Do 'food deserts' influence fruit and vegetable consumption?--A cross-sectional study

Lack of access to affordable healthy foods has been suggested to be a contributory factor to poor diet. This study investigated associations between diet and access to supermarkets, transport, fruit and vegetable price and deprivation, in a region divergent in geography and socio-economic indices. A postal survey of 1000 addresses (response rate 42%) gathered information on family demographics, supermarket and shop use, car ownership, mobility and previous day's fruit and vegetable intake. Postcode information was used to derive road travel distance to nearest supermarket and deprivation index. Fruit and vegetable prices were assessed using a shopping basket survey. Generalised linear regression models were used to ascertain predictors of fruit and vegetable intake. Male grocery shoppers ate less fruit than female grocery shoppers. Consumption of vegetables increased slightly with age. Deprivation, supermarket fruit and vegetable price, distance to nearest supermarket and potential difficulties with grocery shopping were not significantly associated with either fruit or vegetable consumption. These data suggest that the three key elements of a food desert, fruit and vegetable price, socio-economic deprivation and a lack of locally available supermarkets, were not factors influencing fruit or vegetable intake. We suggest that food policies aimed at improving diet should be orientated towards changing socio-cultural attitudes towards food.     

Does social class predict diet quality?

A large body of epidemiologic data show that diet quality follows a socioeconomic gradient. Whereas higher-quality diets are associated with greater affluence, energy-dense diets that are nutrient-poor are preferentially consumed by persons of lower socioeconomic status (SES) and of more limited economic means. As this review demonstrates, whole grains, lean meats, fish, low-fat dairy products, and fresh vegetables and fruit are more likely to be consumed by groups of higher SES. In contrast, the consumption of refined grains and added fats has been associated with lower SES. Although micronutrient intake and, hence, diet quality are affected by SES, little evidence indicates that SES affects either total energy intakes or the macronutrient composition of the diet. The observed associations between SES variables and diet-quality measures can be explained by a variety of potentially causal mechanisms. The disparity in energy costs ($/MJ) between energy-dense and nutrient-dense foods is one such mechanism; easy physical access to low-cost energy-dense foods is another. If higher SES is a causal determinant of diet quality, then the reported associations between diet quality and better health, found in so many epidemiologic studies, may have been confounded by unobserved indexes of social class. Conversely, if limited economic resources are causally linked to low-quality diets, some current strategies for health promotion, based on recommending high-cost foods to low-income people, may prove to be wholly ineffective. Exploring the possible causal relations between SES and diet quality is the purpose of this review.     

Obesity and Supermarket Access: Proximity or Price?

Objectives. We examined whether physical proximity to supermarkets or supermarket price was more strongly associated with obesity risk.Methods. The Seattle Obesity Study (SOS) collected and geocoded data on home addresses and food shopping destinations for a representative sample of adult residents of King County, Washington. Supermarkets were stratified into 3 price levels based on average cost of the market basket. Sociodemographic and health data were obtained from a telephone survey. Modified Poisson regression was used to test the associations between obesity and supermarket variables.Results. Only 1 in 7 respondents reported shopping at the nearest supermarket. The risk of obesity was not associated with street network distances between home and the nearest supermarket or the supermarket that SOS participants reported as their primary food source. The type of supermarket, by price, was found to be inversely and significantly associated with obesity rates, even after adjusting for individual-level sociodemographic and lifestyle variables, and proximity measures (adjusted relative risk = 0.34; 95% confidence interval = 0.19, 0.63)Conclusions. Improving physical access to supermarkets may be one strategy to deal with the obesity epidemic; improving economic access to healthy foods is another.Access to food sources within the built environment can exert a powerful influence on diet quality, body weight, and other health outcomes.1–10 Inequitable access to healthful foods, in particular, is thought to be one root cause of the obesity epidemic.11,12In many studies, people living in low-income or minority communities were reported to be at greater distance from full-service supermarkets and from grocery stores selling healthful foods.13–22 Lower income census tracts had fewer supermarkets compared with wealthier areas.20,23,24 African Americans were less likely to live in census tracts with a supermarket compared with Whites.4,25 In other studies, closer proximity to full-service supermarkets was associated with healthier eating, lower body mass index values, and with lower rates of obesity and diabetes among adults.1–5,7,26–30Studies on obesity and access to healthful foods were based, for the most part, on 2 underlying assumptions. The first assumption was that full-service supermarkets were most likely to offer healthful foods at affordable prices.7,12 Consequently, full-service supermarkets were clearly distinguished from fast-food outlets and convenience stores.3,4,7,10,16,18,31,32 It may also be helpful to differentiate supermarkets further by food quality or food price.33–36The second assumption was that most people shopped for food either at the nearest food store or in their own neighborhood or census tract. Physical distance to the nearest supermarket became the principal measure of access to healthful foods. The density of supermarkets or other food stores in a given area was then linked with measures of diets and health in the same area.7,11,27,31,36 Some studies employed more realistic street network distances to calculate the distance between the participant''s home and the nearest supermarket.37–41To our knowledge, a study from Newcastle, United Kingdom, was the only observational study that collected data on food retail access—distance to the food shops, food availability, and price—and examined these in relation to socioeconomic status (SES), diets, and health.35,36 The present Seattle Obesity Study (SOS), was the first US-based study to collect data on supermarkets, SES, and health, advancing the field in 3 important ways. First, the geocoding of study participants’ home addresses and the locations of their principal food sources, as obtained from a telephone survey, allowed for the calculation of network distances between the participants’ homes, the nearest supermarket, and the supermarket that study respondents actually shopped at. Second, supermarket chains were stratified into 3 price levels based on the average cost of the market basket of 100 representative foods. The stratification of supermarkets by price allowed for the novel reconceptualization of access to healthy foods both in terms of physical proximity and economic access as determined by supermarket price. Third, the SOS was the first study to collect all data at the individual level, eliminating potential bias because of geographic aggregation.The goal was to determine whether supermarket proximity or price would be more strongly associated with obesity rates, adjusting for individual level demographics, education, and income. In previous studies, obesity was linked to the consumption of low-cost, energy-dense foods.42,43     

Attitudinal and demographic determinants of diet quality and implications for policy targeting

Background: Poor diet quality is a major public health concern that has prompted governments to introduce a range of measures to promote healthy eating. For these measures to be effective, they should target segments of the population with messages relevant to their needs, aspirations and circumstances. The present study investigates the extent to which attitudes and constraints influence healthy eating, as well as how these vary by demographic characteristics of the UK population. It further considers how such information may be used in segmented diet and health policy messages. Methods: A survey of 250 UK adults elicited information on conformity to dietary guidelines, attitudes towards healthy eating, constraints to healthy eating and demographic characteristics. Ordered logit regressions were estimated to determine the importance of attitudes and constraints in determining how closely respondents follow healthy eating guidelines. Further regressions explored the demographic characteristics associated with the attitudinal and constraint variables. Results: People who attach high importance to their own health and appearance eat more healthily than those who do not. Risk‐averse people and those able to resist temptation also eat more healthily. Shortage of time is considered an important barrier to healthy eating, although the cost of a healthy diet is not. These variables are associated with a number of demographic characteristics of the population; for example, young adults are more motivated to eat healthily by concerns over their appearance than their health. Conclusions: The approach employed in the present study could be used to inform future healthy eating campaigns. For example, messages to encourage the young to eat more healthily could focus on the impact of diets on their appearance rather than health.     

Why do women of low socioeconomic status have poorer dietary behaviours than women of higher socioeconomic status? A qualitative exploration

In developed countries, persons of low socioeconomic status (SES) are generally less likely to consume diets consistent with dietary guidelines. Little is known about the mechanisms that underlie SES differences in eating behaviours. Since women are often responsible for dietary choices within households, this qualitative study investigated factors that may contribute to socioeconomic inequalities in dietary behaviour among women. Semi-structured interviews were conducted with 19 high-, 19 mid- and 18 low- SES women, recruited from Melbourne, Australia, using an area-level indicator of SES. An ecological framework, in which individual, social and environmental level influences on diet were considered, was used to guide the development of interview questions and interpretation of the data. Thematic analysis was undertaken to identify the main themes emerging from the data. Several key influences varied by SES. These included food-related values such as health consciousness, and a lack of time due to family commitments (more salient among higher SES women), as well as perceived high cost of healthy eating and lack of time due to work commitments (more important for low SES women). Reported availability of and access to good quality healthy foods did not differ strikingly across SES groups. Public health strategies aimed at reducing SES inequalities in diet might focus on promoting healthy diets that are low cost, as well as promoting time-efficient food preparation strategies for all women.     

Socioeconomic status and weight control practices among 20- to 45-year-old women.

OBJECTIVES. This study examined the relationship between socioeconomic status (SES) and weight control practices in women. METHODS. SES, defined by family income, was examined in an economically diverse sample of 998 women in relation to dieting practices by means of multivariate regression analyses controlling for age, ethnicity, smoking, and body mass index. RESULTS. SES was positively associated with healthy, but not unhealthy, weight control practices; inversely related to energy and fat intake; and positively associated with weight concern and perceived social support for healthy eating and exercise. SES gradients were particularly striking at the low end of the income distribution (i.e., family income < or = $10,000 per year). The SES gradient in body mass index persisted in analyses controlling for attitudes and behaviors. CONCLUSIONS. Economic deprivation may contribute to high rates of obesity among lower SES women. The reasons for this require further research.     

The cost and availability of healthy food choices in southern Derbyshire

There has been general agreement among experts over the last decade on what constitutes a healthy diet for the prevention of many of the major causes of morbidity and mortality in the UK, and for the treatment of diabetes mellitus and hyperlipidaemias. People are generally aware of the link between diet and health, but there is concern that foods which need to be included in the diet for it to meet current recommendations may be difficult to find and expensive. The 7-day intake of an adult woman, which matched many of the current diet targets (including those of NACNE, the Department of Health and the British Diabetic Association), was costed in supermarkets in southern Derbyshire in 1990, 1992 and 1994, and also in smaller retail outlets in 1994. Whilst the availability of foods making up a healthy diet has improved in supermarkets in southern Derbyshire over the years of the study, and the cost to supermarket shoppers is coming down, a healthy diet is still more expensive than the average diet. Also, those who shop with smaller retailers (usually those on lower incomes and at higher risk of diet related disease) will still have difficulty finding some food items, and will find a healthy diet prohibitively expensive.     

The relationship between diet and perceived and objective access to supermarkets among low-income housing residents

In the U.S., supermarkets serve as an important source of year-round produce (Chung & Myers, 1999), and yet access to supermarkets may be scarce in "food deserts," or poor, urban areas that lack sources of healthy, affordable food (Cummins & Macintyre, 2002). This study examined objective distance to the nearest supermarket and participant-report of supermarket access in relation to fruit and vegetable intake. Street-network distance to the closest supermarket was calculated using GIS mapping. Perceived access was assessed by a survey question asking whether participants had a supermarket within walking distance of home. Cross-sectional survey data were collected from 828 low-income housing residents in three urban areas in greater-Boston. Generalized estimating equations were used to estimate the association between perceived and objective supermarket access and diet. Fruit and vegetable consumption was low (2.63 servings/day). Results suggest that most low-income housing residents in greater-Boston do not live in "food deserts," as the average distance to a supermarket was 0.76 km (range 0.13-1.22 km). Distance to a supermarket was not associated with fruit and vegetable intake (p = 0.22). Perceived supermarket access was strongly associated with increased fruit and vegetable intake (0.5 servings/day) after controlling for socio-demographic covariates (p < 0.0001). Patterns of mismatch between perceived and objective measures revealed that mismatch between the two measures were high (31.45%). Those who did not report a supermarket within walking distance from home despite the objective presence of a supermarket within 1 km consumed significantly fewer fruits and vegetables (0.56 servings/day) than those with a supermarket who reported one, even after controlling for socio-demographic variables (p = 0.0008). Perceived measures of the food environment may be more strongly related to dietary behaviors than objective ones, and may incorporate components of food access not captured in objective measures.     

Associations of supermarket accessibility with obesity and fruit and vegetable consumption in the conterminous United States

Background  

Limited access to supermarkets may reduce consumption of healthy foods, resulting in poor nutrition and increased prevalence of obesity. Most studies have focused on accessibility of supermarkets in specific urban settings or localized rural communities. Less is known, however, about how supermarket accessibility is associated with obesity and healthy diet at the national level and how these associations differ in urban versus rural settings. We analyzed data on obesity and fruit and vegetable (F/V) consumption from the Behavioral Risk Factor Surveillance System for 2000-2006 at the county level. We used 2006 Census Zip Code Business Patterns data to compute population-weighted mean distance to supermarket at the county level for different sizes of supermarket. Multilevel logistic regression models were developed to test whether population-weighted mean distance to supermarket was associated with both obesity and F/V consumption and to determine whether these relationships varied for urban (metropolitan) versus rural (nonmetropolitan) areas.     

Food access and cost in American Indian communities in Washington State

Limited access to foods that make up a nutritious diet at minimal cost may influence eating behaviors and, ultimately, obesity. This study examined the number and type of food stores (convenience, grocery, supermarket) on federal reservations in Washington State, and the availability and cost of foods in the US Department of Agriculture Community Food Security Assessment Toolkit market basket, to describe the food environment of American Indians. Stores were identified by telephone survey of tribal headquarters, a commercial database, and on-site visitation. Foods were assessed using a standardized instrument containing 68 items in seven major food groups during April and May 2009. Store type and availability and cost of foods were recorded on a checklist. Fifty stores were identified on 22 American Indian reservations, including 25 convenience, 16 grocery, and 9 supermarkets. Across all stores, about 38% of checklist items were available, with supermarkets having the most and convenience stores the fewest. Foods from the dairy and sugars/sweets groups were the most prevalent, while fresh fruits/vegetables were the least. Cost of the most commonly available items was lowest in supermarkets. Seventeen reservations did not have a supermarket on their reservation, and the nearest off-reservation supermarket was about 10 miles from the tribe's headquarters, which was used as the standard for distance calculations. These results demonstrate that American Indians living on federal reservations in Washington State may have limited access to foods that make up a nutritious diet at minimal cost.     

Binge eating and binge eating disorder in a small-scale, indigenous society: the view from Fiji

OBJECTIVE: Although the cross-cultural prevalence of anorexia and bulimia nervosa has been investigated in multiple studies, little is known about the prevalence and correlates of binge eating and binge eating disorder (BED) cross-culturally. No published studies to date have explored BED in small-scale, indigenous, or developing societies. The current study investigated the prevalence and correlates of binge eating in a community sample of Fijian women living in rural Fiji. METHODS: Fifty ethnic Fijian women completed a self-report measure developed for this study on dieting and attitudes toward body shape and change, a Nadroga-language questionnaire on body image, and the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R). Their height and weight were also measured. Patterns of dieting, high body mass index (BMI), and attitudes toward eating and body image were compared between women with and without a history of binge eating. RESULTS: Ten percent of respondents reported at least weekly episodes of binge eating during the past 6 months and 4% endorsed symptoms consistent with BED. Binge eating in this sample was associated significantly with a BMI value above 35, a history of dieting, and a high concern with body shape. Binge eating was not associated with several markers of acculturation in this sample, although it was associated with a key, nontraditionally Fijian (i.e., acculturated) attitude toward the body. DISCUSSION: Binge eating occurred in a social context with traditions concerning weight and diet widely disparate from Western populations. However, correlates of binge eating in this sample suggest that nontraditional Fijian attitudes toward weight and body shape play a contributory role.     

Geographic disparities in Healthy Eating Index scores (HEI–2005 and 2010) by residential property values: Findings from Seattle Obesity Study (SOS)

BackgroundHigher socioeconomic status (SES) has been linked with higher-quality diets. New GIS methods allow for geographic mapping of diet quality at a very granular level.ObjectiveTo examine the geographic distribution of two measures of diet quality: Healthy Eating Index (HEI 2005 and HEI 2010) in relation to residential property values in Seattle-King County.MethodsThe Seattle Obesity Study (SOS) collected data from a population-based sample of King County adults in 2008–09. Socio-demographic data were obtained by 20-min telephone survey. Dietary data were obtained from food frequency questionnaires (FFQs). Home addresses were geocoded to the tax parcel and residential property values were obtained from the King County tax assessor. Multivariable regression analyses using 1116 adults tested associations between SES variables and diet quality measured (HEI scores).ResultsResidential property values, education, and incomes were associated with higher HEI scores in bivariate analyses. Property values were not collinear with either education or income. In adjusted multivariable models, education and residential property were better associated with HEI, compared to than income. Mapping of HEI–2005 and HEI–2010 at the census block level illustrated the geographic distribution of diet quality across Seattle-King County.ConclusionThe use of residential property values, an objective measure of SES, allowed for the first visual exploration of diet quality at high spatial resolution: the census block level.     

Evaluation of a supermarket intervention to increase consumption of fruits and vegetables

PURPOSE: The purpose of this study was to evaluate whether a supermarket point-of-purchase intervention could increase shoppers' consumption of fruits and vegetables. METHODS: Eight supermarkets in rural Iowa were randomized to receive either an 8-month intervention or no intervention. The intervention consisted of: (1) one-page supermarket flyers that identified fruits and vegetables on sale, gave receipts and menu ideas for using sale foods, and gave a store coupon worth 50 cents toward the purchase of any fruit or vegetable; (2) store signage to identify fruits and vegetables featured on the flyer; and (3) consciousness raising activities such as food demonstrations and nutrition related signage. Evaluation was based on exit interviews and take-home surveys, completed by random samples of 120 shoppers from each store at baseline and approximately 1-year post randomization. RESULTS: At follow-up, 42.9% of intervention store shoppers and 6.5% of control shoppers recalled seeing the intervention flyer. Thirty-six percent of intervention shoppers had used a 50-cent coupon and 18% had used a recipe. Approximately 70% of all shoppers had purchased fruits or vegetables on the day they were interviewed, which did not differ between intervention and control stores. Compared to change in control shoppers, there was a borderline statistically significant 8.4 percentage point increase (p < .07) in the percentage of intervention store shoppers in the action or maintenance stages of dietary change, but there was no corresponding increase in fruit or vegetable consumption. DISCUSSION: Studies to test point-of-purchase interventions are difficult to design, implement, and evaluate. More powerful interventions are probably necessary to induce shoppers to purchase and consume more fruits and vegetables.     

Optimising women's diets. An examination of factors that promote healthy eating and reduce the likelihood of unhealthy eating

The majority of nutrition promotion research that has examined the determinants of unhealthy or healthy dietary behaviours has focused on factors that promote consumption of these foods, rather than factors that may both promote healthy eating and buffer or protect consumption of unhealthy foods. The purpose of this paper is to identify factors that both promote healthy eating and also reduce the likelihood of eating unhealthily amongst women. A community sample of 1013 Australian women participated in a cross-sectional self-report survey that assessed factors associated with diet and obesity. Multiple logistic regressions were used to examine the associations between a range of individual, social and environmental factors and aspects of both healthy and unhealthy eating, whilst controlling for key covariates. Results indicated that women with high self efficacy for healthy eating, taste preferences for fruit and vegetables, family support for healthy eating and the absence of perceived barriers to healthy eating (time and cost) were more likely to consume components of a healthy diet and less likely to consume components of a unhealthy diet. Optimal benefits in overall diet quality amongst women may be achieved by targeting factors associated with both healthy and unhealthy eating in nutrition promotion efforts.     

Health concern, food choice motives, and attitudes toward healthy eating: the mediating role of food choice motives

This study addresses how various health concerns might influence not only consumers' food choice motives but also consumers' subsequent attitudes toward healthy eating. This study expects that those consumers with greater health concerns would have different food choice motives and better attitudes toward healthy eating. A self-completion questionnaire was used to gather information. Participants, a random sample of 500 undergraduate students from a national university in Taipei, Taiwan, provided a total of 456 usable questionnaires, representing a valid response rate of 91%. The average age of the respondents at the time of the survey was 21 years and 63% of respondents were females. The relationship between health concern and healthy eating attitudes was confirmed. The relationship between health concern of developing diseases and attitudes toward healthy eating was fully mediated by food choice motives. However, the relationship between calorie consumption health concern and healthy eating attitudes was only partially mediated by food choice motives. Implications of these findings are discussed.     

Associations between health risk appraisal scores and employee medical claims costs in a manufacturing company

BACKGROUND. The bivariate relationships between 18 health-related measures on a health appraisal and prospective medical claims costs were examined among 1,838 employees for three consecutive years. METHODS. Employees were classified into high- or low-risk categories for each of the 18 health-related measures, and divided into high- or low-cost categories according to their averaged three-year medical costs respective to the mean of their sex/age subgroup. RESULTS. Average annual medical costs for the 18 health-related measures were $67 to $778 higher for the employees classified at high risk. The high-cost category was statistically associated with high-risk status in 11 of 18 health-related measures with a high-cost/high-risk to high-cost/low-risk ratio of 1.26 to 2.50. The average annual medical claims costs were also significantly related to number of high-risk classifications. DISCUSSION. This study provides strong statistical evidence that, regardless of age and sex, employees in this sample with positive behaviors cost less in medical claims from 11 of 18 health-related measures.     

Prevalence and correlates of binge eating in white and African American adolescents

OBJECTIVE: This study examined the prevalence and correlates of binge eating in a biracial sample of adolescent males and females. METHOD: White and African American students in Grades 6-12 (N=822) completed measures of social economic status (SES), body mass index (BMI), depression, current-ideal body image discrepancy, eating attitudes, dieting frequency, dietary intake, and activity level. RESULTS: Binge eating prevalence was highest among African American boys relative to the other demographic groups: 26% African American boys, 17% African American girls, 19% white boys, 18% white girls. Binge eating rates increased with age for white participants and decreased with age for African American participants. Depressive symptoms and consumption of high-fat foods predicted binge status among adolescents, whereas SES, BMI, eating attitudes, body image discrepancy, dieting, and low activity level failed to add predictive value. DISCUSSION: The observation of developmental differences in binging between whites and African Americans corresponds to their physical maturational divergence. These findings underscore the need for population-based surveys that sample binge eating across age, gender, and ethnicity.     

Regular users of supermarkets in Greater Tunis have a slightly improved diet quality

Despite the recent and rapid expansion of supermarkets in developing countries, their association with diet quality has been hardly studied. The study took place in Tunisia, where incidences of obesity and nutrition-related diseases are rising. The target population was households of the Greater Tunis area where supermarkets are mostly located. Households (n = 724) were selected by a 2-stage clustered random sampling. A purposely developed quantitative questionnaire assessed food retail habits. Socioeconomic data were collected at individual and household levels. The diet quality index-international (DQI-I) derived from a FFQ specific for Tunisia measured diet quality. Data analysis by regression or logistic regression models adjusted for energy intake and socioeconomic confounders when relevant. Overall, 60% of the households used supermarkets. Most households still used the nearby grocer; only 26% shopped at the market. Characteristics associated with supermarket use were urban milieu, small-sized households, greater educational attainment, higher economic level, steady income, or easy access. Associations between these variables and using supermarkets as a first shopping place (20% of households) were even stronger. After adjustment for energy intake and socioeconomic and access data, using supermarkets chosen as first food shopping place vs. other retail resulted in a slightly higher DQI-I (63.2 vs. 59.6; P = 0.0004). Despite the long-standing presence of supermarkets in Tunis, shopping at supermarkets has not yet spread to the whole population. Supermarkets do not yet markedly modify food consumption in the Greater Tunis. However, a slight improvement of diet quality can be observed among those people who use supermarkets regularly.     

Relationship of Diet-Health Attitudes and Nutrition Knowledge of Household Meal Planners to the Fat and Fiber Intakes of Meal Planners and Preschoolers

The relationship of household meal planners’ diet-health attitudes and nutrition knowledge to their fat and fiber intakes and to the intakes of 2- to 5-year-old children in the households was examined using data from the 1989–91 Continuing Survey of Food Intake by Individuals and Diet Health Knowledge Survey (CSFII/DHKS). Selected households (n = 478) provided 24-hour diet recalls and the households’ main meal planners responded to the DHKS. Meal planner attitude variables were defined according to the Health Belief Model and selected CSFII/DHKS questions served as proxy measures. The relationship of meal planners’ attitudes and knowledge to meal planners’ and children's fat and fiber consumption at home and in the total diet was analyzed using multiple regression. Several diet-health attitude variables were significantly related to meal planners’ fat and fiber intakes and relationships were similar for foods eaten at home and for foods eaten in the total diet. Knowledge was significantly related to meal planners’ and children's home fat intake (p < .05) but the relationships failed to reach statistical significance for the total diets. Meal planners’ taste concerns differed significantly in their relationship to meal planners’ and children's fiber consumption (p < .05). Results indicate that parents’ diet-health attitudes are more influential in their diets than in the diets of preschoolers. Findings also suggest that taste and practical food concerns are significant barriers to healthy eating among younger adults and that general nutrition knowledge may not be as helpful in making healthy food choices outside the home as it may be in the home setting.