and consumption. For example, a higher proportion of healthy food outlets can increase the purchasing and consumption of foods such as fruit and vegetables, which is associated with good health.  [4] Conversely, evidence suggests that people living in areas of greater disadvantage also have poorer access to healthy food outlets and experience poorer health outcomes. [4] 


In this section you will learn more about:


See a summary of the above evidence

Food retail facilities


Location of food retail outlets where the predominant offer is healthy food 


Access to healthy food outlets has significant potential to positively influence the health of communities.  [19] For children and adolescents, the presence of adequate food outlets in communities significantly predicted adequate vegetable consumption.  [20] 


The PANORG  [4] study found that: 

  • areas with a higher density (proportion) of, and proximity to, healthier stores are associated with healthier purchases and consumption of items, particularly vegetables. 
  • the density of healthy food outlets (and proximity to a supermarket) was associated with a lower likelihood of being overweight or obese. 


A factor contributing to reduced access to healthy food is a reduction in the number of smaller locally owned food stores when there are larger supermarkets.  [21] Centralisation of food outlets posed food-access challenges for residents living on the edges of town  or those with poor access to public transport.  [22] 


Therefore, to ensure adequate access to healthy food outlets for all residents and economic development  [23], a range of healthy food outlets should be encouraged. This would include locally owned outlets, rather than only supermarkets.  [21] For more information regarding the importance of including fresh food outlets in neighbourhood destinations, and how local centres support the community’s shopping needs, see Destinations. Also see Housing Diversity for more information regarding locating supermarkets close to residences. 


While the evidence is mixed in relation to the proximity and density of supermarkets and prevalence of obesity  [4], several international studies suggest a lower BMI and/or lower likelihood of obesity is linked with the presence of supermarkets.  [4, 24-26] Childhood obesity risk decreased with an increasing number of outlets selling healthy food within 800 metres of home,  [10] while increasing distance to a supermarket has been associated with increased odds of obesity.  [4] 


Higher socio-economic locations have been shown to have a greater density of healthy food outlets per 10,000 residents  [27] and to be closer to the nearest supermarket or fruit and vegetable store. This has resulted in higher consumption of fruit and vegetables among children in these locations.  [4] In contrast, residents in lower socio-economic areas or minority populations have poorer access to stores selling healthier foods and supermarkets,  [24, 27-33] which has been associated with poorer diet quality  [34] and increased risk of obesity.  [33] 


The creation of new supermarkets in such locations has resulted in increased availability of and access to healthy food,  [4, 35] particularly when supermarket location was determined by road network, rather than ‘as the crow flies’ distance.  [4] This is especially important for residents who rely on active or public transport methods to purchase food.  [4] 


Further, integrating the location of food outlets into areas where residents conduct other activities, such as collecting children from schools, can facilitate easier purchasing.  [36] Home deliveries of healthy food options,  [4, 21] store pick-up and drop-off services  [29] are additional, important considerations beyond provision of outlets alone.

 

Despite the differences in methodologies used, healthy food outlets located near residential areas have been shown to increase availability, access, purchasing and consumption of healthy food such as fruit and vegetables  [4, 37] and reduce the likelihood of a high BMI and obesity.  [4, 24-26] 


Therefore, a practical strategy is to ensure there are a variety of healthy food outlets available for communities, inclusive of services such as home deliveries. This is especially important in low socio-economic locations. For more information about how food destinations promote healthy eating behaviours, see Destinations. 

Location of prepared food outlets


Through zoning and land use regulation, the built environment can be shaped to support or inhibit healthy eating options. 


Some locations have an abundance of outlets selling predominantly fast food; often these outlet types can outnumber food outlets selling predominantly healthy food by up to six to one.  [23] Availability of fast food outlets  [4, 38] and convenience stores  [4] can result in poorer diet quality such as low fruit and vegetable consumption and increased consumption of sugar sweetened beverages,  [4, 25, 32] saturated fat and fast food.  [4] 


Whereas the same review has suggested there is no relationship between proximity and density of fast food outlets and consumption of these foods.  [4] Therefore, the evidence is mixed relating to density and proximity of fast food outlets and consumption behaviours.  [4] 


There is also mixed evidence regarding whether an association exists between density and proximity to fast food outlets and high BMI.  [4] This is particularly the case in Australia.  [4] However, a study in the U.S determined that residents had a significantly higher BMI and lower fruit and vegetable consumption when they lived closer to fast food outlets.  [39] The inconsistency in evidence has been suggested to result, in part, from the complex, interwoven factors associated with obesity such as the influence of both nutrition and physical activity environments on weight status.  [26] 


There is consensus that disadvantaged areas have higher concentrations of low-quality food sources, such as fast food outlets.  [31, 32, 40, 41] This increased access has been associated with higher fast food consumption in disadvantaged areas.  [4] 


More research is required regarding whether proximity of fast food outlets to schools influences children’s food purchasing and consumption and the impact on their weight.  [4] In Australia, fast food outlets have been shown to be more accessible to secondary schools, in comparison to primary schools, especially in metropolitan areas. The median distance to outlets in metropolitan areas was 1.5 kilometres, in comparison to 10.6 kilometres in inner regional and 37.5 kilometres in outer regional locations.  [41] 


More evidence is also required but national and international studies suggest there are links between the density of outlets selling predominantly fast food, low socio-economic status and the increased likelihood of a poor diet quality and risk of obesity. Despite inconsistencies in these associations, it seems sensible and prudent to limit the number and density of fast food outlets. In Australia, this will require action to address issues with both local government level instruments and state and federal legislation. 



For more information about how food destinations could be designed to promote healthy eating behaviours, see Destinations. 


Farmers’ markets 


Well-located markets are particularly important in under-served areas,  [42] where low-income residents may have difficulty accessing healthy food. This has been identified as an area requiring attention to ensure equitable access for all residents.  [43] Greater rates of frequent purchasing from farmers’ markets has been found among residents that lived close to markets.  [44] See Housing Diversity for more information regarding locating food destinations close to residential areas 


Locating markets near residential areas is one way of improving access and another strategy is to establish markets on public transport routes.  [44] This can increase the sense of community and social capital,  [43] as well as fostering relationships between producers and consumers and provision of a “social shopping experience”.  [44] 


USA research has demonstrated that shopping at farmers’ markets has been associated with increased fruit and vegetable consumption,  [4, 39] with some consumers reportedly increasing intake by as much as 40%.  [4] Increased consumption has been found among groups of all incomes, including low-income earners,  [29] such as recipients of the U.S. Supplemental Nutrition Assistance Program (SNAP).  [4] 


There is mixed evidence relating to the association between farmers’ market density and BMI.  [4] An Italian study found that higher density of farmers’ markets was associated with lower BMI, particularly for residents who had limited access to supermarkets.  [4] 


However, in the USA, there was no association between farmers’ markets and BMI among residents in combined metropolitan and non-metropolitan analyses. When only non-metropolitan data was considered, an association existed between farmers’ markets and lower obesity rates . [4] The inconsistencies in relationships seen internationally may be in part explained by the background diet of different countries. 



Farmers’ markets can increase purchasing and consumption of fruit and vegetables and can ensure produce is transferred efficiently between producers and consumers. Important considerations include locating farmers’ markets on public transport routes and close to residential areas. For more information on utilising school or community facilities for initiatives such as farmers’ markets, see Community Facilities. 


Urban and peri-urban agriculture and food cooperatives​ 


Attention on urban food production is increasing, as concerns about food security due to factors including climate change and rising transport costs.  [45] Literature has called on governments to preserve agricultural land on the urban fringe, which is increasingly used for residential development.  [46] 


Peri-urban agriculture makes an important contribution to local food security  [23] and can safeguard local access to healthy food through the creation of regional food systems,  [15] potentially increasing resilience and reducing supply risks and environmental impacts  [45] associated with longer and increasingly fragile food supply chains.  [15, 47] Further, strategies to support local food production include increased utilisation of recycled water available in city areas and reduced food transport costs.  [48] 


Local food production could also facilitate local food processing  [49] and food distribution through farmers’ markets.  [50] This may boost local economies through the development of industry, and potentially tourism, through niche markets.  [49] Local food production can also increase community members’ awareness of food production.  [45] 


Despite these benefits, urban agriculture currently plays a small role in the food supply of urban populations, largely because securing land for urban food production is costly and constrained by the limited space available.  [47] Therefore, consideration by town planners of land use capability is important to facilitate primary production  [49] and achieve additional sustainability safeguards for the food system. 



Peri-urban agriculture makes an important contribution to safeguarding local healthy food access and economic viability of local producers. Hence, one strategy to build resilient, future-proofed food systems includes the support for land allocation for peri-urban agriculture. Streamlined distribution of produce for sale to local residents may also need to be considered. 


Food hubs 


Economic benefits of food hubs include the development of local food production, networks and outlets such as distribution to local residents, restaurants, hospitals, schools and independent supermarkets. Environmental and social considerations include donations of surplus food to food banks and skill development through health and social programs, schools and TAFE.  [13] Additional advantages include increased employment opportunities and increased sense of community. 


Further, these facilities are potential solutions for locations with limited fresh food supply or job opportunities, such as under-served locations and regional and remote areas.  [13] For more information on shared use of facilities or co-location of new facilities, see Community Facilities. 



While there is emerging evidence on the impact of food hubs and increased fruit and vegetable consumption, food hub models in Australia have demonstrated both increased awareness of healthy eating and healthy food consumption amongst more than half of food box scheme subscribers.  [51] Therefore, food hubs could be a useful strategy to consider, particularly within peri-urban, regional and remote local government authorities. See Housing Diversity for more information regarding locating food locations in residential areas. 


Healthy food community amenities


Provision of breastfeeding facilities 


The Australian Dietary Guidelines “Encourage and support breastfeeding”,  [8] which aligns with the World Health Organization recommendation that mothers should be encouraged and supported to breastfeed.  [52] 


The practice of exclusive breastfeeding for infants can delay the introduction of ‘unhealthy’ foods that could increase weight gain.  [52] Breastfeeding can also reduce breast cancer risk among mothers and significantly decrease the risk of their children becoming overweight or obese.  [21, 53] 


The built environment can play a direct role in encouraging breastfeeding through the provision of convenient locations to do so. Opportunities could be included in the design of shopping centres, commercial areas and workplaces.  [5, 52] Evidence supports the provision of acceptable public spaces for breastfeeding as an important policy action.  [54] 


The community encourages and supports the provision of adequate facilities for breastfeeding in public areas.  [54] However, it is noted that these are urban design considerations, and are not required by planning regulation. For more information about how a sense of place could be enhanced in public locations, see Sense of Place. 


Provision of water fountains 


Water fountains are provided by local government authorities for many reasons, such as hydration, public convenience, and environmental sustainability through a reduction in single-use containers.  [55, 56] As open space is a key location for leisure activities, a large proportion of community members have both considered water fountains in public places important,  [56] and reported using water fountains located in parks and playgrounds.  [57] 


Water plays an essential role in human health  [58] with consumption linked to improved weight status, cognitive benefits and a reduction in dental caries.  [59] In contrast, high consumption of energy-dense sugar-sweetened beverages can contribute to poor health such as increased dental caries and obesity.  [56, 60] 



Providing public water fountains in locations such as parks, playgrounds and schools can increase accessibility and consumption of water.  [56, 59] Therefore, provision of sufficient access to water in public spaces can make the healthy choice (water) the easy, affordable and environmentally friendly choice. This is an important strategy to shift preferences from sugar-sweetened beverages to water  [59] and thus reduce energy intake and obesity risk.  [61] Furthermore, water is the preferred beverage for all Australians as recommended by the Australian Dietary Guidelines.  [8] 


The provision of public water fountains in locations such as parks, playgrounds and schools is encouraged, considering they can increase accessibility and consumption of water,  [56, 59] and reduce the environmental and economic impact of packaged drink containers.  [55, 56] 

Community gardens 


The benefits of community gardens extend beyond food production alone and positively contribute to other aspects of participants’ health, through planned and incidental interaction.  [62] These spaces can contribute to good mental health  [15, 63] by providing a place to socialise  [21] and interact. This creates a sense of belonging  [63] and community ownership.  [62] Community connectedness  [4] and involvement,  [29] cross-cultural interaction  [63] and reduced social exclusion  [23] are other such benefits. 


The likelihood of residents engaging in their community is also increased in locations that promote health,  [64] and community gardens can make an important contribution to the perception of a safe, connected and aesthetically pleasing community.  [4, 43] Further, they can better connect people to the food system and reduce food expenditure.  [17] 


Community gardens can increase availability and access to fruit and vegetables,  [18, 62, 65] particularly for urban residents  [66] and low-income families  [29] as well as children through kitchen gardens located on school sites.  [67] When these gardens are available to the wider community after hours, these benefits can be extended to local residents.  [42] While the key motivating factor and perceived benefit of participation cited by gardeners in some locations was food production,  [17] the evidence is largely mixed regarding whether community gardens increase nutrition attitude or practices relating to fruit and vegetables.  [49] 


In the USA, adults who participated in a community garden ate fruit and vegetables more often than those who did not, suggesting that intake may be improved by participation.  [66] Community gardens that have been developed in disadvantaged locations have resulted in benefits such as increased social capital and access to fresh produce.  [63] 



Given that community gardens’ contribution extends beyond increased availability of fruit and vegetables, such as increased social connectivity and increased sense of belonging, they are a useful inclusion to foster cultural and social inclusion. For more information on community gardens, see Public Open Space.


Urban orchards and edible landscapes 


Urban orchards and edible landscapes can form attractive and functional ‘community focal points’, which are important for social connectedness in communities.  [49] Further, they can serve an educational purpose for a range of settings including schools and make important environmental contributions through a reduction in food transportation.  [16] 


The establishment of edible landscapes on vacant public land, streets and in parks can increase the availability of nutritious food such as fruit and vegetables.  [15, 42] Further, the planting of productive varieties can create social and educational opportunities.  [4] Green spaces have additional environmental benefits, such as trees and vegetation reducing the temperature of the urban environment.  [62] For more information about how trees, such as edible varieties, can increase thermal comfort for pedestrians, see Movement Networks. 


Some evidence has reported a 22% lower odds of being obese in neighbourhoods with more and varied green spaces (vegetation), in comparison to locations with less green space.  [68] Green space is also important for mental and physical health and access to fresh fruit and vegetables. Therefore, locating edible landscapes in communities and suburbs could provide holistic health benefits. For more information on plazas, piazzas, parks and community gardens, see Public Open Space. 


Verge side and residential food growing 


Over time, residential food production has decreased,  [69] partly due to changes to the food system and reduced use of undeveloped land areas in developing urban environments. Smaller lot sizes have also reduced opportunities for future generations to rely on home gardening as a key food source.  [70] 


However, recently there has been increased interest in residential food production, with more than half of Australian households reporting growing food through a home or community garden.  [69] Among these, the most popular form of food production was through a front or backyard garden (74%), followed by a verge garden (13%) and balcony garden (12%). The additional 1% of people surveyed indicated their food production is through a community garden.  [69] These findings suggest residential gardening could potentially make a larger contribution to food production at a local level.  [69] 


In locations with poor access to healthy food, designing housing estates and individual lots to ensure sufficient sunlight hours for vegetable production can help. This can improve access to fresh produce by ensuring lot layouts encourage home production of fruit and vegetables.  [42] Encouraging front gardens without fences can also increase social connectivity among the local community.  [49] There is potential to increase food growing on social housing estates, both within existing and new developments – one way is by including garden plots. Given the social, health and environmental outcomes of food growing, local government authorities could consider participatory projects on public housing estates. 



There is currently limited evidence relating to the impact of home food growing on health. However, the available evidence suggests positive impacts on mental and physical health through community connectedness,  [49] social support and community ownership.  [62] There is also some evidence to demonstrate a significant positive association between possession of an edible garden and fruit intake.  [71] These benefits can be reinforced by encouraging shared spaces for growing food in large residential buildings and communal facilities.  [62] For more information about how streetscapes can increase social connectedness, see Sense of Place. 


Healthy food transport opportunities


Public transport 


Many people rely on public transport to access food, which can be suboptimal in some locations, particularly regional and remote areas  [22] or poorly serviced areas such as new developments.  [72] Infrequent and unreliable public transport services are often cited as a barrier to travel to food outlets.  [73] 


Locating new healthy food retail outlets on public transport routes,  [74] or increasing public transport routes to existing outlets,  [29] can reduce access barriers for local residents. This can impact low-income residents who have difficulty transporting food.  [75] Additional benefits include increased financial profits for local business owners with an increased customer base as a result of increased accessibility.  [74] For more information about the importance of providing accessible public transport for all community groups, see Movement Networks. 


Community transport provided by local government authorities, particularly in areas where private transport is limited or residents are immobile,  [21, 49] could facilitate easier access to healthy food. 


Important considerations regarding public transport include ensuring adequate service provision to healthy food outlets, either through buses and train networks or community transport. This would contribute to a reduction in access barriers for disadvantaged groups. For more information regarding how mixed-use neighbourhoods can increase the viability of public transport, see Destinations. 


Active transport 


Active transport includes modes of travel such as walking and cycling, and can increase opportunities for interaction between residents.  [70] Shoppers have reported a preference for food outlets that were positioned close to where they lived, enabling them to walk to purchase food.  [36] 



The numerous benefits of active transport could be harnessed through locating healthy food outlets near residential areas, and on well maintained, safe pathways.  [74] Residents have reported increased difficulty accessing food outlets where there were a lack of footpaths,  [22] when footpaths were not maintained or where there was a lack of pedestrian crossings.  [73] For more information about how planning can increase active transport, see Destinations. For more information about pedestrian and cycling networks, see Movement Networks. 


Food delivery services


Transport directly impacts food availability, quality, variety and price of food.  [9] An effective food transport system is recommended as a strategy to reduce the cost and increase the quality and availability of healthy food.  [42] Produce delivery initiatives from farmers’ markets have been shown to increase fruit and vegetable consumption by 94% among vulnerable segments of the population, such as elderly or immobile residents.  [76] Street vendors are also an innovative strategy used to bring produce to communities.  [29] 



Food delivery services should be considered by local government authorities, with a focus on supporting vulnerable segments of the population. 


Summary of evidence

Access to sufficient healthy food outlets is associated with increased purchasing and consumption of healthier food (i.e. increased fruit and vegetable intake, healthier diet/diet quality).

The presence of supermarkets can result in a lower Body Mass Index (BMI) and lower likelihood of obesity.

Access to unhealthy food outlets such as convenience stores is associated with unhealthy eating behaviours (i.e. decreased fruit and vegetable intake and increased energy intake).

Residents living in areas of lower socio-economic advantage have poorer access to healthy food outlets and greater access to unhealthy outlets.

Breastfeeding is associated with a significantly reduced risk of children becoming overweight or obese

Community purpose sites that are located close to residential areas, are diverse in type (i.e. plaza, garden) and are well connected via transport routes, can increase social and cultural inclusion.

Ensuring that healthy food is accessible through public, active and community transport can reduce access barriers for disadvantaged or immobile community members

Use of farmers’ markets is associated with higher fruit and vegetable consumption.

Establishing community gardens can increase potential for educational and social benefits.

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