An Analysis of Public Health Policy and Legal Issues Relevant to Mobile Food Vending

Mobile food vending is a component of the food environment that has received little attention in the public health literature beyond concerns about food sanitation and hygiene issues. However, several features of mobile food vending make it an intriguing venue for food access.We present key components of mobile vending regulation and provide examples from 12 US cities to illustrate the variation that can exist surrounding these regulations.Using these regulatory features as a framework, we highlight existing examples of “healthy vending policies” to describe how mobile food vending can be used to increase access to nutritious food for vulnerable populations.THERE IS A GROWING FOCUS on the role of the food environment for the obesity epidemic.¹ In particular, there is a need for greater access to nutritious food and more limits on energy-dense food with low nutritional value. Greater relative availability of nutritious food in local food stores is associated with greater intake of those foods.² Although there are some existing strategies to increase purchase of fruits and vegetables within grocery stores,³ access to stores with nutritious food remains an issue. Supermarkets are more likely to carry fresh produce,⁴ but they are less likely to be found in low-income neighborhoods and communities of color.^5,6 There are a variety of factors that have historically been barriers to supermarket location in lower-income urban areas,^7,8 and the rural poor appear to have even less access to supermarkets than do their metropolitan counterparts.⁹ Neighborhoods without supermarkets tend to have small corner stores or convenience markets that have limited inventories of nutritious food.¹⁰Although public health scholars have given some attention to corner store interventions, mobile food vending has received little attention in the public health literature beyond concerns about food sanitation and hygiene issues.^11,12 But several features of mobile food vending make it an intriguing venue for food access. Unlike a corner store, mobile food vendors sell a small range of merchandise. Specialized vendors (e.g., vendors selling only fruit) can more easily ensure fresh merchandise because of rapid turnover. Because these vendors are mobile, they have the capacity to reach places that otherwise lack access to food establishments or food stores. Mobile food vendors have been found to converge around schools to sell foods to students after school.¹³ Mobile vendors appear to be a familiar phenomenon in urban as well as rural communities with large numbers of Latino immigrants,^13–15 and understanding how to encourage the sale of nutritious food rather than energy-dense food would be valuable to these communities and others that have disproportionately high rates of obesity.¹⁶The need for increased access to nutritious food and the unique features of mobile food vending lead to some compelling questions. Could mobile vendors contribute to the accessibility of nutritious food, particularly for underserved and vulnerable communities? Could a mobile cart or truck function like a supermarket produce aisle on wheels? We focused on how local government law and policy could support healthy mobile vending mainly because the law has the advantages of broader application and permanence. Here, we present key components of mobile vending regulation by using examples from the municipal codes of 10 US cities to illustrate the variation that can exist surrounding these regulations. Then, using this framework of regulatory features and highlighting noteworthy policy examples, we describe how mobile food vending can be used to increase access to nutritious food for vulnerable urban populations. We chose to limit our scope to mobile food vendors in urban settings because, even though the potential for mobile vending to increase nutritious food access in rural areas is also worth exploring, the unique characteristics of rural settings such as low population density and differences in local government authority warrant a separate examination that takes these features into account.     

Campus-Based Snack Food Vending Consumption

ObjectiveTo evaluate the purchases of university vending machine clientele and to understand what consumers purchase, purchase motivations, and purchase frequency after implementation of a vending policy designed to promote access to healthier snack options.MethodsCross-sectional data collection from consumers at 8 campus vending machines purposefully selected from a list of highest-grossing machines. Vending machines were stocked with 28.5% green (choose most often), 43% yellow (occasionally), and 28.5% red (least often) food items.ResultsConsumers were predominately students (86%) and persons aged 18–24 years (71%). Red vending choices were overwhelmingly selected over healthier vending options (59%). Vended snack food selections were most influenced by hunger (42%) and convenience (41%). Most consumers (51%) frequented vending machines at least 1 time per week.Conclusions and ImplicationsDespite decreased access to less healthful red snack food choices, consumers chose these snacks more frequently than healthier options in campus vending machines.     

Food Environment in Secondary Schools: À La Carte, Vending Machines, and Food Policies and Practices

Objectives. This study described the food environment in 20 Minnesota secondary schools.

Methods. Data were collected on school food policies and the availability and nutritional content of foods in school à la carte (ALC) areas and vending machines (VMs).

Results. Approximately 36% and 35% of foods in ALC areas and in VMs, respectively, met the lower-fat criterion (≤ 5.5 fat grams/serving). The chips/crackers category constituted the largest share of ALC foods (11.5%). The median number of VMs per school was 12 (4 soft drink, 2 snack, 5 other). Few school food policies were reported.

Conclusions. The availability of healthful foods and beverages in schools as well as school food policies that foster healthful food choices among students needs greater attention.

     

Food Sold in School Vending Machines Is Associated With Overall Student Dietary Intake

PurposeTo examine the association between food sold in school vending machines and the dietary behaviors of students.MethodsThe 2005–2006 U.S. Health Behavior in School-aged Children survey was administered to 6th to 10th graders and school administrators. Dietary intake in students was estimated with a brief food frequency measure. School administrators completed questions regarding food sold in vending machines. For each food intake behavior, a multilevel regression analysis modeled students (level 1) nested within schools (level 2), with the corresponding food sold in vending machines as the main predictor. Control variables included gender, grade, family affluence, and school poverty index. Analyses were conducted separately for 6th to 8th and 9th–10th grades.ResultsIn all, 83% of the schools (152 schools; 5,930 students) had vending machines that primarily sold food of minimal nutritional values (soft drinks, chips, and sweets). In younger grades, availability of fruit and/or vegetables and chocolate and/or sweets was positively related to the corresponding food intake, with vending machine content and school poverty index providing an explanation for 70.6% of between-school variation in fruit and/or vegetable consumption and 71.7% in sweets consumption. Among the older grades, there was no significant effect of food available in vending machines on reported consumption of those food.ConclusionVending machines are widely available in public schools in the United States. In younger grades, school vending machines were either positively or negatively related to the diets of the students, depending on what was sold in them. Schools are in a powerful position to influence the diets of children; therefore, attention to the food sold at school is necessary to try to improve their diets.     

Reliability of the Hospital Nutrition Environment Scan for Cafeterias,Vending Machines,and Gift Shops

According to ecological models, the physical environment plays a major role in determining individual health behaviors. As such, researchers have started targeting the consumer nutrition environment of large-scale foodservice operations when implementing obesity-prevention programs. In 2010, the American Hospital Association released a call-to-action encouraging health care facilities to join in this movement and improve their facilities' consumer nutrition environments. The Hospital Nutrition Environment Scan (HNES) for Cafeterias, Vending Machines, and Gift Shops was developed in 2011, and the present study evaluated the inter-rater reliability of this instrument. Two trained raters visited 39 hospitals in southern California and completed the HNES. Percent agreement, kappa statistics, and intraclass correlation coefficients were calculated. Percent agreement between raters ranged from 74.4% to 100% and kappa statistics ranged from 0.458 to 1.0. The intraclass correlation coefficient for the overall nutrition composite scores was 0.961. Given these results, the HNES demonstrated acceptable reliability metrics and can now be disseminated to assess the current state of hospital consumer nutrition environments.     

Food and Beverage Environment Analysis and Monitoring System: A Reliability Study in the School Food and Beverage Environment

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS),^? to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals.     

Associations Between Weight Loss Attempts,Food Planning,and the Home Food Environment

ObjectiveTo evaluate whether food planning behaviors mediate the relationship between a reported weight loss attempt and the home food environment (HFE).DesignSecondary data analysis of 4 home visits, included collecting an objective home food inventory of the HFE and self-reported food planning behaviors.ParticipantsThere were 196 participants (mean age, 44.4 years; 83.7% female).Main Outcome MeasuresThe percentage of obesogenic foods and fruits and vegetables (FV).AnalysisFour regression analyses to test mediation.ResultsMeal planning and grocery list use did not explain the relationship between a weight loss attempt and obesogenic foods or FV in the home (P > 0.05). Post hoc analyses that examined participants with a body mass index of >25, >28, and >30 found that a weight loss attempt was associated with fewer obesogenic foods. In contrast, mediation analyses with planning behaviors and associations with FV in the home were nonsignificant (P > 0.05).Conclusions and ImplicationsObesity was more indicative of the HFE than making a weight loss attempt. A weight loss attempt was not associated with food planning behaviors, which may be used for multiple reasons, including organization and time management. Future studies should evaluate individual differences in strategies to create a healthy HFE in the context of a weight loss attempt.     

山东、四川部分区县环境和食物中氟化物水平调查

目的了解调查地区环境和食物中氟化物的水平。方法采用燃烧水解一氟离子选择电极法测定土壤中氟化物的含量；离子选择电极法直接测定饮水中氟化物的含量，扩散一氟离子选择电极法测定粮食和蔬菜样品中氟化物的含量。结果山东和四川省调查地区饮用水氟化物的含量为0．14～39mg/L，符合我国生活饮用水卫生标准（GB5749—1985）；调查地区土壤氟化物含量为175．4～625．1mg/kg；调查地区6种粮食氟化物的含量，除四川邛崃县面粉外，其他均符合我国粮食含氟标准；调查地区蔬菜氟化物的含量除山东淄川的韭菜、油菜氟超出限值（1mg/kg）4倍和0．9倍。四川邛崃干辣椒氟超出限值（1mg/kg）4倍外，其余各类蔬菜氟化物含量为0．028～0．694mg/kg，均在我国相应的标准限值内。结论调查地区环境和主要食物中氟化物的浓度是安全的，居民对氟的摄入处于安全水平。     

Validation of a Home Food Environment Instrument Assessing Household Food Patterning and Quality

The home food environment (HFE) is associated with dietary intake; yet measuring HFE quality often requires burdensome collection of detailed inventories. This project evaluated the capacity of the Home Inventory to Describe Eating and Activity, version 2 (Home-IDEA2) to capture HFE quality by measuring the presence or absence of household foods. Validity was tested using a modified application of the Healthy Eating Index-2010 (HEI). Comparative data were drawn from the National Food Acquisition and Purchase Survey (FoodAPS) Food-at-Home Public Use File. HEI scores were calculated for 4202 households in FoodAPS using Home-IDEA2 inventories and full reported inventories. Paired t-tests compared: (1) estimated vs. total edible grams (EEG; TEG); (2) limited vs. all reported foods; and (3) EEG + limited foods vs. TEG + all reported foods. Sensitivity and range of scores were compared. Mean HEI scores for Home-IDEA2 were higher (p < 0.003) than FoodAPS: (1) 51.6 ± 16.1 vs. 49.6 ± 18.1 (food amounts); (2) 53.5 ± 15.8 vs. 49.8 ± 15.4 (food items); (3) 55.5 ± 15.7 vs. 49.8 ± 15.4 (full instrument); differences were small. Scores demonstrated comparable sensitivity and range. The study found that the Home-IDEA2 can capture HFE quality adequately with low data collection burden.     

Difficulty in the Food Environment and the Experience of Food Insecurity among Refugees Resettled in the United States

The objective of this cross-sectional study was to assess the prevalence and correlates of food insecurity in 281 refugees resettled in the United States. Participants were recruited through a resettlement center and word of mouth. In addition to measures of socioeconomic status, education, time in the U.S., and food insecurity, we also measured individual difficulty in navigating the food environment using a food difficulty scale. Only 23% of the sample did not endorse any of the food insecurity items. Nearly half of the sample also noted difficulty in navigating the food environment. Food insecurity scores above the median were predicted by both income and non-income variables. In a multivariable logistic model, income and having more than one year of education were associated with lower food insecurity (p < .05), while “difficulty in the food environment” was associated with high food insecurity (p < .01). Results suggest that income is an important constraint but that non-income variables may also be important determinants of food insecurity.     

Evidence-Based Development of a Mobile Telephone Food Record

Mobile telephones with an integrated camera can provide a unique mechanism for collecting dietary information that reduces burden on record-keepers. Objectives for this study were to test whether participant's proficiency with the mobile telephone food record improved after training and repeated use and to measure changes in perceptions regarding use of the mobile telephone food record after training and repeated use. Seventy-eight adolescents (26 males, 52 females) ages 11 to 18 years were recruited to use the mobile telephone food record for one or two meals. Proficiency with the mobile telephone food record was defined as capturing a useful image for image analysis and self-reported ease of use. Positive changes in perceptions regarding use of the mobile telephone food record were assumed to equate to potentially improved proficiency with the mobile telephone food record. Participants received instruction for using the mobile telephone food record prior to their first meal, and captured an image of their meals before and after eating. Following the first meal, participants took part in an interactive session where they received additional training on capturing images in various snacking situations and responded to questions about user preferences. Changes in the participants' abilities to capture useful images and perceptions about the usability of the mobile telephone food record were examined using McNemar, Wilcoxon rank-sum test, and paired t test. After using the mobile telephone food record, the majority of participants (79%) agreed that the software was easy to use. Eleven percent of participants agreed taking images before snacking would be easy. After additional training, the percent increased significantly to 32% (P<0.0001). For taking images after snacking, there was also improvement (21% before training and 43% after; P<0.0001). Adolescents readily adopt new technologies; however, the mobile telephone food record design needs to accommodate the lifestyles of its users to ensure useful images and continuous use. Further, these results suggest that additional training in using a new technology may improve the accuracy among users.     

Consideration of the Food Environment in Cancer Risk Reduction

Recently, there has been increased attention to the food environment's impact on chronic disease, specifically obesity and cardiovascular disease. Cancer is certainly another substantial public health concern, and dietary intake and obesity/overweight have been identified as two key cancer risk factors; however, the role of the food environment in cancer-prevention efforts seems largely uncharted territory. Previous research has shown that areas with a higher proportion of individuals in racial minority groups and areas with lower incomes have more limited access to healthful foods, which can negatively impact dietary intake and body mass index. Parallel patterns of higher cancer incidence and mortality rates among these vulnerable populations could be linked to lack of access to healthful foods. Future research utilizing food environment measures could point to broad community-level approaches for modifying diet-related cancer risk. Nutrition professionals will be a crucial element in designing and implementing food environment-based individual, family, and community interventions, which could be potent strategies for cancer prevention.     

Calorie Offsets: Environmental Policy for the Food Environment

Although obesity continues to challenge the public’s health, effective policy solutions are wanting. Borrowing from environmental protection efforts, we explored the potential for a “calorie offset” regulatory mechanism, which is similar to the carbon emission offsets used to curb greenhouse gas emissions, to mitigate the harmful health externalities of unhealthy food production. This approach might have a number of advantages over traditional policy tools, and warrants attention from health policymakers and industry alike.Over the past 30 years, the prevalence of obesity has increased 3-fold in many high-income countries. This increase in obesity has partially driven the current chronic disease epidemics, including diabetes mellitus, and cardiac and cerebrovascular disease.In the United States, health demographers have suggested that obesity may underlie a forthcoming decline in life expectancy, the first in more than a century.1 Although recent reports have suggested a slowing of the rate of obesity, particularly among children,2 this evidence has been contested.3 Obesity remains among the most important public health challenges of our time.2