A Nutrition Environment Measures Survey for Dollar Stores (NEMS-DS) in Rural South Carolina: Assessing Nutrition Equity and WIC Readiness

Background Rural areas in the southern United States (U.S) experience a disproportionate burden of diet-related disorders, driven by limited access to nutritious and affordable foods. Dollar stores have rapidly grown in these regions —including South Carolina’s Lowcountry—often replacing traditional grocery stores and shaping residents’ nutritional behavior. However, their food environment and their readiness to serve as vendors for the Women, Infants, and Children (WIC) nutrition program remain under-examined. This study addressed this gap using a newly developed Nutrition Environment Measures Survey for Dollar Stores (NEMS-DS), which captures dimensions overlooked by previous assessment tools, particularly given dollar stores’ reliance on shelf-stable and ultra-processed foods. Methods A quantitative, cross-sectional study was conducted in 13-dollar stores across six rural counties in the Lowcountry. All stores were located in rural, high-deprivation areas identified through the Area Deprivation Index (ADI). Food environments of sampled stores were assessed across three domains: (1) Healthy Food Availability (HFA); (2) WIC Readiness; and (3) marketing of healthy versus unhealthy items (e.g., shelf-space allocation). Descriptive statistics, F-tests, and χ²-tests were employed to compare Lowcountry stores with 202-dollar stores from a parallel multi-state assessment. Results Lowcountry’s stores demonstrated limited HFA scores (mean 23 out of a possible 62) and low WIC readiness (mean 51 out of a possible 190). Stores allocated only 12% of the total shelf space to healthy items. None marketed healthy foods at checkout, whereas 100% promoted sugar-sweetened beverages and ultra-processed snacks—patterns consistent with stores in other regions. Although fresh produce availability was slightly higher in the Lowcountry than in a sample of different states, frozen and shelf-stable produce availability was significantly lower. Conclusion Dollar stores in the Lowcountry mirrored national patterns of heavy reliance on ultra-processed foods, reinforcing unhealthy food environments in rural high-poverty settings. Findings provide a policy-actionable framework for expanding WIC vendor eligibility to dollar stores, incentivizing healthy product placement, and regulating marketing to improve nutritional behavior, promote equitable access to nutritious foods, and prevent diet-related chronic disease in rural communities.