Research demonstrates that food desert environments limit low-income shoppers' ability to purchase healthy foods, thereby increasing their likelihood of diet-related illnesses. We sought to understand how individuals in an urban American food desert make grocery-purchasing decisions, and specifically why unhealthy purchases arise. Analysis is based on ethnographic data from participant observation, 37 in-depth interviews, and three focus groups with low-income, primarily African American shoppers with children. We found participants had detailed knowledge of and preference for healthy foods, but the obligation to consistently provide food for their families required them to apply specific decision criteria which, combined with structural qualities of the supermarket environment, increased unhealthy purchases and decreased healthy purchases. Applying situated cognition theory, we constructed an emic model explaining this widely shared grocery-purchasing decision process and its implications. This context-specific understanding of behavior suggests that multifaceted, system-level approaches to intervention are needed to increase healthy purchasing in food deserts.

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Supermarket-based interventions are one approach to improving the local food environment and reducing obesity and chronic disease in low-income populations. We implemented a multicomponent intervention that aimed to reduce environmental barriers to healthy food purchasing in a supermarket in Southwest Baltimore. The intervention, Eat Right-Live Well! used: shelf labels and in-store displays promoting healthy foods, sales and promotions on healthy foods, in-store taste tests, increasing healthy food products, community outreach events to promote the intervention, and employee training. We evaluated program implementation through store environment, taste test session, and community event evaluation forms as well as an Employee Impact Questionnaire. The stocking, labeling, and advertising of promoted foods were implemented with high and moderate fidelity. Taste test sessions were implemented with moderate reach and low dose. Community outreach events were implemented with high reach and dose. Supermarket employee training had no significant impact on employees' knowledge, self-efficacy, or behavioral intention for helping customers with healthy purchasing or related topics of nutrition and food safety. In summary, components of this intervention to promote healthy eating were implemented with varying success within a large supermarket. Greater participation from management and employees could improve implementation.

To discover how organic food factors into low-income consumers' overall understanding of healthy eating, we analyzed 36 in-depth interviews with adults in Baltimore, Maryland. We asked participants to discuss their understanding of healthy eating. Unprompted, many participants discussed organic food or attributes commonly understood to define organic food. Some participants believed health issues including cancer, weight gain, and allergies can arise from consuming nonorganic foods. Participants expressed that organic competes with other food attributes such as nutrient content in informing their perception of whether a food is healthy. Several voiced concern that nonorganic foods are responsible for weight gain and abnormal development. Our results show that despite limited access, organic is an important factor in some consumers' understanding of healthy food. Consumers' perceptions of organic can swamp or compete with other messages about healthy eating. Therefore, consumers' understanding of organic should be considered in developing diet-related messages and programs.

This study demonstrates the ways in which family and community members can influence dietary change in people with diabetes. Interventions targeting diabetes management should incorporate families and communities as sources of information, learning, and support.