U.S. children and adolescents from low-income and ethnic/racial minority backgrounds experience greater risk for obesity and poor nutrition. In addition, a growing body of evidence documents differences in obesity and dietary patterns between urban and rural areas. Societal efforts to eliminate these disparities in established risk factors for chronic disease will require a comprehensive understanding of the social and physical environmental factors that may be contributing. Recent studies have identified several factors within school environments and residential neighborhoods along with multiple aspects of food marketing and cultural norms that are likely barriers to achieving health equity. To better inform public health improvement strategies, future research efforts are needed to clarify their contribution to disparities and there is an urgent need to build on the more limited research to date addressing the potential for improvements in child care environments and food system policy to promote health equity.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Rundle A, Richards C, Bader M, et al. Individual- and school-level sociodemographic predictors of obesity among New York City Public School children. Am J Epidemiol. 2012;176(11):986–94.
Greves Grow HM, Cook A, Arterburn D, et al. Child obesity associated with social disadvantage of children’s neighborhoods. Soc Sci Med. 2010;71(3):584–91.
Boumtje P, Huang C, Lee J-Y, Lin B-H. Dietary habits, demographics, and the development of overweight and obesity among children in the United States. Food Policy. 2005;30(2):115–28.
Eagle T, Sheetz A, Gurm R, et al. Understanding childhood obesity in America: linkages between household income, community resources, and children’s behaviors. Am Heart J. 2012;163(5):836–43.
Mushi-Brunt C, Haire-Joshu D, Elliott M, Brownson R. Fruit and vegetable intake and obesity in preadolescent children. Am J Health Educ. 2007;38(5):258–65.
Brener N, Eaton D, Kann L, et al. Behaviors related to physical activity and nutrition among US high school students. J Adolesc Health. 2013;53(4):539–46.
Ogden C, Carroll M, Kit B, Flegal K. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806–14.
Neumark-Sztainer D, Wall M, Larson N, et al. Secular trends in weight status and weight-related attitudes and behaviors in adolescents from 1999 to 2010. Prev Med. 2012;54(1):77–81.
Arcan C, Larson N, Bauer K, et al. Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and White adolescents. J Acad Nutr Diet. 2014;114(3):375–83.
Kirkpatrick S, Dodd K, Reedy J, Krebs-Smith S. Income and race/ethnicity are associated with adherence to food-based dietary guidance among US adults and children. J Acad Nutr Diet. 2012;112(5):624–35.
Fahlman M, McCaughtry N, Martin J, Shen B. Racial and socioeconomic disparities in nutrition behaviors: targeted interventions needed. J Nutr Educ Behav. 2010;42(1):10–6.
Larson N, Hannan P, Fulkerson J, et al. Secular trends in fast-food restaurant use among adolescents and maternal caregivers from 1999 to 2010. Am J Public Health. 2014;104(5):e62–9.
Han E, Powell L. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet. 2013;113(1):43–53. This article presents current national data on ethnic/racial and socioeconomic disparities in the heavy consumption of sugar-sweetened beverages, which represents a dietary behavior strongly associated with obesity.
Davy B, Harrell K, King D, Stewart J. Body weight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi. South Med J. 2004;97(6):571–7.
Goodwin D, Knol L, Eddy J, et al. Sociodemographic correlates of overall quality of dietary intake of US adolescents. Nutr Res. 2006;26(3):105–10.
Liu J, Jones S, Sun H, et al. Diet, physical activity, and sedentary behaviors as risk factors for childhood obesity: an urban and rural comparison. Child Obes. 2012;8(5):440–8. This article uses national data to comprehensively examine urban/rural disparities in diet, physical activity, sedentary behaviors, and weight status among children and adolescents.
Ettienne-Gittens R, McKyer E, Odum M, et al. Rural versus urban Texas WIC participants’ fruit and vegetable consumption. Am J Health Behav. 2013;37(1):130–40.
National Institutes of Health Obesity Research Task Force. Strategic plan for NIH obesity research. National Institutes of Health, U.S. Department of Health and Human Services, 2011 NIH Publication No. 11-5493
Centers for Disease Control and Prevention - Division of Community Health. A practitioner’s guide for advancing health equity: community strategies for preventing chronic disease. Atlanta, GA: 2013. This report defines key terms relevant to advancing health equity and provides a discussion of community-level strategies to address limited access to healthful food and beverages in rural areas, low-income communities, and ethnically/racially diverse communities.
Institute of Medicine. Creating equal opportunities for a healthy weight: workshop summary. Washington, D.C.: 2013. This report reviews obesity prevention strategies of relevance for schools and other environments with an emphasis on strategies key to reducing disparities in weight-related health.
Bleich S, Jarlenski M, Bell C, LaVeist T. Health inequalities: trends, progress, and policy. Annu Rev Public Health. 2012;33:7–40. This article describes national commitments to reduce health inequalities and gaps in the scientific literature that need to be addressed in order to better inform intervention and policy action to address these goals.
Metos J, Nanney M. The strength of school wellness policies: one state’s experience. J Sch Health. 2007;77:367–72.
Nanney M, Davey C, Kubik M. Rural disparities in the distribution of policies that support healthy eating in U.S. secondary schools. J Acad Nutr Diet. 2013;113(8):1062–8. This article provides recent data on ethnic/racial, socioeconomic, and urban/rural disparities in the distribution of food and nutrition policies for secondary schools in 28 U.S. states.
Finkelstein D, Hill E, Whitaker R. School food environments and policies in U.S. public schools. Pediatrics. 2008;122(1):e251–9.
Nanney M, Bohner C, Friedrichs M. Poverty-related factors associated with obesity prevention policies in Utah secondary schools. J Am Diet Assoc. 2008;108(7):1210–5.
Schwartz M, Henderson K, Falbe J, et al. Strength and comprehensiveness of district school wellness policies predict policy implementation at the school level. J Sch Health. 2012;82:262–7.
Johnston L, Delva J, O’Malley P. Soft drink availability, contracts, and revenues in American secondary schools. Am J Prev Med. 2007;33(4S):S209–25.
Addison C, Jenkins B, White M, Young L. Examination of the food and nutrient content of school lunch menus of two school districts in Mississippi. Int J Environ Res Public Health. 2006;3(3):278–85.
Delva J, O’Malley P, Johnston L. Availability of more-healthy and less-healthy food choices in American schools. A national study of grade, racial/ethnic, and socioeconomic differences. Am J Prev Med. 2007;33(4S):S226–39.
Tester J, Yen I, Pallis L, Laraia B. Healthy food availability and participation in WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) in food stores around lower- and higher-income elementary schools. Public Health Nutr. 2011;14(6):960–4.
Neckerman K, Bader M, Richards C, et al. Disparities in the food environments of New York City public schools. Am J Prev Med. 2010;39(3):195–202.
Kwate N, Loh J. Separate and unequal: the influence of neighborhood and school characteristics on spatial proximity between fast food and schools. Prev Med. 2010;51(2):153–6.
Simon P, Dwan K, Angelescu A, et al. Proximity of fast food restaurants to schools: do neighborhood income and type of school matter? Prev Med. 2008;47(3):284–8.
Austin S, Melly S, Sanchez B, et al. Clustering of fast-food restaurants around schools: a novel application of spatial statistics to the study of food environments. Am J Public Health. 2005;95(9):1575–81.
Sturm R. Disparities in the food environment surrounding US middle and high schools. Public Health. 2008;122(7):681–90.
Zenk S, Powell L. U.S. secondary schools and food outlets. Health Place. 2008;14(2):336–46.
Frampton A, Sisson S, Horm D, et al. What’s for lunch? An analysis of lunch menus in 83 urban and rural Oklahoma child-care centers providing all-day care to preschool children. J Acad Nutr Diet. 2014;114(9):1367–74.
Ritchie L, Sharma S, Gildengorin G, et al. Policy improves what beverages are served to young children in child care. J Acad Nutr Diet. doi:10.1016/j.jand.2014.07.019.
Ritchie L, Boyle M, Chandran K, et al. Participation in the Child and Adult Care Food Program is associated with more nutritious foods and beverages in child care. Child Obes. 2012;8(3):224–9. This article describes the most recent data comparing the foods and beverages served to preschool-aged children in different types of child-care settings for a statewide sample.
Monsivais P, Kirkpatrick S, Johnson D. More nutritious food is served in child-care homes receiving higher federal food subsidies. J Am Diet Assoc. 2011;111(5):721–6.
Whitaker R, Gooze R, Hughes C, Finkelstein D. A national survey of obesity prevention practices in Head Start. Arch Pediatr Adolesc Med. 2009;163(12):1144–50.
Dev D, McBride B, Speirs K, et al. Predictors of Head Start and child-care providers’ healthful and controlling feeding practices with children aged 2 to 5 years. J Acad Nutr Diet. 2014;114(9):1396–403.
Larson N, Story M, Nelson M. Neighborhood environments: disparities in access to healthy foods in the U.S. Am J Prev Med. 2009;36(1):74–81.
Hilmers A, Hilmers D, Dave J. Neighborhood disparities in access to healthy foods and their effects on environmental justice. Am J Public Health. 2012;102(9):1644–54.
Walker R, Keane C, Burke J. Disparities and access to healthy food in the United States: a review of food deserts literature. Health Place. 2010;16(5):876–84.
Lucan S, Maroko A, Bumol J, et al. Mobile food vendors in urban neighborhoods - implications for diet and diet-related health by weather and season. Health Place. 2014;27:171–5.
Bower K, Thorpe R, Rohde C, Gaskin D. The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States. Prev Med. 2014;58:33–9. This article advances the literature on neighborhood-level disparities in food store access by accounting for interactions of racial residential segregation, poverty, and urbanicity in describing disparities among U.S. neighborhoods.
Hosler A, Kammer J. Trends of fruit and vegetable availability in neighbourhoods in Albany, NY, USA, 2003-2012. Public Health Nutr. 2015, in press.
Grimm K, Moore L, Scanlon K, Centers for Disease Control and Prevention. Access to healthier food retailers - United States, 2011. MMWR. 2013;62 Suppl 3:20–6. This article uses recent national data to describe regional variation in the distribution of healthier food retailers (e.g., supermarkets, supercenters) by income, race, and urbanicity.
Kersten E, Laraia B, Kelly M, et al. Small food stores and availability of nutritious foods: a comparison of database and in-store measures, Northern California, 2009. Prev Chronic Dis. 2012;9:E217.
Richardson A, Boone-Heinonen J, Popkin B, Gordon-Larsen P. Are neighbourhood food resources distributed inequitably by income and race in the USA? Epidemiological findings across the urban spectrum. BMJ Open. 2012;2:e000698. This article advances the literature on neighborhood-level disparities in access to healthy and unhealthy foods by describing variation in the distribution of food resources by income and race across the U.S. urban spectrum.
Lee H. The role of local food availability in explaining obesity risk among young school-aged children. Soc Sci Med. 2012;74(8):1193–201.
Lucan S, Maroko A, Shanker R, Jordan W. Green Carts (mobile produce vendors) in the Bronx - optimally positioned to meet neighborhood fruit-and-vegetable needs? J Urban Health. 2011;88(5):977–81.
Widener M, Metcalf S, Bar-Yam Y. Dynamic urban food environments a temporal analysis of access to healthy foods. Am J Prev Med. 2011;41(4):439–41.
Hearst M, Pasch K, Laska M. Urban v suburban perceptions of the neighborhood food environment as correlates of adolescent food purchasing. Public Health Nutr. 2011;15(2):299–306.
Gordon C, Purciel-Hill M, Ghai N, et al. Measuring food deserts in New York City’s low-income neighborhoods. Health Place. 2011;17(2):696–700.
Dean W, Sharkey J. Rural and urban differences in the associations between characteristics of the community food environment and fruit and vegetable intake. J Nutr Educ Behav. 2011;43(6):426–33.
Sharkey J, Johnson C, Dean W, Horel S. Focusing on fast food restaurants alone underestimates the relationship between neighborhood deprivation and exposure to fast food in a large rural area. Nutr J. 2011;10:10.
Sharkey J, Horel S, Dean W. Neighborhood deprivation, vehicle ownership, and potential spatial access to a variety of fruits and vegetables in a large rural area in Texas. Int J Health Geogr. 2010;9:26.
Michimi A, Wimberly M. Associations of supermarket accessibility with obesity and fruit and vegetable consumption in the conterminous United States. Int J Health Geogr. 2010;9:49.
Lee R, Heinrich K, Medina A, et al. A picture of the healthful food environment in two diverse urban cities. Environ Health Insights. 2010;4:49–60.
Kwate N, Yau C-Y, Loh J-M, Williams D. Inequality in obesigenic environments: fast food density in New York City. Health Place. 2009;15(1):364–73.
Dunn D, Sharkey J, Lotade-Manje J, et al. Socio-economic status, racial composition and the affordability of fresh fruits and vegetables in neighborhoods of a large rural region in Texas. Nutr J. 2011;10:6.
Filomena S, Scanlin K, Morland K. Brooklyn, New York foodscape 2007-2011: a five-year analysis of stability in food retail environments. Int J Behav Nutr Phys Act. 2013;10:46. This article uses records of stores licensed to sell food in the state of New York to provide information on the stability of food retail environments and variations in stability according to race and income.
Neff R, Palmer A, McKenzie S, Lawrence R. Food systems and public health disparities. J Hunger Environ Nutr. 2009;4(3–4):282–314.
U.S. Department of Agriculture. 2014 Farm Bill Highlights [Online]. Washington DC: U.S. Department of Agriculture; 2014 [updated March 2014; cited 2014 August 20]. Available from: http://www.usda.gov/documents/usda-2014-farm-bill-highlights.pdf.
Fleming-Milici F, Harris J, Sarda V, Schwartz M. Amount of Hispanic youth exposure to food and beverage advertising on Spanish- and English-language television. JAMA Pediatr. 2013;167(8):723–30.
Harris J, Schwartz M, Munsell C, et al. Fast food FACTS 2013: measuring progress in nutrition and marketing to children and teens. New Haven, CT: Yale Rudd Center for Food Policy and Obesity; 2013 [updated November 2013; cited 2014 August 20]. Available from: http://www.fastfoodmarketing.org/media/FastFoodFACTS_report.pdf. This article describes recent, national data on ethnic/racial disparities in child and adolescent exposure to advertising on websites and both national and cable broadcast television.
Harris J, Schwartz M, Brownell K, et al. Cereal FACTS 2012: Limited progress in the nutrition quality and marketing of children's cereals. New Haven, CT: Yale Rudd Center for Food Policy and Obesity; 2012 [cited 2014 August 20]. Available from: http://www.cerealfacts.org/media/Cereal_FACTS_Report_2012_7.12.pdf.
Powell L, Szczypka G, Chaloupka F. Trends in exposure to television food advertisements among children and adolescents in the United States. Arch Pediatr Adolesc Med. 2010;164(9):794–802.
Henderson V, Kelly B. Food advertising in the age of obesity: content analysis of food advertising on general market and African American television. J Nutr Educ Behav. 2005;37:191–6.
Powell L, Szczypka G, Chaloupka F. Adolescent exposure to food advertising on television. Am J Prev Med. 2007;33(4S):S251–6.
Thompson D, Flores G, Ebel B, Christakis D. Comida en venta: after-school advertising on Spanish-language television in the United States. J Pediatr. 2008;152(4):576–81.
Powell L, Wada R, Kumanyika S. Racial/ethnic and income disparities in child and adolescent exposure to food and beverage television ads across the U.S. media markets. Health Place. 2014;29:124–31. This article builds on the existing evidence base relating to the targeted marketing of foods and beverages by using designated market area spot television ratings to assess disparities in child and adolescent exposure.
Eaton D, Kann L, Kinchen S, et al. Youth risk behavior surveillance - United States, 2011. MMWR Surveill Summ. 2012;61(4):1–162.
Yancey A, Cole B, Brown R, et al. A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising. Milbank Q. 2009;87(1):155–84.
Hillier A, Cole B, Smith T, et al. Clustering of unhealthy outdoor advertisements around child-serving institutions: a comparison of three cities. Health Place. 2009;15(4):935–45.
Kwate N, Lee T. Ghettoizing outdoor advertising: disadvantage and ad panel density in black neighborhoods. J Urban Health. 2006;84(1):21–31.
Chester J, Montgomery K. Interactive food and beverage marketing: targeting children and youth in the digital age. An update Berkeley, CA: Berkeley Media Studies Group; 2008 [updated July 2008; cited 2014 August 20]. Available from: http://www.digitalads.org.
Chester J, Montgomery K. Interactive food and beverage marketing: targeting children and youth in the digital age. Berkeley, CA: Berkeley Media Studies Group, 2007 May.
Institute of Medicine. Speaking of health: assessing health communication strategies for diverse populations. Washington, D.C.: 2002.
Caprio S, Daniels S, Drenowski A, et al. Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment. Diabetes Care. 2008;31(11):2211–21.
Kumanyika S. Environmental influences on childhood obesity: ethnic and cultural influences in context. Physiol Behav. 2008;94:61–70.
Pascoe E, Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531–54.
Zenk S, Schulz A, Israel B, et al. Food shopping behaviors and exposure to discrimination. Public Health Nutr. 2014;17(5):1167–76. This article uniquely describes exposure to discrimination at food retail outlets and relationships with the neighborhood environment.
Shonkoff J, Garner A, Siegel B, et al. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):e232.
Larson N, Story M. A review of environmental influences on food choices. Ann Behav Med. 2009;38 Suppl 1:S56–73.
Fitzgibbon M, Beech B. The role of culture in the context of school-based BMI screening. Pediatrics. 2009;124(Suppl 1):S50–62.
Lundahl A, Kidwell K, Nelson T. Parental underestimates of child weight: a meta-analysis. Pediatrics. 2014;133(3):e689–703.
Satia-Abouta J. Dietary acculturation: definition, process, assessment, and implications. Int J Hum Ecol. 2003;4(1):71–86.
Mulasi-Pokhriyal U, Smith C, Franzen-Castle L. Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9-18 years. Public Health Nutr. 2011;15(1):176–85.
Liu J-H, Chu Y, Frongillo E, Probst J. Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. J Nutr. 2012;142:298–305.
Batis C, Hernandez-Barrera L, Barquera S, et al. Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic whites. J Nutr. 2011;141(10):1898–906.
Allen ML, Elliott M, Morales L, et al. Adolescent participation in preventive health behaviors, physical activity, and nutrition: differences across immigrant generations for Asians and Latinos compared with Whites. Am J Public Health. 2007;97(2):337–43.
Viruell-Fuentes E, Miranda P, Abdulrahim S. More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med. 2012;75(12):2099–106. This review article advances the literature on the role of cultural factors in determining health outcomes and proposes a shift in research from individual culture-based frameworks to perspectives that address how multiple dimensions of inequality may intersect.
This manuscript was supported in part by the Robert Wood Johnson Foundation Healthy Eating Research Program.
Compliance with Ethics Guidelines
Conflict of Interest
Nicole Larson and Mary Story declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Dietary Patterns and Behavior
About this article
Cite this article
Larson, N., Story, M. Barriers to Equity in Nutritional Health for U.S. Children and Adolescents: A Review of the Literature. Curr Nutr Rep 4, 102–110 (2015). https://doi.org/10.1007/s13668-014-0116-0
- Dietary patterns
- Health equity
- School environment
- Child care environment
- Neighborhood environment
- Food access
- Food marketing
- Food system policy