PROXIMITY of FAST FOOD RESTAURANTS to SCHOOLS in Eastern Jackson County (EJC) BACKGROUND

APRIL 2019

DIVISION OF HEALTH PROMOTION

JACKSON COUNTY HEALTH DEPARTMENT

REPORT

Obesity by the Numbers JACKSON COUNTY Low Income Children at RESIDENTS WHO Obesity in the United States has be- Higher Risk ARE OBESE come an epidemic. It is a leading Childhood obesity disproportionately factor of chronic disease and health affects children in low income- fami issues and, according to the National lies. While the rate of childhood obe- Center for Health Statistics, the prev- sity increased by 10% from 2003 to alence of adults with obesity in the 2007, it increased somewhere between U.S. is 39.8%.1 Jackson County is not 23-33% for children in low-education, immune to overweight and obesity low-income, and higher-unemploy- rates either. According to the Missouri ment households in that same time County Level Study, 30.58% of Jack- period. A recent study on school dis- son County residents are obese.2 Obe- MISSOURI tricts in Massachusetts found that for sity not only impacts adults; the rate ADOLESCENTS every 1 percent increase in low-income of youth with obesity is 18.5% nation- (10-17 year olds) status, school districts saw a 1.17% in- ally.1 Adolescents in Missouri (10 - 17 WHO ARE OBESE crease in overweight/obesity rates.6 year olds) are obese at a rate of 12.7%. Studies have shown that low-income When considering high school stu- communities often face more barriers dents alone (9th – 12th grade), obe- to improving their overweight/obesity sity rates increase to 16.6%. Interest- status than their higher income neigh- ingly, obesity rates for youth aged 10 bors. For example, low-income com- – 17 year olds have slightly decreased munities may lack full-service grocery over the last year, but the rate in high stores, exercise facilities, and recre- school students has nearly doubled ational programs and parks, but have MISSOURI HIGH since 1999 and increased by nearly 3% an increased access to fast food outlets SCHOOLERS from 2015 – 2017.3 and convenience stores. (9th-12th grade) Childhood Obesity and WHO ARE OBESE Health Children with obesity are at an increased risk for a number of health issues including: high blood pressure and high cholesterol, increased risk of impaired glucose tolerance, insulin resistance, type 2 diabetes, breathing problems (such as asthma and sleep apnea) joint problems and fatty liver disease, gallstones, and heartburn.4 sity. If an individual is overweight or Children with obesity also face so- obese as an adolescent, there is a 70% cial and emotional stress as they are chance they will remain overweight or often targets of bullying, experience obese as an adult.6 Adults who have social isolation, and feel an overbur- experienced lifelong obesity also tend den of stress.5 Additionally, childhood to have more serious health problems obesity sets the trajectory for lifelong than those who become obese later in health conditions including adult obe- life.

2 91% of parents reported purchasing Fast Food and “Dining Out” lunch or dinner students who attend schools within on the Rise for their child in one half mile of fast food restaurants While there is often an excess of avail- the past week at are more likely to be overweight or ability of fast food within low income one of the four obese.14 communities, all Americans are im- largest chains. pacted by the inundation of fast food. In major metro cities throughout the of children ages 2 – 19 The proportion of meals Americans 1/3 country, including New York City, eat fast food on any given day. eat away from their homes has signifi- Chicago, and Los Angeles, studies cantly increased. The technological have consistently shown fast food advances of the food industry have clustering near schools. Nearly 80% allowed restaurants to mass produce of schools in Chicago have at least their meals, leading to the expansion one fast food restaurant within 800 m of the fast-food industry.7 The number overall sugar, more fat, more saturat- (or about ½ mile).15 This is especial- of fast food outlets in the United States ed fat, and more sodium, while con- ly true for high schools. For instance, has increased from about 30,000 lo- suming less fiber, less fruits and veg- researchers in Los Angeles County 11,12 cations in 1970 to more than 233,000 etables, and less milk. have found a greater proximity of locations in 2004. Additionally, fast fast food restaurants to high schools food outlets have been classified as the Regular consumption of fast food can than middle or elementary schools.16 most rapidly expanding sector of US lead to weight gain and insulin re- And across the United States, 67% of food distribution.8 sistance. In a 15 year study of young high schools in major cities are within adults in the U.S., those who ate fast 800 meters of a fast food outlet.17 The In 2016, 91% of parents reported pur- food two or more times a week gained proximity of fast food locations near chasing lunch or dinner for their child approximately 10 more pounds and high schools could be for various rea- in the past week at one of the four had double the increase of insulin re- sons including the tendency for both largest chains (McDonald’s, Burger sistance over the 15 year period than to locate near major thoroughfares, King, Wendy’s, and Subway). This was those who consumed fast food less or major commercial zones serving 13 an increase from 2010, where 79% of than once per week. Weight gain larger populations. Conversely, mid- parents reported purchasing a meal and insulin resistance increase the dle and elementary schools are often from one of these chains once in the risk of developing obesity and type 2 located in residential neighborhoods past week.9 Results from the 2012 diabetes. serving a smaller number of students NHANES survey showed that children and further from commercial zones and adolescents received an average Fast Food Outlets and Prox- and thoroughfares. of 12.4% of their daily calories from imity to Schools fast food. Adolescents ages 12 – 19 ate As fast food consumption contrib- The location of fast food near high twice as many calories from fast food utes to obesity in children, it is worth schools is important because the rate than children ages 2 – 11. Combined, considering the relationship between of teenage obesity has steadily in- one third of children ages 2 – 19 eat fast food outlets and schools. A 2014 creased in recent years. Among ad- fast food on any given day.10 On days study in Arkansas found that fast olescents aged 12 - 18 years old, the where they do eat fast food, children food restaurants within one mile of a percentage of total energy intake from consume about 126 more calories and school do impact school-level weight restaurant and fast foods consump- adolescents consume about 310 more outcomes and that an addition of a tion increased by nearly 300% from calories than days where they do not fast-food restaurant within one mile 1977 to 1996.18 This may be due to eat fast food. They also consume more radius increases school obesity rates various reasons including that high sugar sweetened beverages, more by 1.23%.7 Another study found that school students have more choice in

3 SOCIAL DETERMINANTS METHODS OF HEALTH AFFECTED

the foods they eat because of their A total of 106 public schools and 451 ECONOMIC disposable incomes, their ability to fast food restaurants were included in STABILITY drive or walk themselves to food op- this analysis. Information on fast food tions, their flexible schedules, and restaurants was gathered using Goo- open campus policies that allow them gle. Restaurants labeled as fast food to leave school for lunch.19 In a 2011 or fast casual and convenience loca- EDUCATION study, researchers surveyed adoles- tions were labeled as fast food restau- cents at fast food restaurants on what rants (McDonald’s, Burger King, influenced them to eat there; 57% re- Wendy, Subway, etc.).21 Full service sponded that ease mattered ‘some’ or grocery stores and department stores HEALTH AND ‘a lot’ and 48% responded that loca- with grocery sections were labeled as HEALTH CARE tion was the most important factor. healthy food vendors. Information In that same study, researchers found on public schools was gathered using that adolescents who purchased fast Missouri Spatial Data Information. Data on census tract-level median NEIGHBORHOOD food without a caregiver present tend- AND BUILT ed to order meals with higher calorie household income was obtained from ENVIRONMENT content.20 the U.S. Census. Schools were cate- gorized by elementary school (n= 71), In recognizing the rate of obesity in middle school (n= 19), and high school SOCIAL AND Jackson County, and acknowledging (n=16). Schools were also classified COMMUNITY the fact that fast food consumption by the median household income of CONTEXT contributes to childhood obesity, the the census tract in which the school aim of this study was to examine the was located and then divided into proximity of fast food restaurants four quartiles. Schools and fast food to Eastern Jackson County schools. restaurants were geocoded using lon- Specifically, this study addressed two gitudinal and latitudinal coordinates. questions: 1) Is there a difference in From the geocoded schools, layers proximity of fast food restaurants were created representing buffered ar- among elementary, middle, and high eas around each school at ½ mile and schools? 2) Is there an association 1 mile radius. between proximity of fast food restaurants to schools and neighborhood in- The mean number of fast food restau- come level? rants, and the percentage of schools with one or more fast food restaurants within the two buffers were calculat- ed and examined by school type and neighborhood income quartile. Differ- ences in percentages were assessed for statistical significance with the Chi- Square test. Single-factor analysis of variance (ANOVA) models were run to examine whether the mean number of fast food restaurants with ½ and 1 mile of schools varied significantly by school type and neighborhood income.

4 RESULTS

This study found a high concentra- quartile was not significantly lower tion of unhealthy fast food restaurants than the estimated means for all oth- surrounding Eastern Jackson County er quartiles. When the 1 mile buffer public schools. Out of all food ven- was implemented, the estimated mean dors within one mile of high schools, number of fast food restaurants in 90.48% were labeled as unhealthy. close proximity to schools in the high- Similarly, 89.13% of food vendors est income quartile was significantly within one mile of middle schools lower than the estimated means for were unhealthy, and 88.22% of food schools in the lowest (p= 0.002) and vendors within one mile of elementary second highest quartile (p= 0.049). schools were unhealthy. When controlling for population den- Overall, 48.1% and 78.3% of pub- sity, the effect of neighborhood income lic schools had one or more fast food was significant when estimating the restaurants located within ½ mile and mean number of fast food restaurants 1 mile, respectively (as seen in Table within 1 mile. However, only the low- 1). The percentage of schools with one est income quartile was significant or more fast food restaurants within when compared to the highest income ½ mile was highest for high schools quartile (see Figures 4 & 5 for refer- (62.5%), intermediate for elementary ence). schools (46.5%), and lowest for middle schools (36.8%). The same trend was seen with the 1 mile buffer.

In assessing the relationship between When the ½ mile buffer was imple- mean number of fast food outlets and mented, the estimated mean number neighborhood income, a single-fac- of fast food restaurants in close prox- tor analysis of covariance (ANCOVA) imity to high schools was significantly was applied using population density higher than the estimated mean for as a covariate. This helped to account middle schools (p= 0.015). The esti- for differences in population density mated mean for high schools was not across neighborhood income levels.22 significantly different than the estimated means for elementary schools Geographic analysis was performed (see Figures 1-3 for reference). When using ArcGIS 10.6.1 and subsequent the 1 mile buffer was implemented, statistical analyses were performed the estimated mean number of fast using IBM SPSS 25. Post-hoc com- food restaurants in close proximity parisons were performed using the to high schools was not significantly Games Howell adjustment for mul- higher than the means for middle or tiple comparisons because the test of elementary schools. homogeneity of variances failed, and a significance level of α= 0.05 was used When the ½ mile buffer was imple- throughout. mented, the estimated mean number of fast food restaurants in close proximity to schools in the highest income UNHEALTHY FOOD VENDORS WITHIN 1/2 MILE OF EJC HIGH SCHOOLS

FIGURE 1

90.48% of food vendors within one mile of high schools were unhealthy

62.5% of high schools have one or more fast food restaurants within half a mile

TABLE 1

6 UNHEALTHY FOOD VENDORS WITHIN 1/2 MILE OF EJC ELEMENTARY SCHOOLS

FIGURE 2

88.22% of food vendors within one mile of elementary schools were unhealthy

46.5% of elementary schools have one or more fast food restaurants within half a mile

UNHEALTHY FOOD VENDORS WITHIN 1/2 MILE OF EJC MIDDLE SCHOOLS

FIGURE 3

89.13% of food vendors within one mile of middle schools were unhealthy

36.8% of middle schools have one or more fast food restaurants within half a mile

7 FIGURE 4

FIGURE 5

8 DISCUSSION

High schools in Eastern Jackson Fighting the Obesity They could also go a step further by County have a significantly high- Epidemic with Schools offering healthier after school snacks. er number of fast food restaurants Another option is to start a school gar- Schools have the ability to influence within ½ a mile than middle schools den, where students can learn how to fast food intake for their students. in the area. Additionally, schools in grow fresh produce. School gardens Schools throughout Missouri have the lowest income quartile had a sig- have been shown to increase student enacted policies reducing impact of nificantly higher number of fast food knowledge of different vegetables nearby fast food restaurants. In St. restaurants within 1 mile than schools and increase students’ vegetable con- Louis, a Richmond School District in the highest income quartile, even sumption.25 elementary school banned fast food after controlling for population den- from being brought into the cafete- sity. These results are consistent with Fighting the Obesity ria at the beginning of the 2018-2019 similar studies from across the U.S.17 Epidemic through City school year.23 In Eastern Jackson Policy and Environment County, some school districts’ student As discussed previously, there is a con- handbooks restrict students from On a broader level, communities nection between proximity of fast food leaving campus at lunch unless writ- across the U.S. and around the world to schools and school level obesity ten notice is provided. The Grandview have noticed these same patterns rates. The results of this study, there- High School student handbook takes and taken action. Local municipali- fore, may shed light on why the obesi- further actions and prohibits bringing ties control ordinances, zoning regu- ty rate among Missouri high schoolers catered foods and fast food into the lations, and land use policies within increased by 3% from 2015 to 2017. school cafeteria.24 By creating poli- their jurisdictions that can be used to Additionally, the fact that schools in cies that limit bringing fast foods into increase healthy food consumption lower income census tracts in Eastern school buildings, school districts can while decreasing fast food intake. For Jackson County have a higher number curb the intake of fast food during the instance, major cities, such as Lon- of fast food restaurants confirms the school day. don, have committed to this kind of observation that other studies have policy change. shown: that low income individuals Eastern Jackson County can take fur- are disproportionately affected by un- ther action to prevent the negative Beginning in January 2019, London will healthy food environments and are at effects of fast food availability from no longer allow unhealthy foods includ- greater risk of obesity and obesity-re- becoming a problem. One option is to ing burgers, candy and salted food and lated diseases. make sure all students are receiving sugary drinks to be advertised in their comprehensive nutrition education major public transit system, The Lon- that includes information about fast don Underground. Fast food restau- food. Specifically, students should rants will be able to advertise only if learn about the high fat, sugar, and they promote their healthy food items sodium content in many fast food and sugar free drinks. Beyond the ad- meals, the health risks of consuming vertising ban, the city is taking further foods high in fat, sugar, and sodium, action by no longer allowing any new and how to choose healthier options fast food restaurants, including cor- at these establishments. ner stores that sell hot food, and street vendors to open and operate within one Schools should also provide healthy quarter of a mile near primary and sec- alternatives to the fast food options ondary schools.26 This makes London nearby. After undergoing much scru- one of the first major cities in the world tiny in recent years, school lunch op- to take extensive policy action to reduce tions are more nutritious and healthy. the risk of obesity. 9 LIMITATIONS

This study had some limitations. Fast food locations were identified using Google Maps; while this provided over 450 fast food establishments there is risk of inaccurate counts based on an outdated map. This has likely caused an underestimation of the number of fast food locations. As mentioned previously, high schools are often located near major thoroughfares or commercial zones. It was not possible to cal- Some U.S. cities have taken a variety families from bringing fast food onto culate commercialization for Eastern of zoning actions as well. To reduce school campus, and restricting adver- Jackson County schools with the data the impact fast food has on children, tising for unhealthy food and beverag- available to determine if this affected Detroit, Michigan and Monterey, Cali- es in and around schools. the high number of fast food restau- fornia both implemented zoning ordi- rants near high schools. However, nances near schools. In 2017, Detroit Whether through school policies or population density was accounted for enacted a policy that restricts fast food broader city ordinances, the need for in the income analysis. Additionally, restaurants from opening within 500 action is clear. Neglecting to inter- the half mile and one mile buffer zones feet of an elementary, middle or high vene now could lead to an even higher do not factor in roadways or paths, so school while Monterey prohibited fu- rate of obesity in tomorrow’s gener- while a location may be within half a ture development of fast food restau- ation. Jackson County in particular mile of a school it does not necessarily rants within 500 feet of public and pri- has seen an increase in obesity rates mean that a route available for a per- vate elementary schools, public parks among both high schoolers and adults son to walk or drive is within a ½ mile 27,28 or recreation facilities. in recent years. Therefore, the more or 1 mile. Due to this reason, there is high schoolers that graduate at an a possibility of some overestimation of Eastern Jackson County cities can unhealthy weight today, the more di- fast food proximity to schools. In ad- join these efforts to serve as leaders abetes, heart disease, and other health dition, this study was a broad analy- among U.S. cities and pass healthy issues our community will have to face sis from a community level measure. food zoning ordinances. These ordi- in the future. Because students were not surveyed nances would prohibit new fast food they were unable to self-report their restaurants from opening within half consumption of fast food. Individual a mile (walking distance) of a school. students’ or school-level BMIs were This could prevent the concentration not available either. School food pol- of fast food around existing schools icies for large districts including Blue from becoming even higher. Howev- Springs, Grandview, Independence er, these ordinances would have the and Lee’s Summit were available, but greatest impact on future schools that smaller districts within the county have not yet been built, as it could were not accessed. completely prevent fast food restaurants from opening up around them. Other policy options include encour- aging healthy food vendors to locate near schools through permit or tax incentives, prohibiting students and

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