Changing Food Offerings in Baltimore's Small Stores: The Baltimore Healthy Eating Zones Study

    • November 19, 2012

The problem. Nearly one-third of U.S. children are overweight or obese, and children from lower-income or minority families are at highest risk—38 percent of Mexican-American children and almost 35 percent of Black children are obese or overweight, compared with almost 31 percent of White children.

In Baltimore, as in many other cities, low-income Black neighborhoods have fewer supermarkets and more small convenience and corner stores than higher-income White neighborhoods. Therefore, youth living in these neighborhoods have less access to healthy foods, although little information is available on their food-purchasing behaviors, especially food purchased outside of school.

An anthropologist studies nutrition and obesity. Joel Gittelsohn, MS, PhD, has always been interested in cultural influences. "My mother is Chinese-American and my father is Jewish-American. I had a bicultural upbringing, and I think that is part of what prompted my interest in how cultural factors relate to health and nutrition."

From the start, Gittelsohn took a real-life approach to his research. "When I was doing science as an undergraduate [at the University of California–Berkeley], nutrition science made the most sense to me. Other science didn't seem as grounded in what people really do. And I was interested in why people ate what they did."

Gittelsohn's graduate studies [at the University of Connecticut] took him to distant places and high altitudes. With support from the National Science Foundation and the University of Connecticut, he analyzed infant and child feeding in Peru. His doctoral dissertation led him to rural villages in Nepal to study how people allocated food in family settings—for example, whether they made decisions based on age, gender, or generation.

Gittelsohn joined the faculty at Johns Hopkins University in Baltimore in 1989 and continued using anthropological methods to study nutrition, focusing initially on schools. Over time, however, his interest shifted to community settings. "I became disenchanted with school-centric interventions for obesity prevention. I became convinced that whatever we did in schools would be offset by what kids did out of school."

To modify the community food environment, he started Baltimore Healthy Stores, a culturally appropriate, store-based intervention aimed at adults in low-income areas designed to increase the supply of healthy foods and promote their purchase. His Healthy Stores work has also had projects in the Marshall Islands, Hawaii, the White Mountain and San Carlos Apache Reservations in Arizona, and elsewhere.

Gittelsohn's Healthy Eating Research study. Gittelsohn heard about the Robert Wood Johnson Foundation (RWJF) Healthy Eating Research program through its 2006 call for proposals. After winning a grant, he led a study entitled the Baltimore Healthy Eating Zones (BHEZ) from September 2007 through August 2010.

BHEZ expanded Baltimore Healthy Stores by focusing on food purchasing behavior among low-income Black Baltimore youth, ages 10–14, who frequented seven community recreation centers and purchased food at nearby stores. Seven other recreation centers served as a comparison group during the nine-month intervention phase.

"We worked with corner stores and got them to offer healthier items and we used some point-of-purchase marketing in the stores. To do this, we put up simple signs that, for example, indicated, ‘This choice is lower fat than that one.' We also used posters developed by local artists and had interactive educational sessions and taste tests in the stores." An additional component of the BHEZ program worked to improve carryout restaurants through improved signage and using healthier preparation methods.

Researchers also conducted training sessions for recreation center staff about ways to modify the food and beverages they offered, and helped staff organize cooking classes. Youth peer educators trained by researchers helped disseminate project messages and conducted taste tests, cooking demonstrations, and store promotions.

Participating youths and their caregivers completed questionnaires at baseline and at the end of the intervention. Youth indicated how much money they spent on food for themselves, how frequently they purchased 29 food and beverage items, and where they usually purchased each one. Caregivers also described their own food purchasing patterns. In all, 242 youth-caregiver dyads completed the baseline questionnaires and 153 of the same dyads completed the post-intervention questionnaires.

To measure changes in the food environment, researchers administered a Store Impact Questionnaire to owners of 18 corner stores and three carry-out restaurants near the recreation centers. The questionnaires asked owners for food-stocking and sales data and about their attitudes toward stocking healthy foods.

During each intervention (cooking class, in-store promotion, taste test), project staff recorded the number of people exposed to the intervention or the number of promotional materials distributed. They also recorded store owners' adherence to the program, noting whether they stocked the promoted foods and used the promotional material. Researchers also surveyed the recreation centers to determine what food and beverages were available to visitors and whether the centers had changed their food offerings during or after the intervention.

Findings and observations. In an article published in the American Journal of Preventive Medicine (Dennisuk LA, et al., June 2011), researchers reported that youth spent a surprisingly high daily average of $3.96 on foods and beverages, about twice a week, most frequently at corner stores and fast-food establishments. They most often spent their money on chips, candy, and soda. Almost half of the youth in the sample were overweight or obese. "Food purchasing among low-income, urban African-American youth is frequent and substantial," concluded the researchers.

At baseline, youth purchased an average of 1.5 healthy foods in the week prior to their interview, or 11.6 percent of total food purchased. The most commonly purchased healthy foods were water and sunflower seeds. These findings appeared in an article published in 2010 in Public Health Nutrition.

Recruiting stores to stock healthier foods proved challenging, according to Gittelsohn. "Most small stores owners in these settings don't perceive demand for healthy foods. They are motivated by profit, so they will sell what they think will profit." Having a Korean-speaking person doing the recruitment was helpful, Gittelsohn noted, since more than 70 percent of store owners were Korean.

Despite these challenges, most participating stores increased their inventory of the key promoted foods during the eight-month intervention. And the city of Baltimore removed vending machines from all of its recreation centers, which the researchers viewed as a key accomplishment.

In an analysis of how meals were prepared at home, Gittelsohn found that adolescent children of caregivers who used healthier cooking methods were more likely to use healthy cooking methods themselves and were at less risk of being overweight or obese. However, children with more meals prepared by a caregiver were likely to have higher BMI-for-age, suggesting that meals prepared at home do not necessarily promote healthy BMI in adolescents. These findings were published in the Journal of Nutrition in 2012.

Other findings, not yet published as of October 2012, indicate that overweight youth who lived in healthy eating zones around recreation centers, significantly decreased their body mass index (BMI) compared with overweight youth in the comparison population.

An emerging field of like-minded researchers. "I hope my extreme enthusiasm for Healthy Eating Research comes through," says Gittelsohn. He was especially enthusiastic about being part of a collaborative group. "It is more than the money. The money was great but I am equally appreciative of the networking opportunities available."

At the request of the Healthy Eating Research national program office, Gittelsohn formed the Corner Store Working Group. Among their activities, members of the working group published two papers (in the American Journal of Public Health and Public Health Nutrition) that analyzed the impact of changes in the federal WIC program (Special Supplemental Nutrition Program for Women, Infants and Children) on small stores.

"Most of us on the working group are no longer funded by Healthy Eating Research, but it would be great to bring the group back to an annual meeting to continue our work," Gittelsohn says.

Since the project ended. During Gittelsohn's study, the mayor of Baltimore formed a food-policy task force that developed a series of recommendations to improve the city's food environment. "As an outgrowth of our report," he says, "Baltimore hired a food policy director, one of the few cities to have this position. We are working through details to create a healthy corner stores criteria program. The city also took the model of our work with carry-outs, and is expanding this approach to all six public markets in the city." That kind of collaboration helps link the research and practice communities, he says. "We [academics] bring the evidence, the trial, and a small program. They [local government] bring the scale. There is all this exciting possibility when academics and city officials work together." For more information, visit

Gittelsohn also has other projects underway. "Small stores and carry-out stores operate within the environment of the food wholesalers they do business with. The owners say the wholesalers don't carry healthy food or they charge too much for those foods. So we received an NIH [National Institutes of Health] grant to work with wholesalers."

In November 2011, with major support from the NIH, Johns Hopkins established a Global Center for Childhood Obesity. Gittelsohn directs one project at the center, which allows him to expand the work he started under Healthy Eating Research. He is also collaborating with researchers at the University of Maryland and staff at the Maryland Department of Health and Mental Hygiene to create a Maryland Healthy Stores project for rural areas of the state.

And with support from the U.S. Department of Agriculture, Gittelsohn is directing OPREVENT (a multi-level Obesity Prevention Trial for American Indian Communities). OPREVENT runs through March 2014.

RWJF perspective. The Healthy Eating Research program is part of RWJF's efforts to reverse the childhood obesity epidemic by 2015. These efforts include improving access to affordable, healthy foods and increasing opportunities for physical activity in schools and communities across the nation.

"The Healthy Eating Research Program provides policy-makers and other key decision-makers and with evidence they can use to improve children's nutrition and access to healthy foods," says C. Tracy Orleans, Ph.D., RWJF senior scientist.

"In collaboration with other national research funders, RWJF is working to build solid evidence for action, especially in the lower-income and racial/ethnic communities at highest risk. Our goal is to fund rigorous, solution-oriented studies, to build a diverse and robust network of researchers, and to communicate findings effectively to inform policy and guide action." Orleans says that Program Director Mary Story's "pioneering vision and leadership" were critical to the program's success and national progress towards reversing the childhood obesity epidemic.

See the Healthy Eating Research Progress Report for more information about the program or visit