Denise Holston, Melissa Cater and Stephanie Broyles

People living in rural settings have significantly higher rates of nutrition-related chronic diseases and lower diet quality than those living in more urban settings. This may be due in part to lack of access to healthy, affordable foods, especially fruits and vegetables. Rural grocery stores tend to be few and far between, and those that are in rural areas tend not to carry quantities of fresh fruits and vegetables because of the high cost to obtain them and their short shelf life. Thus, adoption of preventative behaviors to meet dietary recommendations and to reduce chronic disease risk may be challenging in rural areas.

To address this dilemma of getting healthier foods into rural grocery stores and getting the people in the rural areas to buy these foods, the LSU AgCenter has embarked upon a long-range research project with multiple studies, funded through the Centers for Disease Control and Prevention. One three-year study, which began in 2015, involved a community-participatory, multilevel approach to obesity prevention in three rural Louisiana parishes — Madison, St. Helena and Tensas. These three parishes have high rates of poverty (range 25%-42%) and obesity (greater than 40%) (Table 1). Interventions within the three-year study, which involved working with local food stores, were designed to influence the policy, systems and environment that may ultimately influence dietary behaviors among citizens and make healthy choices easier among residents.

A variety of interventions were used, but all hinged on working closely with food store managers. Numerous meetings were held with these managers, providing them with retail marketing and technical assistance and encouraging them to stock more healthy foods and to better display the healthier food choices.

The other part of the strategy was to encourage consumers to buy more of these foods to increase demand so that the store managers would see that these new practices were good for business. Some of the techniques aimed at consumers were:

• Signs in the stores calling attention to good nutritional practices.
• Signs on shelves pointing to healthy foods, called “shelf talkers.”
• Food demonstrations at the stores, allowing people to taste healthy foods and then handing out recipe cards for these dishes.

The evaluation used a descriptive, mixed methods design that focused on first- and third-year project data related to a healthy retail program. Nutrition environments at the food stores were assessed using the Nutrition Environment Measurement Survey. Pre- and post-survey scores were compared to determine if healthy retail policy, systems and environment interventions were effective in improving the rural nutrition environment.

Overall, 48 food stores were assessed at baseline, while 45 food stores were assessed at follow-up. Different numbers between baseline and follow-up assessments are due to store closures/openings. Except for the grocery store in Madison Parish, the food environments were poor across the targeted parishes, with scores indicating a lack of healthy grocery items. With few exceptions, average scores generally increased slightly over the assessments, which is a positive trend; however, these positive changes did not result in the food retail environment moving from unhealthy to healthy (Table 2).

Within the program, five stores were targeted to implement a healthy retail program. All of the partner stores’ scores improved from baseline to post-intervention (Figure 1). Further, of the partner stores, the average number of healthy foods available increased in all categories, except skim or low-fat milk, from baseline to post-intervention (Figure 2).

Findings from baseline indicate that the nutrition environment in these high-poverty, high-obesity, rural parishes can present challenges to individuals attempting to meet preventative health recommendations. Community-driven policy, systems and environment interventions can improve the nutrition environment in these locations, but more research is needed to determine the appropriate strategies that will influence residents’ behavioral and health outcomes.

The research begun with this study will continue and be expanded to four more parishes — Assumption, Claiborne, East Carroll and Morehouse — under a new five-year, $5 million grant from the Centers for Disease Control and Prevention Division of Nutrition, Physical Activity and Obesity, which was awarded to the AgCenter in 2018. The AgCenter agents will be working with the food stores in the parishes, along with restaurants, to develop collective purchasing from food distributors to make it worth their while to deliver healthier foods to rural Louisiana. They will also be expanding their strategies to encourage the residents to demand healthier food options.

Denise Holston is an assistant professor in the School of Nutrition and Food Sciences and a nutrition specialist; Melissa Cater is an evaluation specialist and director of the Northeast Region; Stephanie Broyles is an associate professor at the Pennington Biomedical Research Center, Baton Rouge.

Acknowledgements: This study, which is part of the LSU AgCenter’s Healthy Access, Behaviors, Communities (Healthy ABCs) program was partially funded through a three-year, $2.27 million grant from the Centers for Disease Control High Obesity Program. Research partners included Southern University Agricultural Research and Extension Center, LSU’s Pennington Biomedical Research Center and the Louisiana Department of Health and Hospitals.

This article appears in the fall 2019 issue of Louisiana Agriculture.

Doug Curtis, owner of Doug's Market in Tallulah, offers healthy snack options in a recently installed refrigerated snack bar and point-of-purchase aisle rack. Curtis is a member of the Madison Parish Healthy Communities coalition that is working to improve access to healthy foods for local consumers. Photo by Karol Osborne

Table 1. Descriptive characteristics of target parishes.

Table 2. Average Nutrition Environment Measurement Survey scores by store type (baseline/ post comparison).

Note: The highest possible score for a grocery store is 39.3. Values ranging from 25-39.3 are considered good, while values below 25 indicate a lack of healthy food items. The highest possible score for a convenience store is 33.2. Values ranging from 23 to 33.3 are considered good, while values below 23 indicate a lack of healthy grocery items. The highest possible score for variety store is 27.5. Values ranging from 18-27.5 are considered good, while values below 18 indicate a lack of healthy grocery items.

Figure 1.Nutrition Environment Measurement Survey scores at targeted sites

Note: The highest possible score for a grocery store is 39.3. Values ranging from 25-39.3 are considered good, while values below 25 indicate a lack of healthy food items. The highest possible score for a convenience store is 33.2. Values ranging from 23 to 33.3 are considered good, while values below 23 indicate a lack of healthy grocery items.

Figure 2. Baseline and post-intervention availability of healthy food offerings (average number of varieties) across partner stores.