The demand for food prepared outside the home, especially fast food, is increasing. It dominates away-from-home consumption, contributes energy-dense foods to the diet, and has been implicated in the obesity epidemic [2, 6–12, 44, 45]. Although spatial access to fast-food restaurants has been shown to correlate with dietary intake [6, 46–48], the picture we have, which focuses primarily on chain fast-food restaurants as the source of fast food, is incomplete and may underestimate the exposure to fast food .
This study extends our understanding of potential spatial access to fast food from rural neighborhoods, not just to fast-food restaurants, but to all retail opportunities for fast-food entrées and side dishes . We examined two dimension of spatial access: 1) proximity or the distance to the nearest fast-food restaurant, fast-food opportunity, and fast-food opportunity with a good variety of healthier options, and 2) coverage or the number of fast-food restaurants or opportunities to purchase fast food within a specified distance of the neighborhood . This is apparently the first study, to our knowledge, that evaluates the measurement of the fast-food environment and examines the relationship between neighborhood characteristics and potential spatial access to fast food from all opportunities that market fast food and healthier fast-food options in a large rural area. Our analyses revealed that identifying fast-food restaurants as the sole source of fast-food entrées and side dishes underestimated neighborhood exposure to fast food, and in terms of both neighborhood proximity and coverage. Definitions of the fast-food environment should not be limited to traditional fast-food restaurants, as this can significantly misrepresent neighborhood access to all fast food and to a variety of healthier fast-food options. In addition, residents of high deprivation neighborhoods had relatively better spatial access to all fast food and to a variety of healthier fast-food entrée and side dish options compared to residents of low deprivation neighborhoods.
Spatial access to fast food
This study builds on the work of Creel and colleagues who were the first to describe nontraditional fast-food opportunities by documenting the presence of fast-food entrées and side dishes in retail food stores (convenience stores, supermarkets, and grocery stores) in a large rural area . In a complete picture of the retail fast-food environment, convenience stores and supermarkets/grocery stores that marketed fast food provided almost 60% of the opportunities to purchase fast food . This has been explained by the recognition by convenience stores of the consumer's preference for convenient shopping, fast service, and longer hours; and for the need of convenience stores to attract and hold customers in the face of increased cost and competition [49–51]. However, little was known regarding the extent to which neighborhood spatial access to fast food differed between traditional fast-food restaurants and fast-food opportunities. We found that spatial access to fast-food entrées and side dishes from fast-food opportunities (traditional fast-food restaurants, convenience stores, or supermarkets/grocery stores) was significantly better than access to traditional fast-food restaurants. The median distance to the nearest fast-food opportunity was 2.7 miles, compared with 4.5 miles to the nearest fast-food restaurant. On the average, there were 3.2 fast-food opportunities within 1 mile and 9.9 within 3 miles of a neighborhood, compared with 1.6 (within 1 mile) and 5.0 (within 3 miles) traditional fast-food restaurants. The addition of product offerings, such as fast foods, to the primary business of convenience stores and supermarkets provides these retail stores with new sales opportunities, and consumers with increased access to fast food[2, 34]. This extends prior research, primarily in urban areas, that focused on traditional fast-food restaurants, most often the major fast-food restaurant chains [20, 24, 36, 50, 52–57]. Similar relationships in proximity and coverage were observed within each level of neighborhood deprivation. Regardless of definition of fast-food environment (traditional fast-food restaurant or fast-food opportunity), access in terms of proximity and coverage significantly improved across neighborhoods of increasing deprivation. These results overcome the limitations previously identified by researchers when describing fast-food availability [12, 20, 36]. Our results are consistent with prior work that found better potential spatial access to supermarkets and to food stores with fruit and vegetables for residents of high deprivation rural neighborhoods, compared with low deprivation neighborhoods [25, 38], and at odds with a New Zealand study that found more deprived rural areas (using census meshblocks) faced greater distances to multinational fast-food outlets . In fact, the difference in mean and median distances that we observed between high-deprivation neighborhoods and either medium or low-deprivation neighborhoods was extremely large and held for both proximity and coverage, and for fast-food only, fast-food opportunities, and healthier options. As previously observed, one explanation may be that the five urban clusters in our study area (towns with populations of 3,181 - 11,952) had the greatest population density, and clustering of socioeconomic deprivation characteristics, and therefore more fast-food restaurants, convenience stores, and supermarkets/grocery stores .
Spatial availability of healthier fast-food options
Little is known about the availability of healthier options for fast-food entrées and side dishes . Building on the work of Creel and colleagues in the identification of healthier options in rural fast-food opportunities, we found greater spatial access to a healthier option in at least one entrée, compared with access to a traditional fast-food restaurant. This was consistent when considering both proximity and coverage, and within categories of neighborhood socioeconomic deprivation. One explanation may be that some convenience stores and supermarkets/grocery stores provide healthier options for their entrées and/or side dishes . Interestingly, when the number of healthier options increased from one to two, spatial access diminished, and was worse for healthier options in side dishes.
Neighborhood deprivation, access, and availability
Consistent with prior work indicating a relationship between increasing neighborhood deprivation and better potential spatial access to food stores, this study found significantly better access, in terms of proximity and coverage, to fast-food restaurants, fast-food opportunities, and healthier fast-food options by residents of high deprivation neighborhoods . In unadjusted models, access to the nearest fast-food restaurant and fast-food opportunity improved significantly with increasing neighborhood deprivation. Improved access in terms of the number of different fast-food restaurants or fast-food opportunities within one, three, and five miles of the neighborhood population-weighted center was also observed as neighborhood deprivation increased. Within each category of deprivation, proximity and coverage for both fast-food opportunities was significantly better than to fast-food restaurants. Further, the availability of healthier fast-food options improved with increasing deprivation. Finally, the findings from the multivariate models confirmed that significantly better access to fast food - fast-food restaurants, fast-food opportunities, healthier entrée options, and healthier side-dish options - remained after adjusting for population density.
Key findings from this study add to the discussion and understanding of neighborhood exposure to fast food with or without the availability of healthier options. As previously mentioned, exposure to fast food in the U.S., U.K., Canada, Australia, and New Zealand has been based on fast-food restaurants, primarily national or international chains [12, 19–21, 26, 36, 53, 55, 56, 58–62]. At least in rural areas, the opportunities for fast-food entrées and side dishes are greater among nontraditional fast-food outlets, such as convenience stores, supermarkets, and grocery stores. Importantly, in this rural area, reliance on fast-food restaurants as the sole source of fast food would have dramatically underestimated both proximity to the nearest retail source of fast food and coverage in the number of different venues of exposure.
There are several strengths to this study. First, this study relied on identification of all fast-food restaurants and food stores through ground truthing, which has been shown to be more accurate in small-town and rural areas than reliance on secondary or publicly available lists [25, 35]. Second, data on presence of fast-food entrées and side dishes and availability of healthier options in fast-food restaurants and all food stores were collected through a comprehensive on-site observational survey, which provides a more complete picture of the fast-food environment. The inclusion of all fast-food opportunities for assessing exposure to fast food overcomes the limitation association with relying on fast-food restaurants alone and provides a more complete picture of the fast-food environment .
The data allowed us to determine potential access, but do not provide the necessary information to determine utilization or realized access; that is, where, how frequently, and what fast-food entrées and/or side dishes are purchased by rural residents. As we have previously pointed out, potential spatial access assumes that the fast-food trip originates from the residence, which in this study was the population-weighted centroid of each CBG [25, 38]. However, the starting point for fast-food acquisition may vary and depend on time and location of work or other activities in multiple stops [63, 64]. Future work with rural families will allow us to understand the influence of traditional and nontraditional sources of fast food in rural areas on overall dietary intake. Another limitation is use of area data from the 2000 U.S. Census, which is now outdated. We plan to update our work with the release of the 2010 U.S. Census at the level of the CBG. Limitations in the data on healthier fast-food options have been noted elsewhere . Finally, we are unable to generalize our findings beyond this rural area. Future research plans call for a similar examination in small-town and rural areas in other regions of Texas and outside Texas.