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Volume
2:
No. 1, January 2005
ORIGINAL RESEARCH
Using Community Indicators
to Assess Nutrition in Arizona-Mexico Border Communities
Jacob Abarca, PharmD, Sulabha Ramachandran, MS
Suggested citation for this article: Abarca J, Ramachandran S. Using community indicators to assess nutrition in
Arizona-Mexico border communities. Prev Chronic Dis [serial online] 2005 Jan [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2005/ jan/04_0082.htm.
PEER REVIEWED
Abstract
Introduction
Community indicators are used to measure and monitor factors that affect the
well-being of a community or region. Community indicators can be used to assess
nutrition. Evaluating nutrition in communities along the Arizona-Mexico border
is important because nutrition is related to an individual’s risk of overweight
or obesity; obesity is a risk factor for developing type 2 diabetes.
Methods
Local grocery store purchases were selected as a community
indicator for nutrition. A structured 26-question interview was
developed and administered to grocery store managers in
communities along the Arizona-Mexico border that were targeted by
the Border Health Strategic Initiative, a program implemented by
community groups and the University of Arizona. In addition, data
from milk distributors serving the border communities were
collected.
Results
Residents of these communities favor food items with a higher
fat and higher caloric content. This trend held across several
food categories. Major barriers to customer acceptance of
healthier food items include lack of knowledge concerning healthy
foods and their prices.
Conclusion
The demand for healthy food items is relatively low along the
Arizona-Mexico border. Interventions should continue to target
this population with the aim of changing dietary patterns as one
method of improving the health of the community and preventing
and controlling diabetes.
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Introduction
Type 2 diabetes has placed a substantial burden on the health
and well-being of communities along the U.S.-Mexico border.
Several factors place this area at a higher risk of diabetes,
including economic disadvantages and a predominantly Hispanic
population (1,2). Fifteen percent of Mexican-American children
are overweight, and 29% of Mexican-American adults are classified
as obese; overweight and obesity are risk factors for type 2 diabetes (2). Current estimates suggest worsening trends in the
development of diabetes and its complications (3).
The Border Health Strategic Initiative (Border Health
¡SI!) was a comprehensive diabetes prevention
and control program launched in October 2000 with a focus on border communities
along the Arizona-Mexico border (4). As the program was implemented, it became
clear that the comprehensiveness of the community-wide intervention required a
range of indicators to gauge the status of the program. Although the border
communities studied have relatively small populations, the study team decided
that measuring individual-level indicators would be difficult and prohibitively
expensive. We opted for the more practical, less expensive approach of examining
community-level measures (5). Other investigators have used this approach to
evaluate community-based interventions, including interventions focused on
improving nutrition (6). The approach offers the opportunity to collect,
evaluate, and present data on the status of community nutrition in a timely
manner.
This paper describes the development of a grocery store survey as a community
indicator for nutrition in border communities along the Arizona-Mexico border
and reports survey results. The survey was designed to measure the types of food
items purchased by community residents at local grocery stores. Although several
community indicators were selected, only indicators for nutrition are reported
here.
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Methods
This grocery store survey was conducted as a component of a
larger effort to identify and measure community indicators for
nutrition within the communities targeted by Border Health
¡SI!. To make the process of identifying community
indicators representative and sensitive to local issues, we
enlisted the help of community-based special action groups (SAGs)
from each community (7). Selection of community indicators was
guided by criteria developed by Border Health ¡SI!
investigators, and these criteria were based on
investigators’ prior experience working with communities
along the U.S.-Mexico border. The first criterion was that the
community indicator should focus on topic areas targeted by Border
Health ¡SI!. The second criterion was that the indicator
should be practical — it needed to be relatively easy to
measure and simple to understand by lay members of the community.
The third criterion was that the indicator should be relevant to
the unique needs of each community in preventing and controlling
diabetes. A fourth criterion was that the indicator should take
into account the two-year duration of Border Health
¡SI!. The plan called for providing measurement results
to SAGs early enough during the two-year period to allow SAG
members to develop policies on encouraging physical activity and
proper nutrition based on survey results. A fifth criterion was
that the indicator should be “portable” so that it could be used
as a model by other communities.
Although we were interested in collecting information on all types of food
items, we placed greater emphasis on food items for which community members have a clear choice between
higher and lower saturated-fat content (e.g., whole milk compared
with low-fat milk) or between higher and lower total caloric
content per serving (e.g., regular soda compared with diet soda).
We selected these items to serve as a gross measure of community
member preferences. In addition, the items were being addressed
in ongoing Border Health ¡SI! interventions.
We defined the following food items as healthy (most are lower-fat,
lower-calorie alternatives to other items): low-fat yogurt,
ground turkey, Equal®, low-fat mayonnaise,
skinless chicken, olive oil, 100% orange juice, Sugar-Free Jello®, low-sodium salt/salt substitute, skim
milk, whole-wheat bread, lean ground beef (<10%–15%
fat), diet soda, sugar-free candy, canola oil (lower in saturated fat compared
with corn
oil), margarine (lower in saturated fat compared with butter), and whole-grain cereal
(compared with sugar-based cereal).
Initially, we attempted to collect information on food items
purchased by community residents directly from grocery stores.
Several obstacles prevented this strategy, however. First, some
grocery stores refused to provide the data because of corporate
policies prohibiting the disclosure of proprietary sales data.
Other grocery stores agreed to participate conceptually; however,
when the time came to begin extracting the data, they no longer
were able to participate because of the resources required to
extract and assemble the data. We decided to conduct interviews
of grocery store managers for the following reasons: 1)
grocery store managers are most familiar with the data we sought,
2) the managers are accessible, and 3) interviews would require
minimal grocery store resources.
We developed a structured interview to collect information
from community grocery store managers. To develop the instrument,
including selection of appropriate food items, we consulted with
1) Border Health ¡SI! investigators who had
extensive experience working with border communities, 2) community health
workers from each community, and 3) SAG members from each community. In
addition, we visited all the grocery stores to
select healthier food items that were stocked in at least some of
the grocery stores. We pilot-tested interview questions with two
individuals who had prior experience as grocery store managers in
the target communities. The final interview instrument contained
26 questions. The questions were divided into four categories
in which respondents were asked to 1) describe the types of
products purchased within food categories; 2) rate the demand for
specific healthy food items (the first 11 items in the list above, from
low-fat yogurt through whole-wheat bread); 3) compare the demand for less
healthy food items with healthier alternatives; (the rest of the items in the
list above) and 4) describe
perceived barriers to the purchase of healthy foods by customers.
A copy of the structured interview (English and Spanish versions)
is included in Appendix A.
We identified grocery store managers from all the grocery
stores in the communities targeted by the Border Health
¡SI! and approached them in person to ask them
to participate in the survey. All the targeted communities are
located on the border or within 12 miles of the Arizona-Mexico
border. A strict definition of what constituted a grocery store
vs other types of stores that sell food items (e.g.,
convenience store) was not used because the distinction was clear
in these communities. A research associate administered the
questions, which were intended for the grocery store manager or
an equivalent staff member with knowledge of the types of products that
are purchased within the store. Each interview took approximately
35 to 45 minutes to complete. Interviews were conducted between
March and May 2003. We gave respondents a token gift (e.g.,
notepad holder, gift certificate) for their participation. We
analyzed and summarized responses for each category of questions
and used descriptive statistics to analyze the ratings. This
study was approved by the Institutional Review Board at the
University of Arizona.
In addition to conducting interviews, we attempted to collect
data on food-item sales from wholesalers or distributors. We
collected data on milk distribution only. We contacted dairy
distributors that serve southern Arizona to obtain
cross-sectional data on the proportion of different kinds of milk
— whole milk, 2% milk, 1% milk, and skim milk —
distributed to the targeted communities. To avoid proprietary
issues, we did not collect data on volume and dollar sales. We
collected data on other major cities in Arizona for reference
purposes.
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Results
A total of eight grocery store managers agreed to participate out of 11
possible stores. Six of the stores were in communities located on the border and two were in
communities located 10 to 12 miles from the border. Six
respondents had resided in the communities where the stores were
located for a mean of 28.2 years (SD = 14.9). Respondents had
been in their current positions for a mean of 6.7 years (SD =
6.1).
Table 1 shows manager ratings of the demand for specific
healthy foods on a scale of 1 to 10, with 10 representing highest
demand. Four items were rated as having “some demand.” Orange
juice was rated as having the highest demand, with a mean rating
of 3.5. The lowest ratings were for ground turkey, low-fat
mayonnaise, and low-sodium salt/salt substitutes. When we asked
managers to compare the demand for various food items, responses
were consistent with the trend favoring less healthy food items.
When we asked managers to rate the demand for healthy foods in
the community (scale of 1 to 10), the mean rating was 6.6 (SD =
2.2). Most managers considered the demand to be low to moderate,
whereas a few considered it to be very high. One manager noticed
that customers were becoming more health-conscious, but they
also noticed that customers did not necessarily translate their
interest into healthier purchases. This manager recounted an
incident in which a customer asked for “light lard” —
clearly, no such item exists. Other respondents felt that their
customers, on average, had no idea about healthy foods.
When asked to consider hypothetical scenarios in which
specific food items were removed from their stores, respondents
indicated that the removal of lard would generate the most negative
response from customers. Some managers said there would be a
“small riot” in their store if the product was removed. All
managers stated that customers would notice immediately if the
product was not stocked in the store. In contrast, most managers
stated that nobody would notice if sugar-free candy was removed
from the store; only one manager stated that customers would
notice immediately and would begin requesting the item again.
Only one manager stated that customers would not notice if olive oil was removed from the store. The remaining managers stated that
very few people would notice that the product was missing. Two
managers expected to receive requests for the product within the
same day it was removed from store. The remaining managers
expected to start receiving requests within one to four weeks
of removing the product. When asked about the removal of
lean ground beef (<10%–15% fat), responses were mixed. Half of the
respondents indicated that customers would not notice, mainly
because customers make purchases based on price, and lean ground
beef is more expensive than regular ground beef. Respondents
stated that if lean ground beef was on sale, customers would then
definitely notice that it was missing. Three respondents stated
that customers would notice if it was removed from their store
because there is demand for it, and customers would request the
product within a day.
When asked to directly compare the demand for two
products, the trend favoring less healthy items persisted.
Between regular soda and diet soda, all but one manager stated
that regular soda had a much greater demand. One respondent
stated that the demand for regular and diet soda was equal.
Between corn oil and canola oil, five respondents stated that the
demand for corn oil was greater; two respondents indicated that
the demand was equal. Managers offered several explanations for
why demand for corn oil dominates demand for canola oil: there
are large in-store displays for corn oil, customers lack
knowledge and experience with canola oil, and corn oil is less
expensive. Interestingly, a previous survey of grocery stores
participating in this survey found that the price for corn and
canola oils was almost always equal, particularly for the generic
brands. Between whole milk and low-fat milk, all respondents
indicated that the demand for whole milk was much greater.
Between butter and margarine, responses were split — half
stated that they sold more butter, and half stated that they sold
more margarine because it was less expensive. Between whole-wheat
and sugar-based cereals, all respondents indicated that the
demand for sugar-based cereals dominated whole-wheat cereals. The
ratio of products sold ranged from 2:1, favoring sugar-based
cereals, to almost no whole-wheat cereals sold.
Managers named two barriers to customers purchasing healthier
foods. First, managers stated that customers did not have
sufficient knowledge about nutrition to even recognize a food alternative that
is healthier than what they normally purchase.
Managers noted the need for customers to be educated about proper
nutrition. Second, managers stated that the price of healthier
food items was a major barrier. To increase sales of healthier
food items, they needed to be priced more competitively,
particularly for individuals with lower socioeconomic status.
Table 2 shows the proportion of different kinds of milk
purchases in the targeted communities — whole milk, 2%
milk, 1% milk, and skim milk. Phoenix, Tucson, and Yuma are
larger cities in Arizona that are included for comparison.
Communities in closer proximity to the border appear to be
associated with a preference for higher fat milk.
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Discussion
The results of this study suggest that residents living along
the Arizona-Mexico border have a preference for food items that
are less healthy. For food items such as milk or cooking oils,
customers preferred items that were higher in saturated fat
compared with those with less saturated fat. Among food items such as beverages
and cereals, customers preferred food items with a higher caloric content than
those with a lower caloric content (e.g., regular soda compared with diet soda). The difference in
preference between a healthier food item and a less healthy
alternative was often dramatic. For communities along the
U.S.-Mexico border, which are increasingly burdened with chronic
diseases such as diabetes and cardiovascular disease, these
findings suggest worsening health problems in the future unless
unhealthy dietary patterns are curbed.
The results of this study are consistent with previously
published research on this topic. In a study similar to this one,
Wechsler et al evaluated the availability of low-fat milk among
276 grocery stores and supermarkets in an urban Latino
community (8). They found that lower-fat milk was available for
purchase in up to 96% of stores; however, it only constituted 15%
to 37% of milk sales. The authors noted that lower-fat milk was
more difficult to locate in areas that were poorer and had a
higher concentration of Latino residents, but it was available in
the majority of stores. These findings are similar to the results
found in the current study: the closer the proximity to the
border, the greater the preference for milk with a higher fat
content. Lack of knowledge about lower-fat milk and culturally
shaped attitudes about the fat content of milk were listed as
potential contributors to these findings (9,10). Other studies
using individual-level measures of food intake have found that,
on average, Mexican-Americans maintain unhealthy diets compared
with other groups (10). Mexican-American children have been found to 1) exceed
recommended fat servings and have a higher percentage of energy intake from
saturated fat, 2) consume less than half of the recommended daily intake of fruits
and vegetables, and 3) consume more soft drink beverages compared with other
ethnic groups (1,11).
Our results have two practical applications within the border
communities studied. One, the study provides baseline data for
communities to begin evaluating the nutritional intake of the
entire community. The SAG in each community can create an
immediate forum for these data. As the communities continue to
implement prevention and control programs, the structured
interview designed for this study can be readministered to gauge
progress. For many communities, especially those in rural or
border settings, community-level data is extremely difficult to
obtain because of lack of infrastructure. Conducting a structured
interview of grocery store managers is a simple and inexpensive
way to obtain these types of data. Two, the grocery store manager
survey can be useful in identifying key factors that encourage or
inhibit good dietary habits. For example, managers consistently
mentioned two barriers to customer acceptance of healthier food
items: price and lack of knowledge. Interview respondents pointed
out the impact of price on the types of food items that customers
will purchase. Because many residents have a lower socioeconomic
status, they are often more concerned with buying enough food to
feed their families than with looking for healthier alternatives.
Thus, putting an item on sale can have a big impact on whether it
will sell; this was suggested as a potential strategy to improve
sales of healthier food items. For some food items, however,
price was not an issue. For example, healthy alternatives for
milk and cooking oils were available at the same price as less
healthy choices. Yet customers still preferred to buy the less
healthy alternative (e.g., whole milk, corn
oil). This finding is consistent with the second barrier: lack of
knowledge of healthier food items.
Educating customers about healthier alternatives through in-store
demonstrations and food sampling was suggested by respondents. Previous research
has demonstrated that prompting, product sampling, and price reduction can
produce modest increases in customer purchases of food items that have a lower-fat content (12). And, in fact, this approach has been used in grocery stores in
the targeted communities. Whether this type of intervention will produce
measurable changes in the types of food items purchased in these communities
remains to be determined.
Several limitations concerning the use of the
grocery store manager survey to obtain data on nutritional
intake among community residents deserve mention. First, this
approach used grocery store manager responses as a proxy for
community residents’ preferences for food items. The
results could have been influenced by recall bias or other
factors inherent within each respondent. However, these
individuals are responsible for maintaining their store
inventory, and they are most likely to be the best available
source of data (other than actual sales data).
Second, we assumed
that purchases at grocery stores reflect actual food consumption
within each community. Previous researchers have used similar
approaches to measure community-wide behavior (13). For example,
store-level measures have been found to be
significantly correlated with individual-level measures of food
consumption within communities (6,14-16). However, using these
types of measures to track dietary changes in communities over
time is tenuous at best (17). Hence, using this approach is only
likely to capture major shifts in putative changes in food availability at the
community level; smaller,
incremental changes occurring in the community will probably not
be detected.
A third limitation is that it is impossible to link a specific intervention
to the results obtained from this survey, especially in these communities.
Shifting community-level dietary patterns takes time and involves a variety of
factors. Thus, it is impractical to think that a single intervention will result
in a measurable change. The other reality in these communities is
that multiple entities (e.g., local, state, and federal agencies)
may be implementing interventions that target these communities,
thus threatening the internal validity of any experimental or
quasi-experimental research design. For this reason, the focus of
this evaluation was to obtain the best available data on the
putative changes in these communities and not to be overly
concerned with attributing the effect to any one particular
program.
Fourth, these results are only generalizable to
communities that were targeted by Border Health
¡SI!. However, the survey instrument and methodology
should be useful to other border communities facing similar data
needs.
In conclusion, the findings of this study indicate that the
demand for healthy food items is relatively low along the
Arizona-Mexico border. Interventions should continue to target
this population with the aim of changing dietary patterns as one
method of improving the health of the community. This survey
should be administered in future years to measure whether or not there
has been a change in the community concerning the types of food
items that customers prefer.
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AcknowledgmentsThe authors acknowledge the assistance of Nohemi Ortega in conducting the survey research.
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Author Information
Corresponding author: Jacob Abarca, PharmD, Center for
Health Outcomes & PharmacoEconomic Research, College of
Pharmacy, University of Arizona, PO Box 210207, Tucson, AZ
85721-0207. Telephone: 520-325-6532. E-mail: abarca@pharmacy.arizona.edu.
Author affiliations: Sulabha Ramachandran, MS, Center for Health Outcomes & PharmacoEconomic Research,
College of Pharmacy, University of Arizona, Tucson, Ariz.
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