NYC Green Carts
SOMETHING!!!
To Add to the Obesity Visit…
Michael P. Goldman, MD
Lauren Sanlorenzo, MD
Rules
 PLEASE, if your ASCOM rings, just step out to
answer it…. Thank you!
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
The AMAZING CHONY
RESIDENT’S Typical Obesity Visit
• Discuss patient’s BMI.
• 5….2….1…0 – Let’s go Campaign!
• Refer to nutritionist
• Hand out Green Bucks
• Tell families about local fitness center discounts
• Portion control through drawing the mock dinner plate
• Scare tactics – DM, MI, Stroke, Metabolic syndrome
• See you in 3 months for another uplifting discussion!!!!
The Newest… Food Plate
3 Months Later…
 Its only been 3 months and you have put on 7lbs…
 Oh, you missed the nutrionist appointment???
 So now you’re drinking Iced Tea as opposed to cocacola???
 WIC gave you WHAT coupon???
 You got another new video game!!!!!!!
 See you in 3 months… try drinking water!
 WHAT IS GOING ON HERE AND WHAT ELSE CAN I
DO HERE????????
Why Green Carts…
 Think for a second about grocery shopping options
between 72nd St and 96th St. on the UWS and
compare that to grocery shopping between 145th
and 181st in Washington Heights.
 This unequal sharing of healthy food resources is
not unique to NYC, but is seen across the country in
both rural and urban low-income communities.
 The NYC Green Cart Initiative is an innovative
approach to address the issue of access to fruits and
vegetables in low-income neighborhoods in NYC
The Reasoning Behind the
Cause
Eating fruits and vegetables 3 or more times a day vs. less
than 1 time a day is associated with:
• 27% lower risk of having a stroke
• 42% lower risk of dying from stroke
• 24% lower risk of dying from heart disease
• 15% lower risk of dying from all causes
The Reasoning Behind the
Cause
 Eating 5 or more servings of fruits and vegetables per day
significantly lowers the risk of developing type 2 diabetes.
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
How to define a food
desert?
 According to the CDC: Food deserts are areas that lack access to
affordable fruits, vegetables, whole grains, low-fat milk, and other
foods that make up the full range of a healthy diet.
 The Department of Agriculture defines a food desert as: A Census
tract where 33% or 500 people, whichever is less, live more than a
mile from a grocery store in an urban area or more than 10 miles
away in a rural area.
 AND… At least 20% of the residents must live below the federal poverty
line, currently $22,350 for a family of four.
 Although the term “food desert” can mean a literal absence of retail
food in a defined area, studies of food deserts more commonly assess
differential accessibility to healthy and affordable food between
socioeconomically advantaged and disadvantaged areas.
Prevalence of food deserts
Right now, 23.5 million Americans, including 3 million
in New York City, and almost 4 million people across
the state, live in areas known as “food deserts” .
Is CHONY in a food
desert?

The USDA created a website which mapped out food deserts , called Your
Food Environment Atlas http://www.ers.usda.gov/Data/FoodDesert/

You can go to this website and search for your city to identify food
deserts. Again on this atlas the government used the definition of an
urban food desert as : “a census tract that is more than a mile from a
grocery store”.

This caused great controversy given that the USDA counted NYC
bodegas, small corner stores that offer limited supplies, as grocery stores.

With that consideration, the USDA finds there are no food deserts in the
Bronx, Brooklyn or upper Manhattan, though local activists would beg to
differ.

Local officials estimate that if you excluded bodegas from the definition of
“grocery stores” that approximately 3 million New Yorkers live in a food
desert.
The Issue of Access…
In 2009, the Economic Research Service of the USDA reported:
 7% of densely populated urban zip codes lack a grocery store or
supermarket of any kind and 53% lack a chain supermarket.
 African-Americans are half as likely to have access to a chain
supermarket than Caucasians, while Hispanic populations were
one-third as likely.
 Independent, convenience type stores with higher prices were
found to be far more common in minority communities.
 Small stores are also less likely to carry fresh fruits and vegetables.
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
Reviewing
“The Scope of the Problem”
 Nationwide Obesity Trends –
 2009 NYC DOH Community Health Survey by
Neighborhood
 Obesity Rates
 Access to Medical Care
 Sugar Beverages
 Produce Consumption
 T2DM
 The theme, as you all well know, is that the
neighborhoods that score badly in one category tend to
score badly across the board!!!
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends by
Neighborhood
Access to Medical Care
Physical Activity
Sugar Sweetened Beverage
Produce Consumption
Just one Consequence - DM
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
The Food Cart Scene Prior to
Green Carts
• 4,100 mobile food cart permits in NYC
• As many as 2,500 people are on waiting lists for
permits
• Few carts sold fruits and vegetables - < 10%
Green Cart Initiative
 In the Spring of 2008, the Laurie M. Tisch Illumination Fund seeded
the NYC Green Cart Initiative with a leadership grant to increase the
availability of fresh produce in low income neighborhoods
throughout New York City.
 The Initiative addresses an urban issue with an innovative blend of
public policy, private philanthropy and grassroots
entrepreneurship.
 Designed to address issues of access and proximity (two factors
strongly influencing consumption) by bringing fresh, affordable,
high quality fruits and vegetables to high need communities.
 The goal of the initiative is to promote access to healthy food, by
expanding the number of food carts that only sell fresh fruits and
vegetables – ‘Green Carts’- in the New York City Neighborhoods
that need them most.
Proposal
• The proposal was to create permits for 1,000 Green Carts in designated
neighborhoods.
• The Green Carts would be able to sell unprocessed, unfrozen, raw fruits
and vegetables .
• Green Cart areas were chosen to include only neighborhoods with more
than 15% of residents surveyed consumed no servings or fruits and vegetables
on the previous day, as reported in the 2004 Community Health Survey. In
some neighborhoods with lowest fruit and vegetable consumption, that figure
was nearly 26%.
DOHMH identified and targeted five regions across New York City -- the
majority of the Bronx, Northern Manhattan and East/Central Harlem,
North/Central Brooklyn, Western Queens and Northern Staten Island -- based
on their low household consumption rates of fruit and vegetables
Solving a Key Piece of the
Problem
Permits
• A certain number of permits will be allocated for carts in
the Green Cart areas in each borough, based on population
in the designated areas:
Bronx 350 permits
Brooklyn 350 permits
Manhattan 150 permits
Queens 100 permits
Staten Island 50 permits
Goals of program
The City’s Department of Health and Mental Hygiene (DOHMH)
estimated that Green Carts would:
increase access to fresh produce in neighborhoods where produce
consumption was low
 increase consumption of fresh produce by at least 75,000 New Yorkers
save approximately 100 lives annually over the long term
The positive health impacts of increasing fruit and vegetable
consumption occur when consumption remains high for many years, so
the positive health impacts of Green Carts will be seen over the long
term.
Timeline of Green Cart
Initiative
• On February 27, 2008, the City Council voted to
approve the legislation.
On March 13, 2008, Local Law 9 was signed by
Mayor Bloomberg which established 1,000 permits for
Green Carts.
Now Working on another
Key Piece of the Problem
 Carts improved access, but affordability is another
challenge…
 Approximately ONLY 30 carts accept EBT!!!
 Wireless connection
 Battery Power
 Each EBT unit costs $900 – an upfront cost to the
vendor!
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
Why this Matters To
Pediatricians?
 We are a profession of prevention
 Early habits (like healthy eating) die hard, bad
habits (like unhealthy eating) die harder!
 We have few tangible resources to help our obese
patients combat obesity
We Like Evidence Based!
 But there isn’t evidence to say any one of the above
strategies will solve the obesity epidemic.
 And the TRUTH IS that this problem is way beyond
a purely medical issue!
 But allow us to share what the experts recommend
we do with respect to produce’s role in preventing,
assessing and treating obesity.
AHA’s Pediatric Dietary Strategies for
Individuals Aged >2 Years: Recommendations
to All Patients and Families
- Balance dietary calories with physical activity to maintain
normal growth
- 60 min of moderate to vigorous play or physical activity
daily
- Eat vegetables and fruits daily, limit juice intake
- Use vegetable oils and soft margarines low in saturated fat
and trans fatty acids instead of butter or most other animal
fats in the diet
- Eat whole-grain breads and cereals rather than refinedgrain products
- Reduce the intake of sugar-sweetened beverages and foods
- Use nonfat (skim) or low-fat milk and dairy products daily
- Eat more fish, especially oily fish, broiled or baked
- Reduce salt intake, including salt from processed foods
AAP Dietary Recs
• Good nutrition, a physically active lifestyle,
and absence of tobacco use contribute to lower
risk prevalence and either delay or prevent the
onset of cardiovascular disease.
• These observations have established the
concept of prevention of the development of
cardiovascular risk factors in the first place,
now called primordial prevention.
Primordial Prevention
Is Essentially 5…2…1…0
Primordial Prevention
 5…2…1…0 AND
 No skipping meals
 Appreciate/work within cultural differences,
 Address eating behaviors
 minimize food intake outside of the home,
 Involve the whole family in this lifestyle changes.
AAP Dietary Rec’s
 Around 9 months –
 During the transition from a milk-based diet to adult
foods, the types of vegetables consumed change
adversely.
 E.g. Deep-yellow vegetables are consumed by 39% of
children at 7 to 8 months and by 13% at 19 to 24
months,
 French fries become the most commonly consumed
vegetable by this age.
 ***Parents can make age appropriate baby / table
foods if they had access to Produce! – Green Carts!!!
AAP Dietary Recs
 2-6 Years
 Provide a wide variety of nutrient-dense foods such as
fruits and vegetables instead of high-energydensity/nutrient-poor foods such as salty snacks, ice
cream, fried foods, cookies, and sweetened beverages
 Key issue identified = Parents are the role models and
should model healthy eating and healthy FOOD
SHOPPING
 ***Green Carts Attempt to intervene on this level.
AAP Dietary Recs
•
6y – adolescents
– Parallel to the psychosocial transition from dependence on
parental authority to independent thought processes, food
choices and purchases are increasingly made by the
adolescent.
– Peer pressure for conformity, in part driven by media
promotion of fast food directly to teens, makes overeating
natural.
– Currently, adolescents have an increased intake of sweetened
beverages, French fries, pizza, and fast food entrées, including
hamburgers, and a consequent lack of recommended fruits,
vegetables, dairy foods, whole grains, lean meats, and fish.
– ***Green Carts In front of Hospitals, Schools, CBOs can
intervene here.
AAP on Produce
Preventing Obesity
•
An ADA evidence analysis concluded that the evidence supports
a modest effect of fruit and vegetable intake in protecting against
increased adiposity in children.
•
Fruits and vegetables have been promoted for the prevention of
childhood obesity because of their low energy density, high fiber
content, and satiety value.
•
Fruits and vegetables are most likely, compared with other food
groups, to be consumed in inadequate amounts by children
•
34 Several studies found no association between fruit and
vegetable intake and childhood adiposity; nevertheless, in none of
the 17 studies reviewed in the ADA evidence analysis was
increased fruit and vegetable in- take related to increased
adiposity.
Outline / Objectives
• Introduce the Concept of Green Carts
• Discuss Background Issue of Access to Produce and
Define the Term “Food Deserts”
• Review Pattern of Adverse Health Outcomes
Nationwide and Locally
• Revisit Green Cart’s Mission and Legislation
• Connect Green Cart’s Mission to Evidence Supported by
the AAP
• Find Out What YOU Can Do About it!!!
School Lunches… an Ex. of
the Peds’ Role in Advocacy
 Great Bills won’t pass without you!
 Healthy Hunger-Free Act of 2010
 Look who you are up against!
 2010 - Congress blocked Dept of Agriculture from limiting
servings of potato (French Fries) to 2 servings a week
 Potato Growers and frozen food companies (pizzas) lobbied
against this bill and were able to make the Bill less restrictive
than the Obama Admin had hoped for.
 Conservatives said “the Gov’t should not tell children what to
eat.”
But with support from the AAP and others, A Law was passed
1/27/12 changing school lunches!!!!!!!!!
What CAN we do for
Green Carts / Markets?
Conclusion: Existing research provides clear evidence that food deserts exist in
numerous low-income communities and communities of color across the country, and
that they have significant negative impacts on health, social equity, and local economic
development.
Further, there is a legitimate, though not fully evidenced based data to support the role
of fresh produce in the prevention, assessment and treatment of obesity.
Action:
1. Federal Government
2. Local Government
3. Continue to increase your own knowledge of community
resources
Federal Level Advocacy

In December 2009, 39 members of Congress both political parties issued a
resolution in the House of Representatives recognizing the need for national
policy to address limited access to healthy food in underserved communities.

In February 2010, the federal government under the Obama Administration
announced the details of an over $400 million Healthy Food Financing Initiative
(HFFI), which will bring grocery stores and other healthy food retailers to
underserved urban and rural communities across America.

The HFFI is a partnership between the Departments of Treasury, Agriculture,
and Health and Human Services.

The HFFI is a key component of the First Lady’s Let’s Move campaign to reduce
childhood obesity.
Current Legislation: H.R. 3525:
Healthy Food Financing Initiative
Sponsor: Rep. Allyson Schwartz, D-PA
Co-Sponsors: Eleanor Norton [D-DC], Earl Blumenauer [D-OR], Robert Brady [DPA], Michael Burgess [R-TX], Marcia Fudge [D-OH], Jesse Jackson [D-IL].
Status: This bill is in the first step in the legislative process.
Explanation: Introduced bills first go to committees that deliberate, investigate,
and revise them before they go to general debate. The majority of bills and
resolutions never make it out of committee.
Introduced on November 30, 2011.
Referred to Committee- Referred to House of Agriculture
Reported by committee - TBD
House Vote - TBD
Senate Vote - TBD
Signed by President- TBD
Letter Writing
 To show our support of H.R. 3525 we could:
 Write Charles Rangel, the representative for New York’s 15th
congressional district (this is the district where CHONY is
located) stating our support for this bill.
 Write to our state senators: Kristen Gillibrand or Charles
Schummer to state our support of H.R. 3525.
 Of note, Kristen Gillibrand is New York’s first member of the
Senate Agriculture Committee in nearly 40 years! She is already a
supporter of the Green Carts Program!
Local Advocacy Specific to the Green Cart
Initiative
 An organization called Citizens’ Committee for Children of New
York Inc. (CCC) collected data during the first year of Green Cart
implementation to determine if the presence of Green Carts had a
positive impact on the consumption of fruits and vegetables in
targeted communities.
 Summary of key findings, which lead to key advocacy issues
Finding #1: Knowing about Green Carts increased the likelihood of
usage.
Constituents who saw or heard advertising were more likely to
purchase from a Green Cart than those who had not seen or heard
such an advertisement.
ADVOCACY: • Expand public marketing of Green Carts
Local Cont…
Finding #2: For those who used Green Carts, the location played a critical role
in consumer usage. Among Green Cart users: 67% of constituents responded
that the primary reason for shopping at a Green Cart was the convenient
location of the cart.
ADVOCACY: Encourage the targeted placement of Green Carts on
public property, such as NYCHA facilities, Public Hospitals, Child
Health Centers. **THINK CHONY**
Finding #3: Green Carts were reaching targeted populations.
When vendors were asked on the street, “Who purchases from you the most?”
nearly 60% of those who responded said “children and families.”
ADVOCACY: Ask the city to facilitate the placement of
Green Carts in close proximity to CBO’s and allow for CBO
cart adoption or sponsorship. **THINK Aliancia
Dominicana**
Continued..
Finding #4: Vendors were interested in efforts to increase usage of
Green Carts by poor and working poor consumers.
Vendors who participated in focus groups indicated that they need the
ability to accept Electronic Benefit Transfer cards (EBT) if they are to be
profitable in high poverty districts.
ADVOCACY: Ensure that all Green Carts have access to EBT
terminals so they can accept food stamp (SNAP) benefits as well
as WIC allotments. ***A Work In Progress***
What You Can do in Clinic
 Talk to your patients about Green Carts.
 Print out a few recipes from NYC Green Cart
Cookbook to have for your patients!
http://www.lmtilluminationfund.org/pdf/GreenCart
Cookbook_FINAL_2.28.pdf
Increase your own
knowledge on Green Carts
Attend local screening of The Apple Pushers.
The Apple Pushers, written and directed by Mary Mazzio, narrated by
Edward Norton, and underwritten by the Laurie M. Tisch Illumination
Fund, follows immigrant street vendors who are rolling fresh fruits and
vegetables into the inner cities of New York (where finding a fresh red
ripe apple can be a serious challenge). http://www.applepushers.com/
Next Screening: NEW YORK February 6, 2012
Hosted by Citizens Committee for Children
QUESTIONS????