.
Philadelphia Food Deserts, Vehicle Access and Healthy Food Choices
Introduction
Diabetes is an epidemic in the United States with over of 30 million people affected (American Diabetes Association, 2020). This corresponds with a prevalence of approximately 10 percent (Centers for Disease Control, 2019). Another approximately 90 million in the U.S. have prediabetes (American Diabetes Association, 2020). Globally, we have a pandemic, with an incidence close to one half billion individuals affected by diabetes (World Health Organization, 2014). Despite the staggering numbers, many people remain unaware of the diabetes pandemic (International Diabetes Federation, 2017). Unlike the infamous infectious pandemics of the past such as the plague and the flu that left victims dead on the streets, type 2 diabetes is a non-infectious silent disease that quietly takes its toll on its victims, long before even being diagnosed (American Diabetes Association, 2017). Furthemore, those with diabetes have been noted to have worse outcomes if they are diagnosed with COVID-19.
Diabetes is a chronic debilitating disease that occurs when the pancreas becomes incapable of producing adequate amounts of the hormone insulin and/or when the body cannot effectively take up utilize the insulin that is produced. Diabetes is categorized as either type 1 or type 2, depending on the above criteria. Despite extensive and ongoing research, Type 1 diabetes remains relatively unpredictable and is incurable (Bliss,1982).
Type 2 diabetes, however, is strongly linked to a variety of risk factors, some of which are modifiable. Consequently, type 2 diabetes is more predictable, avoidable and potentially reversible. Outside of the scientific community, few people realize the magnitude and repercussions of diabetes and the complications it causes. Since diabetes is a silent disease, complications such as blindness, kidney disease and amputations may seemingly appear out of nowhere and can be devastating. However, these complications are the result of long-term exposure to extremely high glucose concentrations and often begin brewing as prediabetes, oftentimes years before an official diabetes diagnosis.
Scientists and laymen must take this pandemic seriously because we are all susceptible and none of us have immunity. Certain risk factors such as family history, age and ethnicity are non-modifiable. However, there are also modifiable risk factors such as smoking, sedentary lifestyle and unhealthy nutritional status. Society has an obligation to account for those individuals who might be at an additional disadvantage due to their socio economic status (SES). Examination is necessary of how social determinants and disparities such as residential segregation and residing in food deserts create a lack of access to healthy foods such as fruits and vegetables. This situation is compounded when residents do not own a car and become prisoners to the unhealthy food choices that are available.
Statement of Problem
Lack of access to healthy food choices at affordable prices is the beginning of a viscous cycle that contributes to high cholesterol, high blood pressure and obesity (American Diabetes Association, 2017). Obesity is subsequently a driving factor in the type 2 diabetes epidemic and pandemic that we are currently experiencing. Lack of access to an automobile may present a physical barrier to adherence and is an additional independent variable that may play a significant role in determining one’s access to food and ultimately one’s risk of acquiring type 2 diabetes.
Significance of Problem
Type 2 diabetes is a public health catastrophe of unparalleled significance because diabetes is the leading cause of blindness, end stage renal disease and lower extremity amputations (American Diabetes Association, 2017). This issue is of particular significance in Philadelphia, PA, which has the highest prevalence of diabetes when compared to the 11 largest cities in the United States (Phila. CHA, 2016).
Purpose of Our Study
The purpose of our study is to shed light on the health disparities faced by individuals and communities residing in food deserts and the resulting disproportionate risk of contracting diabetes as well as hardships encountered in nutritionally managing existing cases diabetes. The aim of this study is to assess the relationship between those living in high food desert areas, access to healthy food choices and the prevalence of type 2 diabetes. Further analyses will assess the relationship between access to a vehicle and healthy food choices.
Background and significance
Literature Review
Access to healthy, affordable foods has become a national public health priority; research has found that the neighborhood food environment, specifically the types of food products offered and food venues available, are associated with obesity and diet-related chronic diseases. Research from Breyer and Voss-Andreae (2013) has shown that low-income and minority neighborhoods have fewer supermarkets, more liquor stores and convenience stores than higher income and White neighborhoods (Breyer & Voss-Andreae, 2013). In addition, studies from Tach and Amorim (2015) have revealed that there are fewer healthy food options and lower quality foods in low-income and minority neighborhoods (Tach & Amorim, 2015). Also, in Philadelphia neighborhoods even when supermarkets are close by, residents used the same stores regardless of whether they owned a vehicle. Residents of minority and low-income neighborhoods may tend to face more environmental barriers to healthy eating than residents of other neighborhoods. According to the USDA (2015) lack of access is a fundamental cause of obesity and diet-related chronic diseases, including diabetes. (U.S. Department of Health and Human Services, 2015). Placing a source of healthy affordable foods such as a supermarket in food deserts, or areas with restricted access to healthy foods, has been a proposed strategy to improve the diet among residents. The Healthy Foods Financing Initiative of 2014, established programs that provides federally funded incentives to locate full service supermarkets in food deserts (U.S. Department of Health and Human Services, 2015). Pennsylvania has initiated state policies with similar incentivizing programs. However, focusing only on the characteristics of stores in closest proximity to residents' homes may limit the understanding of food access and diet-related chronic diseases such as diabetes. Despite significant empirical developments, additional insight into how individuals who live in food deserts interact with and may be affected by their food environment could be very beneficial. While the science is growing for food purchasing venues closest to residents, this may not encompass the food environment with which they interact.
Obesity is a risk factor for type 2 diabetes across all populations. Domestically, there is a higher risk of Type 2 diabetes in Latinos, African Americans and Native Americans. This is concerning because many people of lower SES reside in neighborhoods considered to be food deserts. This disparity now places a population already at greater risk for diabetes in an even more precarious situation. Furthermore, some neighborhoods in Philadelphia have less access to affordable, healthy foods than more advantaged neighborhoods. Many of these residents rely on corner stores for to purchase food (Stockman, 2011). The food options available at these stores are often limited to high calorie, energy dense foods, sugar sweetened beverages, and only a small amount of fruits and vegetables. In addition many children visit these corner stores regularly and on the way to and from school for snacks (Stockman, 2011). Corner convenience stores are notorious for stocking packaged junk food items with long shelf lives and high profit margins. These foods are loaded with refined carbohydrates that are nutritionally empty. These establishments also dedicate much of their retail space to the promotion of alcohol and tobacco consumption. Residential segregation often prevents people from having access to full service grocery stores and supermarkets offering a wider variety of healthy choices such as nutritionally dense fresh fish, poultry, meat, fruits and vegetables. This geographically restricted access to healthy foods, often exacerbated by lack of access to an automobile, places these lower SES individuals at a substantial risk of developing type 2 diabetes. This is the focal point of our research.
Food Deserts as they relate to type 2 diabetes risk
Disparities such as lack of access to healthy food choices often translate
into unequal health outcomes such as a higher risk for acquiring type 2 diabetes (Tach, 2015). A recent study cites not only financial barriers, but also physical barriers relating to functional limitations and lack of transportation as circumstances routinely experienced by vulnerable populations residing in food deserts (Cuesta-Briand, 2011).
Obesity as a risk factor for type 2 diabetes
While obesity has often been noted as a risk factor for type 2 diabetes, dietary studies have often had difficulty in controlling for confounding variables such as body mass index, physical activity and cigarette smoking. A recent study compared a “prudent” diet (higher consumption of vegetables, fruit, fish, poultry and whole grains) to a “western” diet (higher consumption of red meat, processed grains, and sweets and desserts). This study concluded that a western dietary pattern is associated with a substantially higher risk for type 2 diabetes (Van Dam, 2002).

Diabetes as it relates to food deserts
There are many published references suggesting the connection between the prevalence of diabetes and residing in food deserts. Socioeconomic disparities play a significant role in this relationship. In particular, Low income earners living with diabetes are often faced with food insecurity situations. One of the recurring barriers cited across much of the published literature is the lack of physical access to healthy food created by geographic segregation and lack of automobile ownership or accessibility (Cuesta-Briand, 2011). The definition of food insecurity encompasses reductions in both food quantity and food quality. Food insecurity also reduces self-efficacy, as one’s confidence in their own ability to obtain access to healthy foods is often diminished (Seligman, 2012).
Philadelphia as it relates to diabetes prevalence
According to the Philadelphia Community Health Assessment (2016) the prevalence of diagnosed diabetes in Philadelphia is 15.4 percent (Philadelphia Department of Public Health, 2016) compared to a national average of 9.3 percent (Centers for Disease Control, 2016). Also, data show adult diabetes is the second most prevalent in Philadelphia than any other of the 11 largest U.S. counties, trailing only to New York, NY (Philadelphia Department of Public Health, 2016). In, Philadelphia, diabetes prevalence rose by nearly 50% between 2004 and 2012 (Philadelphia Department of Public Health, 2016). Also adult diabetes is most prevalent among non-Hispanic blacks (Philadelphia Department of Public Health, 2016).
As such, there have been a number of studies conducted regarding diabetes in the Philadelphia region. Most of these studies have traditionally employed “spatial approaches” to food access. An example of a “spatial approach” (Hirsch, 2013) might read as follows: “....living 0.5 miles from the closest supermarket.” A recent study conducted in Philadelphia (Hirsch, 2013) utilized the concept of “activity spaces” and Geographic Information Systems (GIS) in an attempt to better define the environment in which individuals do their food shopping and the perception of residents’ food environments. In this study, the food purchasing decisions of residents living in “favorable food environments” as well as those residing “unfavorable food environments” were both directly tied size of the food purchase and availability of transportation (car) (Hirsch, 2013). It is for this reason that we will address transportation as an additional independent variable.
Vehicle ownership/availability as it relates to access to healthy food
choices and risk for type 2 diabetes
Having access to a car affords food desert residents an opportunity for food security by temporarily escaping for healthy food shopping at a full service food market. Studies have examined whether proximity to fast food outlets can account for the higher prevalence of obesity (an established risk factor for type 2 diabetes) in low-income minority priority populations. A study conducted in Los Angeles (Inagami, 2009) examined the relationship between fast food and general restaurant access, neighborhood socioeconomic levels, BMI of (young male Latino) residents and whether this association is moderated by car ownership. The results of the study support the possibility that those people able to travel farther may have better access to healthier foods, while those without transportation are more likely to patronize convenience stores that sell energy-dense foods that contribute to obesity and diabetes (Inagami, 2009). Another study (already mentioned above) also identified lack of transportation as a physical barrier between food desert residents and access to healthy food shopping opportunities (Cuesta-Briand, 2011).
The USDA Defines Food Desert as “parts of the country vapid of fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas. This is largely due to a lack of grocery stores, farmers' markets, and healthy food providers” (American Nutrition Association , 2011).
Across all communities, there is a direct correlation between the prevalence of obesity and diabetes and the ratio of fast-food restaurants and convenience stores to full service grocery stores and produce vendors where they live (Ingami, 2009). Previous studies have shown that people of lower SES residing in communities that do not offer many healthy choices have the highest rates of obesity and diabetes. Previous research has suggested that health outcomes are a product of the types of foods available in the community and the associated dietary behaviors of the residents (UCLA, 2008). Our objective is to perform a thorough review of the previous work in this area and to develop definitive conclusions based on the existing data. We will also offer suggestions on how to help alleviate the burden of food deserts in our nation. We will attempt to address recurring themes that come up in the literature such as, urban vs rural environments, travel distance to the closest full service supermarket and access to a car.
Urban vs. rural environment
It has already been established in the literature that dietary patterns predict risk for type 2 diabetes (Van Dam, 2002). When one thinks of a food desert the image that comes to mind is often an urban setting where there are large numbers of people, geographically segregated, without access to healthy food choices. While this is true, there are also rural food deserts, where extended travel distance and hardship also makes it difficult to find and purchase healthy foods at affordable prices (Miller, 2016). Car ownership, education and SES influence the distance that people in urban and rural environments are willing and able to travel in search of food (Hirsh, 2013).

Research questions
The research questions of this proposal are: What is the relationship between residing in food deserts, making healthy food choices and the prevalence of type 2 diabetes Additionally, is how does lack of access to an automobile play into the situation as another independent variable or risk factor.
Research hypothesis
It is hypothesized that residing in food deserts is a social disparity that limits residents’ access to healthy food choices at affordable prices, consequently increasing the risk of type 2 diabetes for this population. Additionally, it is hypothesized that lower prevalence of car ownership allows less opportunities to travel in search of healthy food choices and therefore also contributes (as an independent variable or an additional risk factor) to an increased risk of type 2 diabetes.
Methods and procedures
Research study design
A cross-sectional, community-based survey study design will be employed over an 8 week period, among individuals of either sex, aged 18 years and older. The study will be carried out in neighbors of Philadelphia, PA identified as food deserts. This study was used to show the prevalence of diabetes. In this study the prevalence of diabetes is the proportion of individuals with self-reported diabetes in the population of study. This study will also be used to assess the relationship among diabetes prevalence and vehicle ownership.
The independent variable (the exposure) in this study is the individuals’ residing in a neighborhood defined as a food desert. An additional independent variable (possibly a confounding variable) is automobile ownership or easy access to an automobile. The dependent variable (the outcome being measured) is the risk of acquiring type 2 diabetes. It is important to examine the role that transportation plays in escaping the food desert in search of healthier choices. Having access to a car may affect the internal validity of this study because we need to know if the results are truly attributable to the primary exposure (residing in a food desert). It is important to note that the majority of the studies we have referenced have made some type of reference as to the importance of automobile availability in acquiring healthy foods, regardless of what the primary objective of the studies may have been.
The prevalence of diabetes and risk factors of diabetes will be presented as percentages. A Chi-square test for trend will be used to assess the trends in the prevalence of diabetes among vehicle ownership. A P value of < 0.05 will be considered significant. Several studies have confirmed the association of socioeconomic status with diabetes. However, there have been few studies which analyzed vehicle ownership particularly and its relation to diabetes. If people live in neighborhoods which do not have food stores with healthy food options, they can still access food stores in nearby places if they own a personal vehicle. However, in most cases, people living in low income neighborhoods such as food deserts, often do not own vehicles. Food desert residence and car ownership will be assessed using survey items.

Subject recruitment and selection

According to the United States Department of Agriculture (USDA) there are many ways to measure food store access for individuals and for neighborhoods, and many ways to define which areas are food deserts or neighborhoods that lack healthy food sources. Most measures and definitions take into account accessibility to healthy food sources measured by distance to a store or by the amount of stores in an area, individual resources that may affect accessibility, such as family income or vehicle availability, and neighborhood indicators, such as the average income of the neighborhood and the availability of public transportation. The USDA Food Access Research Atlas (FARA) maps food access indicators for census tracts using ½-mile and 1-mile demarcations to the nearest supermarket for urban areas, low income status, and vehicle availability for all tracts. The FARA allows users to view census tracts by food access indicators using these different measures. Food deserts were identified using the USDA Food Access Research Atlas (FARA). The food desert indicators of interest include the number of individuals who live more than 1 miles away from a supermarket within each census tract, the total number of individuals at low access who are also of low income, and the total number of households at low access, without access to a vehicle. Low income was defined as persons with an annual income below or equal to 200 percent of the federal poverty line. Three food deserts were identified using indicator measures. The field areas of study that were identified as food desert using FARA will include the Overbrook neighborhood in West Philadelphia, and the Fox Chase, and Normandy neighborhoods in Northeast Philadelphia. Of these locations 10 corner stores will be identified in each location. Permission will be requested from store owner via phone or in person to administer survey. Approximately 20 surveys will be administered at each study site.
Survey questions were selected from the CDC’s Youth Risk Behavior System (YRBSS). The YRBSS monitors health risk behavior among youths and adults including unhealthy dietary behaviors. Survey questionnaires will be administered to a convenient sample approximately 600 customers at 30 convenience store located in food deserts neighborhoods of Philadelphia. Survey measures include customer dietary behavior, diabetic prevalence, shopping frequency, distance traveled, food accessibility, SNAP participation, and demographic information.

Inclusion and exclusion criteria
Participation is voluntary. Survey respondents must be male or female customers of the convenience stores included in our study. An individual may participate in the survey only once. Participants must 18 years of age or older and must be willing to voluntarily and anonymously complete our questionaire. Potential confounding variables might include age, body mass index, levels of physical activity and smoking status. While excluding those people from the research study might yield more accurate results, we probably would be left with a very small pool of eligible patients.

Location of the study
The location of the study will be at convenience stores located in low income, urban, neighbors of Philadelphia identified as food deserts environments by the researchers using FARA maps.Survey questionnaires will be administered to customers at any of the 30 corner store located in food deserts neighborhoods of Philadelphia.
Participant procedures
The population for this study would consist of individual residing in food deserts of Philadelphia. Undergraduate public health student volunteers embedded into the community will approach customer by asking them to participate in a brief survey about the nutrition behavior and environment. A 20 item survey administered to convenience store customers will either be self administered or administered by the researchers. Convenience store customers can voluntary participant in survey questionnaire. Survey will approximately take 5 minutes to complete. Respondents may stop at any time during the survey. Approximately 20 surveys will be collected from each convenience store site. Refusals of survey participation will be recorded. After completion, the survey will be collected. Survey collection will be completed in an eight week study period.
Protection of subjects
Confidentiality and anonymity
The Survey is voluntary and participants can stop at any time during the survey. We will not collect information that could be used to identify or contact an individual. Data will be kept in encrypted hard drives for research access only.

Potential risks or discomforts to patients
There are minimal potential risks or discomforts anticipated to the subjects. Survey is brief and will approximately only take 5 minutes to complete. The Questionnaire is voluntary respondents discontinue participation at any time.
Potential benefits
High fat and carbohydrate diet are considered risk factors for type 2 diabetes. Therefore, the food environment in which an individual resides may determine to a large extent whether an individual has a higher probability of developing diabetes. Most of the studies related to the built environment, food access and health outcomes have focused on mainly on obesity. There have not been a large number of studies which looked at the association between food environment, diabetes prevalence and having adequate transportation to actually arrive at the healthy food shopping destination. Accessibility and availability of supermarkets, grocery stores and fast food joints influence the health status of individuals, especially when it comes to obesity and type 2 diabetes.
A healthy diet is a major key to preventing and managing type 2 diabetes. Avoiding fatty food and consuming a variety of whole grains, fresh fruits and vegetables, lean meats and limited carbohydrates can reduce the prevalence of diabetes (American Diabetes Association, Fat and Diabetes, 2013). Access to quality food can play a crucial role in determining the diabetes health status of individuals. Philadelphia is plagued with several food deserts where there is no access to grocery stores of supermarkets. Residents of these neighborhoods usually belong to the low income population. They often have to travel long distances to reach a grocery store which at times may not be possible because of a lack of vehicle ownership. Under such circumstances, individuals with a lack of access to healthy food are at higher risk for obesity, and dietary-related health problems such as diabetes. This study highlights the importance of access to healthy food and its implications on diabetes health status. It examines whether there is an association between lack of access to fresh food, large grocery stores or supermarkets in low income, USDA designated food deserts in Philadelphia, PA and the prevalence of diabetes among the residents. The study examines whether one’s geographic location within the Philadelphia influences health status measured by diabetes prevalence. It looks at factors such as household income, transportation and race/ethnicity in food deserts and determines whether there is a significant difference in diabetes prevalence based on the above factors.


References

American Diabetes Association (2017). Standards of Care in Diabetes American Nutrition Association. (2011). USDA defines food deserts. Nutrition Digest,
38(2). Retrieved from: http://americannutritionassociation.org/newsletter/usda-defines-food-desert
Beckles GL, Chou C. Disparities in the Prevalence of Diagnosed Diabetes — United States, 1999–2002 and 2011–2014. MMWR Morb Mortal Wkly Rep 2016;65:1265–1269. DOI: http://dx.doi.org/10.15585/mmwr.mm6545a4

Bliss, M. (1982). The Discovery of Insulin. Chicago: The University of Chicago
Press.
Borradaile, K., Sherman, S., Vander Veur, S., McCoy, T., Sandoval, B., & Nachmani, J.,
… Foster, G., (2009). Snacking in Children: The Role of Urban Corner Stores.
PEDIATRICS, 124(5), 1293-1298. http://dx.doi.org/10.1542/peds.2009-0964

Centers for Disease Control: www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
Cuesta-Briand, B., Saggers, S., McManus, A., (2009) ‘You get the quickest and the
cheapest stuff you can’: Food security issues among low-income earners living
with diabetes. Australian Medical Journal 4(12), 683-691.
http//dx.doi.org/10.4066/AMJ.2011.1104

Diabetes Prevention Program Research Group. (2002). REDUCTION IN THE
INCIDENCE OF TYPE 2 DIABETES WITH LIFESTYLE INTERVENTION OR
METFORMIN. The New England Journal of Medicine, 346(6), 393–403.
http://doi.org/10.1056/NEJMoa012512.
DiSantis, K., Grier, S., Odoms-Young, A., Baskin, M., Carter-Edwards, L., & Young, D. et
al. (2013). What “Price” Means When Buying Food: Insights From a Multisite
Qualitative Study With Black Americans. American Journal Of Public Health, 1
03(3), 516-522. http://dx.doi.org/10.2105/ajph.2012.301149
Economic Research Service (ERS), U.S. Department of Agriculture (USDA). Food Access Research Atlas, https://www.ers.usda.gov/data-products/food-access-research-atlas/
Gordon, C., Purciel-Hill, N, Kaufman, L., Graham, R. and Van Wye, G. (2011).
Measuring food deserts in New York City’s low-income neighborhoods. Health &
Place 17(2011), 696-700.
Grzywacz, J. G., Arcury, T. A., Ip, E. H., Nguyen, H. T., Saldana, S., Reynolds, T., …
Quandt, S. A. (2012). “Culture” in Diabetes-Related Beliefs among Low- and
High-Education African American, American Indian, and White Older Adults.
Ethnicity & Disease, 22(4), 466–472.
Gustafson, A., Lewis, S., Moore, K. and Jilcott, S. (2013). Food Venue Choice,
Consumer Food Environment, But Not Food Venue Availability Within Daily
Travel Patterns Are Associated With Dietary Intake Among Adults, Lexington
Kentucky 2011. Nutr J 12(1).
Hirsch, J.A., and Hiller, A. (2013). Exploring the Role of the Food Environment on Food
Shopping Patterns in Philadelphia, PA, USA: A Semiquantitative Comparison of Two Matched Neighborhood Groups. Int J Environ Res Public Health 10(1),295-313.
International Diabetes Federation. Reference can be found at www.idf.org
www.oxfordbibliographies.com/view/document/obo.../obo-9780199874002-0137.xml
Philadelphia Department of Public Health. (2016). Community Health Assessment.
Retrieved from: http://www.phila.gov/health/pdfs/chareport_52114_final.pdfSeligman, H. K., Jacobs, E.A, Lopez, A., Tschann, J, and Fernandez, A. (2012). Food
Insecurity and Glycemic Control Among Low-Income Patients With Type 2
Diabetes. Diabetes Care 35(2), 233-238.
Tach, L. and Amorim, M. (2015). Constrained, Convenient and Symbolic Consumption:
Neighborhood Food Environments and Economic Coping Strategies among the
Urban Poor. Journal of Urban Health: Bulletin of the New York Academy of
Medicine 92(5).
UCLA Center for Health Policy Research. (2008). Designed for Disease. The Link
Between Local Food Environments and Obesity and Diabetes. Van Dam, R.M., Rimm, E.B., Willet, W.C., Meir, J.S., and HU, F.B. (2002). Dietary
Patterns and Risk for Type 2 Diabetes Mellitus in U.S. Men. Ann Intern. Med 136,
201-209.
World Health Organization. Reference can be found at:
http://www.who.int/topics/diabetes_mellitus/en/
https://en.wikipedia.org/wiki/Geographic_information_system

RESTAURANTS FOOD & GROCERY COUPONS & DELIVERY

ACME COUPONS ACME GIFTCARDS ALAMO DRAFT AMAZON FOOD DELIVERY ALDI ALMONDS ARBYS BAGELS BAKE ME A WISH BOTTLED WATER BOWL MUGS CALIFORNIA OLIVE RANCH CARBONATED WATER COUPONS CRAVEBOX CARE PACKAGE BJ'S COUPONS BOKKSU.COM BREAD BURGER KING COUPONS CARBOHYDRATE CEREAL COUPONS CHEWY COCA-COLA COFFEE COFFEE COUPONS COFFEE DUNKIN COFFEE GIFTCARDS COFFEE STARBUCKS CORN COSTCO COUPONS COUPONS CVS COUPONS DIET DOORDASH DONUTS DUNKIN COUPONS DUNKIN GIFTCARDS EMERIL LAGASSE EMERIL LAGASSE EMERIL LAGASSE FAT FAT FREE FISH FITNESS FITNESS EQUIPMENT FOOD DESERTS FOOD DIARY FOOD SCALE FOOD SHORTAGES FROSTED FLAKES GIANT COUPONS GIFT CARDS GIFT CARDS GIFT CARDS GIFT CARDS GROCERY DELIVERY GRUBHUB HEALTH COACH HELLOFRESH ICE CREAM COUPONS ICE CREAM COUPONS ICE CREAM COUPONS KANSAS CITY STK KFC COUPONS KMART LO-CARB MCDONALDS COUPONS MASKS MASKS MASKS MCDONALD'S COUPONS MERITA BREAD NUTRITION NUTS NUTS.COM OATS OLIVE GARDEN ORANGE JUICE OUTDOOR COOKING OUTDOOR COOKING OUTDOOR COOKING PATHMARK COUPONS PANERA GIFT PANERA GIFT PANERA GIFT PANERA GIFT PANERA GIFT PAPA JOHNS PAPA JOHNS PAPA JOHNS PETCO PIZZA DELIVERY COUPONS POSTMATES.COM POTATO POWER AIR FRYER 360 POWER AIR FRYER 360 POWER AIR FRYER 360 PROTEIN PUBLIC HEALTH CONSTRUCTS PUBLIX RECIPIES RIMINI CHOCOLATES RIMINI CHOCOLATES SAFEWAY SATURATED FAT SCRUB DADDY SCRUB DADDY SCRUB DADDY SHAPE UP SHOPRITE COUPONS SOUP MUGS SOYBEANS STARBUCKS SUGAR TACO BELL COUPONS TARGET COUPONS TATAPELA SNACKS UBER EATS UNSATURATED FAT WATER WATER SHORTAGE WELLNESS WHEAT WHOLE FOODS MARKET WW
PRINTABLE COFFEE COUPONS COMING SOON
ENTER CONTESTS DAILY AT PUBLISHERS CLEARING HOUSE AND START YOUR SEARCHING AND SHOPPING ON COWSAYSMOO.COM
CowSaysMoo.com is an Amazon affiliate and earns small commissions from some of our links. We may also receive small commissions from Rakuten, CJ and other similar programs. We do our best to associate only with reputable businesses and individuals. When you click on the advertisers' links you are taken away from CowSaysMoo.com and we are not responsible for the content of other websites. Never provide your personal information to any individual or entity that is not independently verified as being legitimate. If you observe any bad links or bad players please let us know and we will ZAP them.