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Food in the DesertChristopher Myers

Food in the Desert

In a city where the deep-fryer is king, what does it take to sell yogurt, salad and wraps?

During the lunch-hour peak at Shareef's Grill in West Baltimore, a tightly packed line stretches all the way from the Plexiglas-enclosed counter straight out the front door.

During the lunch-hour peak at Shareef's Grill in West Baltimore, a tightly packed line stretches all the way from the Plexiglas-enclosed counter straight out the front door.

Hungry customers chat in the 15-by-20-foot shop as they wait for the usual carryout fare of wings and fries, steak sandwich and Pepsi, as well as the not-so-usual: a hot veggie wrap, a turkey wrap, corn chowder, 100-percent juices and other healthy items. Also atypical for an urban carryout are signs on the walls that declare, "We only use peanut oil when frying foods," and "Shareef Sorbet: all natural, no high fructose corn syrup, pounds of fruit in every batch," and "One of Baltimore's Healthy Carryouts."

But then Shareef's, located in the economically depressed Harlem Park neighborhood, defies convention. The beneficiary of an initiative called Baltimore Healthy Carryouts led by the Bloomberg School's Center for Human Nutrition, Shareef's encourages its clientele to make better food choices. The project is just one way in which researchers, policymakers and others are making strides toward understanding "food deserts" and their toll on low-income urban populations.

Characterized by areas where the distance to a supermarket is more than one-quarter mile and where more than 40 percent of households do not have access to a vehicle, food deserts commonly plague large American cities like Baltimore, where one in five people lives in one.

With supermarkets out of easy reach, Baltimoreans living in food deserts often rely on corner stores and carryouts for their meals. According to 2012 data compiled by the School's Center for a Livable Future (CLF), the city teems with 440 such corner stores and 709 carryouts, while boasting just 47 supermarkets.

"If you went outside this building [in East Baltimore] and spun around in a circle and walked in whatever direction you wanted, you would probably have to walk a mile or more before you hit a supermarket-probably two miles," notes Joel Gittelsohn, PhD, MS, with both the Center for Human Nutrition and the Global Center for Childhood Obesity. "But if you walk a block or two, you're going to hit a corner store or a carryout or both."

The stakes are significant: The high-sugar, high-fat, low-fiber diet commonly consumed in poor communities is linked to elevated rates of obesity, which in turn raises the risk for diabetes, heart disease and some kinds of cancer.

Bringing healthy food to the city means working the angles of supply and demand.

Gittelsohn has spent the past 10 years exploring the relationship among low-income minority populations, food access and health via the Baltimore Healthy Stores initiative. He's identified barriers to healthy eating in the city and fashioned strategies to increase access to a nutritionally adequate diet, improve food security and reduce the risk of diet-related chronic diseases.

"It's a supply-and-demand issue," he explains. "We work with local food suppliers to increase the supply of healthy foods, and we work with local consumers to increase the demand for those foods, because you can't have one sustainably without the other."

Typically, corner stores and carryouts offer few, if any, options like whole wheat bread, fruits and vegetables, and low-fat milk. Instead, they sell a cornucopia of high-fat, high-sodium and high-sugar foods.

"Most of the people in these communities say that they would love to eat healthier foods," Gittelsohn notes, "but they cost too much or they're of poor quality or they are just not available." Residents have a "relatively good concept" of what healthy foods-and unhealthy ones-mean. Fruits and veggies: good. Sugary sodas: bad. "It's not so much of a knowledge-gap issue," he says.

Following research and feasibility studies, Gittelsohn's Healthy Stores has launched three programs to increase access to healthy foods: B'more Healthy: Retail Rewards; B'more Healthy: Communities for Kids; and Baltimore Healthy Carryouts.

Conducted in 2011, Healthy Carryouts worked with eight West Baltimore shops located in food deserts: four, including Shareef's Grill, emphasized healthy items; four others were left untouched, says former program coordinator Seung Hee Lee, PhD '13. The "healthy" carryouts redesigned menus and signage; promoted bottled water, juices, salads and yogurt; and offered new combo meals like a grilled chicken sandwich, baked chips and bottled water that were sold at a discount.

"In Baltimore City carryouts, the deep-fryer is king," Gittelsohn notes. "Many of these places do not even have a grill or a way to cook food in a low-fat way." To alleviate that problem, the program provided one of the shops with a George Foreman grill.

Sales of healthy foods at the intervention shops went up dramatically-even after just the menus and signage were changed, says Lee, now an Epidemic Intelligence Service officer with the CDC. The final numbers showed a 100 percent sales increase for healthy options and an overall increase in gross receipts; meanwhile, the control carryouts experienced an overall decrease in gross sales during the same time period.

Additionally, pre-intervention versus post-intervention customer surveys indicated a behavioral change. "We noticed that those who recognized the Baltimore Healthy Carryouts intervention materials were more likely to buy healthier items-and a greater variety of healthier items," Lee points out.

Count Tina Jackson among them. The Shareef's Grill customer took notice of the green-leaf-flagged hot jumbo lump crab wrap filled with broccoli before placing her order. "I'm trying to be more conscious about eating heart-healthy foods," she explains. "I like when food is healthy but still tastes good." Then she jokes, "Make me at least feel like I'm not eating healthy."

For his part, Gittelsohn expresses optimism in what the Healthy Carryouts study demonstrated: Not only did healthy food sales improve in the intervention carryouts, people also bought fewer unhealthy items. "Sometimes you worry about these interventions in that you could just get people to eat more healthy foods, but they will keep eating doughnuts and high-sugar cereals at the same time," he says.

For now, the four healthy carryouts "are on their own," he adds. "However, many more carryouts will be part of the B'more Healthy: Communities for Kids trial, which starts in spring 2014."

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