The local food environment and diet: a systematic review

Incorporating Systems Science Principles into the Development of Obesity Prevention Interventions: Principles, Benefits, and Challenges

Systems modeling represents an innovative approach for addressing the obesity epidemic at the community level. We developed an agent-based model of the Baltimore City food environment that permits us to assess the relative impact of different programs and policies, alone and in combination, and potential unexpected consequences. Based on this experience, and a review of literature, we have identified a set of principles, potential benefits, and challenges. Some of the key principles include the importance of early and multilevel engagement with the community prior to initiating model development and continued engagement and testing with community stakeholders. Important benefits include improving community stakeholder understanding of the system, testing of interventions before implementation, and identification of unexpected consequences. Challenges in these models include deciding on the most important, yet parsimonious factors to consider, how to model food source and food selection behavior in a realistic yet transferable manner, and identifying the appropriate outcomes and limitations of the model.

Neighborhood fast food availability and fast food consumption

Recent nutritional and public health research has focused on how the availability of various types of food in a person's immediate area or neighborhood influences his or her food choices and eating habits. It has been theorized that people living in areas with a wealth of unhealthy fast-food options may show higher levels of fast-food consumption, a factor that often coincides with being overweight or obese. However, measuring food availability in a particular area is difficult to achieve consistently: there may be differences in the strict physical locations of food options as compared to how individuals perceive their personal food availability, and various studies may use either one or both of these measures. The aim of this study was to evaluate the association between weekly fast-food consumption and both a person's perceived availability of fast-food and an objective measure of fast-food presence - Geographic Information Systems (GIS) - within that person's neighborhood. A randomly selected population-based sample of eight counties in South Carolina was used to conduct a cross-sectional telephone survey assessing self-report fast-food consumption and perceived availability of fast food. GIS was used to determine the actual number of fast-food outlets within each participant's neighborhood. Using multinomial logistic regression analyses, we found that neither perceived availability nor GIS-based presence of fast-food was significantly associated with weekly fast-food consumption. Our findings indicate that availability might not be the dominant factor influencing fast-food consumption. We recommend using subjective availability measures and considering individual characteristics that could influence both perceived availability of fast food and its impact on fast-food consumption. If replicated, our findings suggest that interventions aimed at reducing fast-food consumption by limiting neighborhood fast-food availability might not be completely effective.

Do people really know what food retailers exist in their neighborhood? Examining GIS-based and perceived presence of retail food outlets in an eight-county region of South Carolina

Measures of neighborhood food environments have been linked to diet and obesity. However, the appropriate measurement methods and how people actually perceive their food environments are still unclear. In a cross-sectional study of 939 adults, the perceived presence of food outlets was compared to the geographic-based presence of outlets within a participant's neighborhood, utilizing percent agreement and Kappa statistics. Perceived presence was based on survey-administered questions, and geographic-based presence was characterized using 1-, 2-, 3- and 5-mile (1-mile=1.6km) Euclidean- and network-based buffers centered on each participant's residence. Analyses were also stratified by urban and non-urban designations. Overall, an individual's perceived neighborhood food environment was moderately correlated with the geographic-based presence of outlets. The performance of an individual's perception was most optimal using a 2- or 3-mile geographic-based neighborhood boundary and/or when the participant lived in a non-urban neighborhood. This study has implications for how researchers measure the food environment.

Outside the exam room: policies for connecting clinic to community in diabetes prevention and treatment

The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation’s Commission to Build a Healthier America recommended 3 strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.

Local food environment interventions to improve healthy food choice in adults: a systematic review and realist synthesis protocol

INTRODUCTION

Local food environments have been linked with dietary intake and obesity in adults. However, overall evidence remains mixed with calls for increased theoretical and conceptual clarity related to how availability of neighbourhood food outlets, and within-outlet food options, influence food purchasing and consumption. The purpose of this work is to develop a programme theory of food availability, supported by empirical evidence from a range of local food environment interventions.

METHODS AND ANALYSIS

A systematic search of the literature will be followed by duplicate screening and quality assessment (using the Effective Public Health Practice Project tool). Realist synthesis will then be conducted according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards, including transparent appraisal, synthesis and drawing conclusions via consensus.

DISSEMINATION

The final synthesis will propose an evidence-based programme theory of food availability, including evidence mapping to demonstrate contextual factors, pathways of influence and potential mechanisms. With the paucity of empirically supported programme theories used in current local food environment interventions to improve food availability, this synthesis may be used to understand how and why interventions work, and thus inform the development of theory-driven, evidence-based interventions to improve healthy food choice and future empirical work.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42014009808.

Advances in physical activity and nutrition environment assessment tools and applications: recommendations

INTRODUCTION

In the past 15 years, researchers, practitioners, and community residents and leaders have become increasingly interested in associations among built environments and physical activity, diet, and obesity. Numerous tools to measure activity and food environments have been developed but vary in quality and usability. Future progress depends on aligning these tools with new communication technology and increasing their utility for planning and policy.

METHODS

The Built Environment Assessment Training Institute Think Thank was held in July 2013. Expert participants discussed priorities, gaps, and promising opportunities to advance the science and practice of measuring obesity-related built environments. Participants proposed and voted on recommended future directions in two categories: "big ideas" and additional recommendations.

RESULTS

Recommendations for the first "big idea" involve developing new, simplified built environment assessment tools and deploying them through online trainings and easily accessible web-based apps. Future iterations of the tools would link to databases of key locations (e.g., parks, food stores); have built-in scoring and analysis; and provide clear, simple feedback to users. A second "big idea" addresses dissemination of results from built environment assessments and translation into policies including land use and food access planning. Additional recommendations include (1) improving multidisciplinary collaborations; (2) engaging stakeholders across sectors; (3) centralized data resource centers; (4) increased use of emerging technologies to communicate findings; and (5) advocating for expanded funding for measurement development, training, and dissemination.

CONCLUSIONS

Implementing these recommendations is likely to improve the quality of built environment measures and expand their use in research and practice.

Combined measure of neighborhood food and physical activity environments and weight-related outcomes: The CARDIA study

Engagement in healthy lifestyle behaviors likely reflects access to a diverse and synergistic set of food and physical activity resources, yet most research examines discrete characteristics. We characterized neighborhoods with respect to their composition of features, and quantified associations with diet, physical activity (PA), body mass index (BMI), and insulin resistance (IR) in a longitudinal biracial cohort (n=4143; aged 25-37; 1992-2006). We used latent class analysis to derive population-density-specific ( Collapse

Key Words

• Diet
• Insulin resistance
• Neighborhood
• Obesity
• Physical activity

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MESH Headings

• Adult
• Body Mass Index
• Diet
• Environment
• Exercise
• Female
• Food Supply
• Health Behavior
• Humans
• Insulin Resistance
• Longitudinal Studies
• Male
• Obesity/epidemiology
• Residence Characteristics
• United States/epidemiology

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Grants

• AG0005 NIA NIH HHS
• P30 DK079626 NIDDK NIH HHS
• HHSN268201300025C NHLBI NIH HHS
• P30DK56350 NIDDK NIH HHS
• HHSN268201300027C NHLBI NIH HHS
• R01 HL114091 NHLBI NIH HHS
• R01HL104580 NHLBI NIH HHS
• P30 DK056350 NIDDK NIH HHS
• K12 HD043488 NICHD NIH HHS
• R01 HL104580 NHLBI NIH HHS
• HHSN268201300026C NHLBI NIH HHS
• P30 ES010126 NIEHS NIH HHS
• HHSN268200900041C NHLBI NIH HHS
• HHSN268201300028C NHLBI NIH HHS
• R24 HD050924 NICHD NIH HHS
• HHSN268201300029C NHLBI NIH HHS
• P30ES010126 NIEHS NIH HHS
• R24HD050924 NICHD NIH HHS

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Affiliation(s)

Katie A Meyer Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
Janne Boone-Heinonen Public Health and Preventive Medicine, Oregon Health and Science University, Portland, OR, United States
Kiyah J Duffey Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute, Blacksburg, VA, United States
Daniel A Rodriguez Department of City and Regional Planning, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
Catarina I Kiefe Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, United States
Cora E Lewis Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
Penny Gordon-Larsen Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States

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A border versus non-border comparison of food environment, poverty, and ethnic composition in Texas urban settings

Purpose

The goal was to examine the relationship between the food environment and selected socioeconomic variables and ethnic/racial makeup in the eight largest urban settings in Texas so as to gain a better understanding of the relationships among Hispanic composition, poverty, and urban foodscapes, comparing border to non-border urban environments.

Methods

Census-tract level data on (a) socioeconomic factors, like percentage below the poverty line and number of households on foodstamps, and (b) ethnic variables, like percent of Mexican origin and percent foreign born, were obtained from the U.S. Census. Data at the census-tract level on the total number of healthy (e.g., supermarkets) and less-healthy (e.g., fast food outlets) food retailers were acquired from the CDC’s modified retail food environment index (mRFEI). Variation among urban settings in terms of the relationship between mRFEI scores and socioeconomic and ethnic context was tested using a mixed-effect model, and linear regression was used to identify significant factors for each urban location. A jackknife variance estimate was used to account for clustering and autocorrelation of adjacent census tracts.

Results

Average census-tract mRFEI scores exhibited comparatively small variation across Texas urban settings, while socioeconomic and ethnic factors varied significantly. The only covariates significantly associated with mRFEI score were percent foreign born and percent Mexican origin. Compared to the highest-population county (Harris, which incorporates most of Houston), the only counties that had significantly different mRFEI scores were Bexar, which is analogous to San Antonio (2.12 lower), El Paso (2.79 higher), and Neuces, which encompasses Corpus Christi (2.90 less). Significant interaction effects between mRFEI and percent foreign born (El Paso, Tarrant – Fort Worth, Travis – Austin), percent Mexican origin (Hidalgo – McAllen, El Paso, Tarrant, Travis), and percent living below the poverty line (El Paso) were observed for some urban settings. Percent foreign born and percent Mexican origin tended to be positively associated with mRFEI in some locations (Hidalgo, El Paso) and negatively associated in others (Tarrant, Travis).

Discussion

Findings are consistent with other studies that suggest the effects of Hispanic concentration on the foodscape may be positive (beneficially healthy) in border urban settings and negative in non-border. The evidence implies that the effects of Hispanic ethnic composition on the food environment are location-dependent, reflecting the unique attributes (e.g., culture, infrastructure, social networks) of specific urban settings.

Tobacco Retail Environments and Social Inequalities in Individual-Level Smoking and Cessation Among Scottish Adults

INTRODUCTION

Many neighborhood characteristics may constrain or enable smoking. This study investigated whether the neighborhood tobacco retail environment was associated with individual-level smoking and cessation in Scottish adults, and whether inequalities in smoking status were related to tobacco retailing.

METHODS

Tobacco outlet density measures were developed for neighborhoods across Scotland using the September 2012 Scottish Tobacco Retailers Register. The outlet data were cleaned and geocoded (n = 10,161) using a Geographic Information System. Kernel density estimation was used to calculate an outlet density measure for each postcode. The kernel density estimation measures were then appended to data on individuals included in the 2008-2011 Scottish Health Surveys (n = 28,751 adults aged ≥16), via their postcode. Two-level logistic regression models examined whether neighborhood density of tobacco retailing was associated with current smoking status and smoking cessation and whether there were differences in the relationship between household income and smoking status, by tobacco outlet density.

RESULTS

After adjustment for individual- and area-level confounders, compared to residents of areas with the lowest outlet densities, those living in areas with the highest outlet densities had a 6% higher chance of being a current smoker, and a 5% lower chance of being an ex-smoker. There was little evidence to suggest that inequalities in either current smoking or cessation were narrower in areas with lower availability of tobacco retailing.

CONCLUSIONS

The findings suggest that residents of environments with a greater availability of tobacco outlets are more likely to start and/or sustain smoking, and less likely to quit.

If we offer it, will children buy it? Sales of healthy foods mirrored their availability in a community sport, commercial setting in Alberta, Canada

BACKGROUND

Community sports settings are often sources of unhealthy foods for children. Many managers in these settings are reluctant to increase availability of healthy food options because they perceive that healthy foods are not profitable. This study assessed the independent contribution of increased availability of healthy foods to their sales in a community sport, commercial context. Change in revenues per patron was also examined.

METHODS

The availability of healthy items was increased from 9.1% at baseline (35 days) to 25.0% during the intervention period (40 days), returning to 9.1% postintervention (6 days). Purchases of all patrons who bought foods/beverages (n=17,262 items sold) from two concessions at an outdoor community pool were assessed from baseline to postintervention. Chi-square analyses assessed differences in the proportion of healthy and unhealthy items sold, as well as in the proportion of total revenues per patron across periods. A trained observer also recorded qualitative observations pertaining to a subset of patrons' (n=221) dietary behaviors and activities.

RESULTS

Healthy items represented 7.7%, 22.7%, and 9.8% of sales during the preintervention, intervention, and postintervention periods, respectively (p<0.01). Sales of healthy beverages exceeded sales of all other product types. The proportion of total revenues per patron did not differ by period.

CONCLUSIONS

Food availability was an important environmental determinant of food purchasing behaviors in this community commercial context, given that sales of healthy foods closely mirrored their availability. Increased availability of healthy foods in community and commercial settings is important because concurrent changes within multiple environments will be required to improve children's dietary behaviors.

Field validation of food outlet databases: the Latino food environment in North Carolina, USA

OBJECTIVE

Obtaining valid, reliable measures of food environments that serve Latino communities is important for understanding barriers to healthy eating in this at-risk population.

DESIGN

The primary aim of the study was to examine agreement between retail food outlet data from two commercial databases, Nielsen TDLinx (TDLinx) for food stores and Dun & Bradstreet (D&B) for food stores and restaurants, relative to field observations of food stores and restaurants in thirty-one census tracts in Durham County, NC, USA. We also examined differences by proportion of Hispanic population (

SETTING

One hundred and seventy-four food stores and 337 restaurants in Durham County, NC, USA.

RESULTS

We found that overall sensitivity of food store listings in TDLinx was higher (64 %) than listings in D&B (55 %). Twenty-five food stores were characterized by auditors as Latino food stores, with 20 % identified in TDLinx, 52 % in D&B and 56 % in both sources. Overall sensitivity of restaurants (68 %) was higher than sensitivity of Latino restaurants (38 %) listed in D&B. Sensitivity did not differ substantially by Hispanic composition of neighbourhoods.

CONCLUSIONS

Our findings suggest that while TDLinx and D&B commercial data sources perform well for total food stores, they perform less well in identifying small and independent food outlets, including many Latino food stores and restaurants.

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Key Words

• Latino

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MESH Headings

• Databases, Factual
• Diet/economics
• Diet/ethnology
• Food Supply/economics
• Hispanic or Latino
• Humans
• Language
• North Carolina
• Residence Characteristics
• Restaurants

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Grants

• R01-HL 114091 NHLBI NIH HHS
• T32 HD07168-33 NICHD NIH HHS
• N01-HC-48050 NHLBI NIH HHS
• DK56350 NIDDK NIH HHS
• HHSN268201300027C NHLBI NIH HHS
• N01HC95095 NHLBI NIH HHS
• N01-HC-48049 NHLBI NIH HHS
• R01 HL114091 NHLBI NIH HHS
• N01HC48048 NHLBI NIH HHS
• R01 HL104580 NHLBI NIH HHS
• HHSN268201300026C NHLBI NIH HHS
• P30 ES010126 NIEHS NIH HHS
• N01-HC-48047 NHLBI NIH HHS
• N01HC48049 NHLBI NIH HHS
• N01-HC-95095 NHLBI NIH HHS
• HHSN268201300025C NHLBI NIH HHS
• HHSN268200900041C NHLBI NIH HHS
• HHSN268201300028C NHLBI NIH HHS
• T32 DK007686 NIDDK NIH HHS
• N01HC48050 NHLBI NIH HHS
• N01HC48047 NHLBI NIH HHS
• T32 HD007168 NICHD NIH HHS
• P30 DK056350 NIDDK NIH HHS
• N01-HC-48048 NHLBI NIH HHS
• R24 HD050924 NICHD NIH HHS
• HHSN268201300029C NHLBI NIH HHS
• R01-HL104580 NHLBI NIH HHS
• P2C HD050924 NICHD NIH HHS

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Affiliation(s)

Pasquale E Rummo University of North Carolina at Chapel Hill, Carolina Population Center, CB# 8120, University Square, 123 West Franklin Street, Chapel Hill, NC 27516-2524, USA
Penny Gordon-Larsen University of North Carolina at Chapel Hill, Carolina Population Center, CB# 8120, University Square, 123 West Franklin Street, Chapel Hill, NC 27516-2524, USA Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Sandra S Albrecht University of North Carolina at Chapel Hill, Carolina Population Center, CB# 8120, University Square, 123 West Franklin Street, Chapel Hill, NC 27516-2524, USA Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

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Identifying the effects of environmental and policy change interventions on healthy eating

Obesity has been characterized as a disease. Strategies to change the incidence and prevalence of this disease include a focus on changing physical and social environments, over and above individual-level strategies, using a multilevel or systems approach. We focus our attention on evidence published between 2008 and 2013 on the effectiveness of interventions in nutrition environments, i.e., environmental interventions designed to influence the intake of healthful foods and amount of energy consumed. An overarching socioecological framework that has guided much of this research was used to characterize different types of environmental strategies. Intervention examples in each area of the framework are provided with a discussion of key findings and related conceptual and methodological issues. The emphasis in this review is on adults, but clearly this literature is only one part of the picture. Much research has been focused on child-specific interventions, including environmental interventions. Some evidence suggests effectiveness of policy-based or other types of interventions that aim to regulate or restructure environments to promote healthy dietary choices, and these strategies would apply to both children and adults. Opportunities to evaluate these policy changes in adults' social and physical environments are rare. Much of the existing research has been with children. As conceptual and methodological issues continue to be identified and resolved, we hope that future research in this domain will identify environmental strategies that can be included in intervention toolboxes to build healthy nutrition environments for both adults and children.

A nutrition/health mindset on commercial Big Data and drivers of food demand in modern and traditional systems

Building greater reciprocity between traditional and modern food systems and better convergence of human and economic development outcomes may enable the production and consumption of accessible, affordable, and appealing nutritious food for all. Information being key to such transformations, this roadmap paper offers a strategy that capitalizes on Big Data and advanced analytics, setting the foundation for an integrative intersectoral knowledge platform to better inform and monitor behavioral change and ecosystem transformation. Building upon the four P's of marketing (product, price, promotion, placement), we examine digital commercial marketing data through the lenses of the four A's of food security (availability, accessibility, affordability, appeal) using advanced consumer choice analytics for archetypal traditional (fresh fruits and vegetables) and modern (soft drinks) product categories. We demonstrate that business practices typically associated with the latter also have an important, if not more important, impact on purchases of the former category. Implications and limitations of the approach are discussed.

Access to healthy food stores modifies effect of a dietary intervention

BACKGROUND

Recent evidence suggests that opening a grocery store in a food desert does not translate to better diet quality among community residents.

PURPOSE

This study evaluated the influence of proximity to a healthy food store on the effect of a dietary behavioral intervention on diet among obese adults randomized to either a high fiber or American Heart Association diet intervention.

METHODS

Participants were recruited from Worcester County, Massachusetts, between June 2009 and January 2012. Dietary data were collected via 24-hour recalls at baseline and 3, 6, and 12 months post-intervention. Based on in-store inspection data, a store was considered as having adequate availability of healthy foods if it had at least one item available in each of 20 healthy food categories. Linear models evaluated maximum change in dietary outcomes in relation to road distance from residence to the nearest June healthy food store. The analysis was conducted in January to June 2014.

RESULTS

On average, participants (N=204) were aged 52 years, BMI=34.9, and included 72% women and 89% non-Hispanic whites. Shorter distance to a healthy food store was associated with greater improvements in consumption of fiber (b=-1.07 g/day per mile, p<0.01) and fruits and vegetables (b=-0.19 servings/day per mile, p=0.03) with and without covariate adjustment.

CONCLUSIONS

The effectiveness of dietary interventions is significantly influenced by the presence of a supportive community nutrition environment. Considering the nationwide efforts on promotion of healthy eating, the value of improving community access to healthy foods should not be underestimated.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00911885.

Farmers' markets and the local food environment: identifying perceived accessibility barriers for SNAP consumers receiving temporary assistance for needy families (TANF) in an urban Oklahoma community

OBJECTIVE

To examine barriers to farmers' market (FM) use by Supplemental Nutrition Assistance Program (SNAP) consumers receiving Temporary Assistance for Needy Families.

DESIGN

Focus groups.

SETTING

An urban community in Oklahoma.

PARTICIPANTS

Supplemental Nutrition Assistance Program beneficiaries receiving Temporary Assistance for Needy Families (n = 64 across 8 focus groups).

PHENOMENON OF INTEREST

Perceptions about FM foods and barriers to FM use.

ANALYSIS

Transcript-based content analysis using the 5 dimensions of access framework.

RESULTS

Few participants ate fresh produce regularly and most appreciated the convenience of shopping at a supermarket. Farmers' markets were not perceived as available or accommodating to shopping needs and affordability and acceptability concerns were expressed. Few were aware of FMs that accepted SNAP. Emerging themes suggested residential segregation and cultural barriers to FM use.

CONCLUSIONS AND IMPLICATIONS

Farmers' market managers, community nutritionists, and researchers should develop interventions that correct common misperceptions about FM products, minimize access barriers, and increase awareness of SNAP payment options. Residential segregation and cultural barriers may have a role in FM use and should be explored further.

A systematic review on empowerment for healthy nutrition in health promotion

Objective

The present review aimed to identify and synthesize studies that used an empowerment approach within the field of healthy nutrition.

Design

A systematic review was conducted. Studies were identified by database searching (PubMed, PsycINFO, Web of Science and Psyndex). Searching, selecting and reporting were done according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) Statement.

Setting

Health promotion including the subject of healthy nutrition.

Subjects

Individuals from non-clinical populations.

Results

A total of 1226 studies were screened for eligibility, eight studies were finally included. Three studies used the empowerment approach within a qualitative research paradigm and five studies within (quasi-) experimental intervention studies. Heterogeneity in settings, samples and evaluation methods was high. Most studies referred to the key message of empowerment, i.e. taking control over one’s own life. However, the ways in which this key message was implemented in the interventions differed considerably.

Conclusions

The number of studies included was very low. Furthermore, most studies had some limitations in terms of reporting how the empowerment approach was actually applied. The empowerment approach still seems to be unfamiliar within the field of healthy nutrition.

Associations between BMI and home, school and route environmental exposures estimated using GPS and GIS: do we see evidence of selective daily mobility bias in children?

Background

This study examined whether objective measures of food, physical activity and built environment exposures, in home and non-home settings, contribute to children’s body weight. Further, comparing GPS and GIS measures of environmental exposures along routes to and from school, we tested for evidence of selective daily mobility bias when using GPS data.

Methods

This study is a cross-sectional analysis, using objective assessments of body weight in relation to multiple environmental exposures. Data presented are from a sample of 94 school-aged children, aged 5–11 years. Children’s heights and weights were measured by trained researchers, and used to calculate BMI z-scores. Participants wore a GPS device for one full week. Environmental exposures were estimated within home and school neighbourhoods, and along GIS (modelled) and GPS (actual) routes from home to school. We directly compared associations between BMI and GIS-modelled versus GPS-derived environmental exposures. The study was conducted in Mebane and Mount Airy, North Carolina, USA, in 2011.

Results

In adjusted regression models, greater school walkability was associated with significantly lower mean BMI. Greater home walkability was associated with increased BMI, as was greater school access to green space. Adjusted associations between BMI and route exposure characteristics were null. The use of GPS-actual route exposures did not appear to confound associations between environmental exposures and BMI in this sample.

Conclusions

This study found few associations between environmental exposures in home, school and commuting domains and body weight in children. However, walkability of the school neighbourhood may be important. Of the other significant associations observed, some were in unexpected directions. Importantly, we found no evidence of selective daily mobility bias in this sample, although our study design is in need of replication in a free-living adult sample.

Electronic supplementary material

The online version of this article (doi:10.1186/1476-072X-14-8) contains supplementary material, which is available to authorized users.

Food for thought: analysing the internal and external school food environment

Purpose

– Availability and access to food is a determinant of obesity. The purpose of this paper is to examine food availability within and outside of post-primary schools in Ireland.

Design/methodology/approach

– Data on the internal school food environment were collected from 63 post-primary schools using questionnaires. The external school food environment for these 63 schools was assessed by mapping food businesses within 1 km of schools, using a Geographic Information System (GIS). Food businesses were categorised based on type of food sold.

Findings

– A total of 68.3 per cent of schools had a canteen, 52.5 per cent had a small food shop and 37.1 per cent had a vending machine. A total of 32.7 per cent of schools reported selling chips (French fries) in their canteen while 44.2 per cent of schools reported selling energy-dense nutrient-poor foods in their school shop. Of the schools surveyed, there was an average of 3.89 coffee shops and sandwich bars, 3.65 full service restaurants, 2.60 Asian and other “ethnic” restaurants, 4.03 fast food restaurants, 1.95 supermarkets, 6.71 local shops and 0.73 fruit and vegetable retailers within a 1 km radius of the post-primary schools. Findings are presented by geography (urban/rural), disadvantage (Delivering Equality of Opportunity in School (DEIS)/non DEIS), gender (girls/boys/mixed) and food policy in place at the school (yes/no).

Practical implications

– These data will facilitate schools working on the framework for Health Promoting Schools in Ireland.

Social implications

– This work can contribute to current discussions on restricting accessibility to certain foods and food premises for school children.

Originality/value

– The study explores the internal and external school food environment. GIS have been used to link the external food environment to specific schools thus allowing a comprehensive analysis of the schools’ food environment. To the authors knowledge, this is the first time that both environments are explored simultaneously.

Determinants of dietary behavior among youth: an umbrella review

BACKGROUND

The literature on determinants of dietary behavior among youth is extensive and unwieldy. We conducted an umbrella review or review-of-reviews to present a comprehensive overview of the current knowledge.

METHODS

Therefore, we included systematic reviews identified in four databases (i.e. PubMed, PsycINFO, The Cochrane Library and Web of Science) that summarized determinants of observable child and adolescent dietary behaviors. Data extraction included a judgment of the importance of determinants, strength of evidence and evaluation of the methodological quality of the eligible reviews.

RESULTS

In total, 17 reviews were considered eligible. Whereas social-cognitive determinants were addressed most intensively towards the end of the 20th century, environmental determinants (particularly social and physical environmental) have been studied most extensively during the past decade, thereby representing a paradigm shift. With regard to environmental determinants, mixed findings were reported. Sedentary behavior and intention were found to be significant determinants of a wide range of dietary behaviors in most reviews with limited suggestive evidence due to the cross-sectional study designs. Other potential determinants such as automaticity, self-regulation and subjective norm have been studied in relatively few studies, but results are promising.

CONCLUSION

The multitude of studies conducted on potential determinants of dietary behavior provides quite convincing evidence of the importance of several determinants (i.e. quite some variables were significantly related to dietary behavior). However, because of the often used weak research designs in the studies covered in the available reviews, the evidence for true determinants is suggestive at best.

Should we use absolute or relative measures when assessing foodscape exposure in relation to fruit and vegetable intake? Evidence from a wide-scale Canadian study

OBJECTIVE

This paper explores which of absolute (i.e. densities of "healthy" and "unhealthy" food outlets taken separately) or relative (i.e. the percentage of "healthy" outlets) measures of foodscape exposure better predicts fruit and vegetable intake (FVI), and whether those associations are modified by gender and city in Canada.

METHODS

Self-reported FVI from participants of four cycles (2007-2010) of the repeated cross-sectional Canadian Community Health Survey living in the five largest metropolitan areas of Canada (n=49,403) was analyzed. Absolute and relative measures of foodscape exposure were computed at participants' residential postal codes. Linear regression models, both in the whole sample and in gender- and city-stratified samples, were used to explore the associations between exposure measures and FVI.

RESULTS

The percentage of healthy outlets was strongly associated with FVI among men both in Toronto/Montreal (β=0.012; P<0.001), and in Calgary/Ottawa/Vancouver (β=0.008; P<0.001), but not among women. Observed associations of absolute measures with FVI were either weak or faced multicollinearity issues. Overall, models with the relative measure showed the best fit.

CONCLUSIONS

Relative measures should be more widely used when assessing foodscape influences on diet. The absence of a single effect of the foodscape on diet positions sub-group analysis as a promising avenue for research.

Does food store access modify associations between intrapersonal factors and fruit and vegetable consumption?

BACKGROUND/OBJECTIVES

Existing theoretical frameworks suggest that healthy eating is facilitated by an individual's ability, motivation and environmental opportunities. It is plausible, although largely untested, that the importance of factors related to ability and motivation differ under varied environmental conditions. This study aimed to determine whether the magnitude of associations between fruit and vegetable consumption and intrapersonal factors (ability and motivation) were modified by differences in access to stores selling these items (environmental opportunities).

SUBJECTS/METHODS

Cross-sectional analysis of 4335 women from socioeconomically disadvantaged neighbourhoods in the state of Victoria, Australia. Self-reported fruit and vegetable consumption was assessed against a number of ability- and motivation-related factors. To examine whether associations were modified by store access, interactions with access to supermarkets and greengrocers within 2 km of participants' households were tested.

RESULTS

Of the two factors related to ability and seven factors related to motivation, almost all were associated with fruit and vegetable consumption. In general, associations were not modified by store access suggesting that these factors were not tempered by environmental opportunities.

CONCLUSIONS

This study provides little support for the hypothesis that the importance of intra-personal factors to fruit and vegetable consumption is modified by food store access. Further research on this topic is required to inform behaviour change interventions.

Built Environment Associations with Adiposity Parameters among Overweight and Obese Hispanic Youth

Objective

The purpose of this cross-sectional study was to establish neighborhood built environment correlates of adiposity as measured by dual X-ray absorptiometry. The utility and methodological gains of using this measure for built environment research were further investigated by comparing model fit across parallel models on body mass index z-scores and waist circumference.

Methods

Pre-existing data collected from 2001 to 2011 on 576 overweight and obese Hispanic youth were compiled with built environment data, and 2000 census data for analyses conducted in 2012. Walking-distance buffers were built around participants' residential locations. Variables for park space, food access, walkability, and neighborhood socio-cultural aspects were entered into a multivariate regression model predicting percent body fat. Parallel models were built for body mass index z-score, and waist circumference.

Results

Significant associations were found between percent body fat and supermarket access for boys, and percent body fat and increased park space and decreased neighborhood linguistic isolation for girls. Neighborhood socio-cultural characteristics accounted for more variance in obesity compared to body mass index z-score or waist circumference.

Conclusion

Park access, food environment, and neighborhood socio-cultural characteristics are independent contributors to body fat in children, and the contribution of these risks differs by gender. There are incremental gains to using a more accurate measure of body fat in built environment obesity studies.

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A study of obese/overweight Hispanic youth using dual X-ray absorptiometry

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Percent body fat (%BF) was modeled on neighborhood environment characteristics.

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Food access, walkability, parks, and socio-cultural aspects were related to %BF.

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The final model for %BF was used to predict BMI z-score and waist circumference.

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Using DXA to measure body fat has incremental gains in built environment research.

Worksite neighborhood and obesogenic behaviors: findings among employees in the Promoting Activity and Changes in Eating (PACE) trial

BACKGROUND

Understanding mechanisms linking neighborhood context to health behaviors may provide targets for increasing lifestyle intervention effectiveness. Although associations between home neighborhood and obesogenic behaviors have been studied, less is known about the role of worksite neighborhood.

PURPOSE

To evaluate associations between worksite neighborhood context at baseline (2006) and change in obesogenic behaviors of adult employees at follow-up (2007-2009) in a worksite randomized trial to prevent weight gain.

METHODS

Worksite property values were used as an indicator of worksite neighborhood SES (NSES). Worksite neighborhood built environment attributes associated with walkability were evaluated as explanatory factors in relationships among worksite NSES, diet, and physical activity behaviors of employees. Behavioral data were collected at baseline (2005-2007) and follow-up (2007-2009). Multilevel linear and logistic models were constructed adjusting for covariates and accounting for clustering within worksites. Product-of-coefficients methods were used to assess mediation. Analyses were performed after study completion (2011-2012).

RESULTS

Higher worksite NSES was associated with more walking (OR=1.16, 95% CI=1.03, 1.30, p=0.01). Higher density of residential units surrounding worksites was associated with more walking and eating five or more daily servings of fruits and vegetables, independent of worksite NSES. Residential density partially explained relationships among worksite NSES, fruit and vegetable consumption, and walking.

CONCLUSIONS

Worksite neighborhood context may influence employees' obesogenic behaviors. Furthermore, residential density around worksites could be an indicator of access to dietary and physical activity-related infrastructure in urban areas. This may be important given the popularity of worksites as venues for obesity prevention efforts.

Measuring food availability and accessibility among adolescents: Moving beyond the neighbourhood boundary

Geographic methods have provided insight about food location availability and accessibility in understanding neighbourhood variations in health. However, quantifying exposure to food locations within a pre-defined range of an individual's residence ignores locations outside of the residential neighbourhood encountered in daily life. Global positioning system (GPS) data enables exploration of multiple contextual influences on health. This study defines place in relation to behaviour, employing GPS data to 1) describe adolescent food environments within and outside of the residential buffer, 2) quantify actual food location visits, and 3) explore associations between availability and accessibility of food locations and dietary intake. Adolescents (N = 380; ages 12-16), wore GPS loggers for up to seven days. Availability and accessibility of food locations were defined by counts and distances to food locations within a 15-min walk (1 km) of home, as well as within 50 m of an adolescent's GPS track. We compared the proportion of food locations within the residential buffer to the proportion outside but within the GPS buffer. These proportions were compared to counts and distances to food locations actually visited. We explored associations between food location availability and accessibility with dietary intake variables. Food location availability and accessibility was greater and visits occurred more commonly outside of the residential buffer than within it. Food location availability and accessibility was greater for urban than suburban and rural adolescents. There were no associations between home-based measures of availability and accessibility and dietary intake and only one for GPS-based measures, with greater distance to convenience stores associated with greater fruit and vegetable consumption. This study provides important descriptive information about adolescent exposure to food locations. Findings confirm that traditional home-based approaches overestimate the importance of the neighbourhood food environment, but provide only modest evidence of linkages between the food environment beyond the residential neighbourhood boundary and dietary intake.

Evidence supporting a promotora-delivered entertainment education intervention for improving mothers' dietary intake: the Entre Familia: Reflejos de Salud Study

Entertainment education and the promotora model are 2 evidence-based health communication strategies. This study examined their combined effect on promoting healthy eating among mothers in a family-based intervention. Participants were 361 Mexican-origin families living in Imperial County, California, who were randomly assigned to an intervention or delayed treatment condition. The intervention involved promotoras (community health workers) who delivered 11 home visits and 4 telephone calls. Home visits included a 12-minute episode of a 9-part situation comedy depicting a family struggling with making healthy eating choices; an accompanying family workbook was reviewed to build skills and left with the family. Baseline and immediate postintervention data were collected from the mothers, including the primary outcome of daily servings of fruits and vegetables. Other dietary and psychosocial factors related to healthy eating were examined. At postintervention, mothers in the intervention reported increases in daily vegetable servings (p ≤ .05); however, no changes were observed in fruit consumption. Improvements were observed in behavioral strategies to increase fiber (p ≤ .001) and to decrease fat intake (p ≤ .001), unhealthy eating behaviors (p ≤ .001), and individual (p ≤ .05) and family-related (p ≤ .01) perceived barriers to healthy eating. Entertainment education and promotoras engaged families and improved mothers' diets. Further research should examine the dose needed for greater changes.

Food store owners' and managers' perspectives on the food environment: an exploratory mixed-methods study

BACKGROUND

Neighborhood characteristics such as poverty and racial composition are associated with inequalities in access to food stores and in the risk of obesity, but the pathways between food environments and health are not well understood. This article extends research on consumer food environments by examining the perspectives of food-store owners and managers.

METHODS

We conducted semistructured, open-ended interviews with managers and owners of 20 food stores in low-income, predominantly African American neighborhoods in Tallahassee, Florida (USA). The interviews were designed to elicit store managers' and owners' views about healthy foods, the local food environment, and the challenges and opportunities they face in creating access to healthy foods. We elicited perceptions of what constitutes "healthy foods" using two free-list questions. The study was designed and implemented in accord with principles of community-based participatory research.

RESULTS

Store owners' and managers' conceptions of "healthy foods" overlapped with public health messages, but (a) agreement about which foods are healthy was not widespread and (b) some retailers perceived processed foods such as snack bars and sugar-sweetened juice drinks as healthy. In semistructured interviews, store owners and managers linked the consumer food environment to factors across multiple levels of analysis, including: business practices such as the priority of making sales and the delocalization of decision-making, macroeconomic factors such as poverty and the cost of healthier foods, individual and family-level factors related to parenting and time constraints, and community-level factors such as crime and decline of social cohesion.

CONCLUSIONS

Our results link food stores to multilevel, ecological models of the food environment. Efforts to reshape the consumer food environment require attention to factors across multiple levels of analysis, including local conceptions of "healthy foods", the business priority of making sales, and policies and practices that favor the delocalization of decision making and constrain access to healthful foods.

Obesity and economic environments

This review summarizes current understanding of economic factors during the obesity epidemic and dispels some widely held, but incorrect, beliefs. Rising obesity rates coincided with increases in leisure time (rather than increased work hours), increased fruit and vegetable availability (rather than a decline in healthier foods), and increased exercise uptake. As a share of disposable income, Americans now have the cheapest food available in history, which fueled the obesity epidemic. Weight gain was surprisingly similar across sociodemographic groups or geographic areas, rather than specific to some groups (at every point in time; however, there are clear disparities). It suggests that if one wants to understand the role of the environment in the obesity epidemic, one needs to understand changes over time affecting all groups, not differences between subgroups at a given time. Although economic and technological changes in the environment drove the obesity epidemic, the evidence for effective economic policies to prevent obesity remains limited. Taxes on foods with low nutritional value could nudge behavior toward healthier diets, as could subsidies/discounts for healthier foods. However, even a large price change for healthy foods could close only part of the gap between dietary guidelines and actual food consumption. Political support has been lacking for even moderate price interventions in the United States and this may continue until the role of environmental factors is accepted more widely. As opinion leaders, clinicians play an important role in shaping the understanding of the causes of obesity.

Foodscapes of southern Ontario: neighbourhood deprivation and access to healthy and unhealthy food retail

OBJECTIVES

We examined whether access to retail sources of healthy and unhealthy food varies according to level of neighbourhood material deprivation in three Ontario regions and whether urban form characteristics help to explain any such variations.

METHODS

Food retail (FR) outlets were identified from a commercial database for 804 urban neighbourhoods in Toronto, Brampton/Mississauga and Hamilton, Ontario. The median number of healthy and unhealthy FR outlets and percentage of outlets that were unhealthy were derived using 720-metre network buffers based on dissemination blocks and aggregated up to neighbourhood level (census tract). The 2006 Canadian Census was used to derive a composite index of material deprivation and three urban form measures related to zoning and urbanization. Multivariate regression models assessed the association between material deprivation, urban form and each measure of FR access.

RESULTS

Compared with the least deprived areas, the most materially deprived neighbourhoods had 2 to 4 times more healthy and unhealthy FR outlets within 720 metres (~ a 10-minute walk) of where most people lived, with the exception of Toronto, where unhealthy FR was more plentiful in less deprived areas. Urban form measures attenuated these associations for Brampton/Mississauga and Hamilton more so than for Toronto. The percentage of unhealthy outlets was generally unrelated to level of neighbourhood deprivation or urban form characteristics.

CONCLUSION

More deprived neighbourhoods had greater access to both healthy and unhealthy FR outlets, with some variation across study regions. Plentiful access to local retail sources of unhealthy food suggests a possible point of intervention for healthy public policy.

Influences of the neighbourhood food environment on adiposity of low-income preschool-aged children in Los Angeles County: a longitudinal study

BACKGROUND

Few studies have examined the association between the food environment and adiposity in early childhood, a critical time for obesity prevention. The objective of this study was to examine the longitudinal association between neighbourhood food environment and adiposity among low-income preschool-aged children in a major metropolitan region in the USA.

METHODS

The study sample was 32 172 low-income preschool-aged children in Los Angeles County who had repeated weight and height measurements collected between ages 2 and 5 years through a federal nutrition assistance programme. We conducted multilevel longitudinal analyses to examine how spatial densities of healthy and unhealthy retail food outlets in the children's neighbourhoods were related to adiposity, as measured by weight-for-height z-score (WHZ), while controlling for neighbourhood-level income and education, family income, maternal education, and child's gender and race/ethnicity.

RESULTS

Density of healthy food outlets was associated with mean WHZ at age 3 in a non-linear fashion, with mean WHZ being lowest for those exposed to approximately 0.7 healthy food outlets per square mile and higher for lesser and greater densities. Density of unhealthy food outlets was not associated with child WHZ.

CONCLUSIONS

We found a non-linear relationship between WHZ and density of healthy food outlets. Research aiming to understand the sociobehavioural mechanisms by which the retail food environment influences early childhood obesity development is complex and must consider contextual settings.

Do minority and poor neighborhoods have higher access to fast-food restaurants in the United States?

BACKGROUND

Disproportionate access to unhealthy foods in poor or minority neighborhoods may be a primary determinant of obesity disparities. We investigated whether fast-food access varies by Census block group (CBG) percent black and poverty.

METHODS

We measured the average driving distance from each CBG population-weighted centroid to the five closest top ten fast-food chains and CBG percent black and percent below poverty.

RESULTS

Among 209,091 CBGs analyzed (95.1% of all US CBGs), CBG percent black was positively associated with fast-food access controlling for population density and percent poverty (average distance to fast-food was 3.56 miles closer (95% CI: -3.64, -3.48) in CBGs with the highest versus lowest quartile of percentage of black residents). Poverty was not independently associated with fast-food access. The relationship between fast-food access and race was stronger in CBGs with higher levels of poverty (p for interaction <0.0001).

CONCLUSIONS

Predominantly black neighborhoods had higher access to fast-food while poverty was not an independent predictor of fast-food access.

Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study

BACKGROUND

Policies that improve access to healthy, affordable foods may improve population health and reduce health disparities. In the United States most food access policy research focuses on urban communities even though residents of rural communities face disproportionately higher risk for nutrition-related chronic diseases compared to residents of urban communities. The purpose of this study was to (1) identify the factors associated with access to healthy, affordable food in rural communities in the United States; and (2) prioritize a meaningful and feasible rural food policy research agenda.

METHODS

This study was conducted by the Rural Food Access Workgroup (RFAWG), a workgroup facilitated by the Nutrition and Obesity Policy Research and Evaluation Network. A national sample of academic and non-academic researchers, public health and cooperative extension practitioners, and other experts who focus on rural food access and economic development was invited to complete a concept mapping process that included brainstorming the factors that are associated with rural food access, sorting and organizing the factors into similar domains, and rating the importance of policies and research to address these factors. As a last step, RFAWG members convened to interpret the data and establish research recommendations.

RESULTS

Seventy-five participants in the brainstorming exercise represented the following sectors: non-extension research (n = 27), non-extension program administration (n = 18), "other" (n = 14), policy advocacy (n = 10), and cooperative extension service (n = 6). The brainstorming exercise generated 90 distinct statements about factors associated with rural food access in the United States; these were sorted into 5 clusters. Go Zones were established for the factors that were rated highly as both a priority policy target and a priority for research. The highest ranked policy and research priorities include strategies designed to build economic viability in rural communities, improve access to federal food and nutrition assistance programs, improve food retail systems, and increase the personal food production capacity of rural residents. Respondents also prioritized the development of valid and reliable research methodologies to measure variables associated with rural food access.

CONCLUSIONS

This collaborative, trans-disciplinary, participatory process, created a map to guide and prioritize research about polices to improve healthy, affordable food access in rural communities.

Associations between neighbourhood environmental characteristics and obesity and related behaviours among adult New Zealanders

Background

The prevalence of adult obesity is escalating in most wealthy and middle income countries. Due to the magnitude of this issue, research and interventions at the individual-level abound. However, the limited success and high costs of such interventions has led to a growing recognition of the potential role of environmental factors in reducing obesity and promoting physical activity and healthy diets.

Methods

This study utilised individual-level data from the 2006/7 New Zealand Health Survey on obesity, physical activity, diet and socio-economic variables linked to geographic information from other sources on potentially aetiologically-relevant environmental factors, based on the respondent’s residential address. We fitted logistic regression models for eight binary measures of weight or weight-related behaviours: 1) overweight; 2) obesity; 3) overweight + obesity; 4) active at least 30 minutes a day for 5+ days per week; 5) active <30 minutes per week; 6) walk 150 minutes + per week; 7) walk <30 minutes per week; and 8) consumption of 5+ fruits and vegetables per day. We included a range of independent environmental characteristics of interest in separate models.

Results

We found that increased neighbourhood deprivation and decreased access to neighbourhood greenspace were both significantly associated with increased odds of overweight and/or obesity. The results for weight-related behaviours indicate that meeting the recommended level of physical activity per week was associated with urban/rural status, with higher activity in the more rural areas and a surprising tendency for less activity among those living in areas with higher levels of active travel to work. Increased access to greenspace was associated with high levels of walking, while decreased access to greenspace was associated with low levels of walking. There was also a significant trend for low levels of walking to be positively associated with neighbourhood deprivation. Results for adequate fruit and vegetable consumption show a significant urban/rural gradient, with more people meeting recommended levels in the more rural compared to more urban areas.

Conclusion

Similar to findings from other international studies, these results highlight greenspace as an amenable environmental factor associated with obesity/overweight and also indicate the potential benefit of targeted health promotion in both urban and deprived areas in New Zealand.

Food-group and nutrient-density intakes by Hispanic and Latino backgrounds in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanics are a heterogeneous group of individuals with a variation in dietary habits that is reflective of their cultural heritage and country of origin. It is important to identify differences in their dietary habits because it has been well established that nutrition contributes substantially to the burden of preventable diseases and early deaths in the United States.

OBJECTIVE

We estimated the distribution of usual intakes (of both food groups and nutrients) by Hispanic and Latino backgrounds by using National Cancer Institute methodology.

DESIGN

The Hispanic Community Health Study/Study of Latinos is a population-based cohort study that recruited participants who were 18-74 y of age from 4 US cities in 2008-2011 (Miami, Bronx, Chicago, and San Diego). Participants who provided at least one 24-h dietary recall and completed a food propensity questionnaire (n = 13,285) were included in the analyses. Results were adjusted for age, sex, field center, weekend, sequencing, and typical amount of intake.

RESULTS

Overall, Cubans (n = 2128) had higher intakes of total energy, macronutrients (including all subtypes of fat), and alcohol than those of other groups. Mexicans (n = 5371) had higher intakes of vitamin C, calcium, and fiber. Lowest intakes of total energy, macronutrients, folate, iron, and calcium were reported by Dominicans (n = 1217), whereas Puerto Ricans (n = 2176) had lowest intakes of vitamin C and fiber. Food-group servings reflected nutrient intakes, with Cubans having higher intakes of refined grains, vegetables, red meat, and fats and Dominicans having higher intakes of fruit and poultry, whereas Puerto Ricans had lowest intakes of fruit and vegetables. Central and South Americans (n = 1468 and 925, respectively) were characterized by being second in their reported intakes of fruit and poultry and the highest in fish intake in comparison with other groups.

CONCLUSION

Variations in diet noted in this study, with additional analysis, may help explain diet-related differences in health outcomes observed in Hispanics and Latinos.

The community and consumer food environment and children's diet: a systematic review

BACKGROUND

While there is a growing body of research on food environments for children, there has not been a published comprehensive review to date evaluating food environments outside the home and school and their relationship with diet in children. The purpose of this paper is to review evidence on the influence of the community and consumer nutrition environments on the diet of children under the age of 18 years.

METHODS

Our search strategy included a combination of both subject heading searching as well as natural language, free-text searching. We searched nine databases (MEDLINE, Web of Science, CINAHL, Embase, Scopus, ProQuest Public Health, PsycINFO, Sociological Abstracts, and GEOBASE) for papers published between 1995 and July 2013. Study designs were included if they were empirically-based, published scholarly research articles, were focused on children as the population of interest, fit within the previously mentioned date range, included at least one diet outcome, and exposures within the community nutrition environment (e.g., location and accessibility of food outlets), and consumer nutrition environment (e.g., price, promotion, and placement of food choices).

RESULTS

After applying exclusion and inclusion criteria, a total of 26 articles were included in our review. The vast majority of the studies were cross-sectional in design, except for two articles reporting on longitudinal studies. The food environment exposure(s) included aspects of the community nutrition environments, except for three that focused on the consumer nutrition environment. The community nutrition environment characterization most often used Geographic Information Systems to geolocate participants' homes (and/or schools) and then one or more types of food outlets in relation to these. The children included were all of school age. Twenty-two out of 26 studies showed at least one positive association between the food environment exposure and diet outcome. Four studies reported only null associations.

CONCLUSIONS

This review found moderate evidence of the relationship between the community and consumer nutrition environments and dietary intake in children up to 18 years of age. There is wide variation in measures used to characterize both the community and consumer nutrition environments and diet, and future research should work to decrease this heterogeneity.

Measuring the healthfulness of food retail stores: variations by store type and neighbourhood deprivation

Background

The consumer nutrition environment has been conceptualised as in-store environmental factors that influence food shopping habits. More healthful in-store environments could be characterised as those which promote healthful food choices such as selling good quality healthy foods or placing them in prominent locations to prompt purchasing. Research measuring the full-range of in-store environmental factors concurrently is limited.

Purpose

To develop a summary score of ‘healthfulness’ composed of nine in-store factors that influence food shopping behaviour, and to assess this score by store type and neighbourhood deprivation.

Methods

A cross-sectional survey of 601 retail food stores, including supermarkets, grocery stores and convenience stores, was completed in Hampshire, United Kingdom between July 2010 and June 2011. The survey measured nine variables (variety, price, quality, promotions, shelf placement, store placement, nutrition information, healthier alternatives and single fruit sale) to assess the healthfulness of retail food stores on seven healthy and five less healthy foods that are markers of diet quality. Four steps were completed to create nine individual variable scores and another three to create an overall score of healthfulness for each store.

Results

Analysis of variance showed strong evidence of a difference in overall healthfulness by store type (p < 0.001). Large and premium supermarkets offered the most healthful shopping environments for consumers. Discount supermarkets, ‘world’, convenience and petrol stores offered less healthful environments to consumers however there was variation across the healthfulness spectrum. No relationship between overall healthfulness and neighbourhood deprivation was observed (p = 0.1).

Conclusions

A new composite measure of nine variables that can influence food choices was developed to provide an overall assessment of the healthfulness of retail food stores. This composite score could be useful in future research to measure the relationship between main food store and quality of diet, and to evaluate the effects of multi-component food environment interventions.

A systematic review of the influence of the retail food environment around schools on obesity-related outcomes

The high prevalence of childhood obesity has led to questions about the influence of 'obesogenic' environments on children's health. Public health interventions targeting the retail food environment around schools have been proposed, but it is unclear if they are evidence based. This systematic review investigates associations between food outlets near schools and children's food purchases, consumption and body weight. We conducted a keyword search in 10 databases. Inclusion criteria required papers to be peer reviewed, to measure retailing around schools and to measure obesity-related outcomes among schoolchildren. Thirty papers were included. This review found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption, but some evidence of an effect on body weight. Given the general lack of evidence for association with the mediating variables of food purchases and consumption, and the observational nature of the included studies, it is possible that the effect on body weight is a result of residual confounding. Most of the included studies did not consider individual children's journeys through the food environment, suggesting that predominant exposure measures may not account for what individual children actually experience. These findings suggest that future interventions targeting the food environment around schools need careful evaluation.

Overcoming challenges to effectiveness of mobile markets in US food deserts

The purpose of this research is to investigate whether mobile food markets may be effective in facilitating healthy food choices in food deserts. We investigate who does and does not use mobile food markets and why, and whether mobile markets have the potential to alter attitudes and food choices, and if so, how? We use a focus group study at four sites in the US to ask groups of mobile market shoppers and non-shoppers about their shopping, cooking, and eating attitudes and behaviors. We find that mobile market shoppers eat significantly more servings of fruits and vegetables, however, both shoppers and non-shoppers perceive fruits and vegetables as luxury items, and both groups lack knowledge about what is a serving and what is the recommended number of servings per day. Both groups identified the following needs for mobile markets to be more successful: increased awareness and advertising; affordability; improved convenience by offering more stops and hours, as well as greater variety of items for one-stop shopping; emphasis on value and service; and building trust within communities.

Academy of Nutrition and Dietetics: Standards of professional performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems

Sustainability is the ability of a system to be maintained over the long term. Resilience is the ability of a system to withstand disturbances and continue to function in a sustainable manner. Issues of sustainability and resilience apply to all aspects of nutrition and dietetics practice, can be practiced at both the program and systems level, and are broader than any one specific practice setting or individual intervention. Given an increasing need to apply principles of sustainability and resilience to nutrition and dietetics practice, as well as growing interest among the public and by Registered Dietitian Nutritionists of health issues related to food and water systems, the Hunger and Environmental Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed the Standards of Professional Performance as a tool for Registered Dietitian Nutritionists working in sustainable, resilient, and healthy food and water systems to assess their current skill levels and to identify areas for further professional development in this emerging practice area. This Standards of Professional Performance document covers six standards of professional performance: quality in practice, competence and accountability, provision of services, application of research, communication and application of knowledge, and utilization and management of resources. Within each standard, specific indicators provide measurable action statements that illustrate how sustainable, resilient, and healthy food and water systems principles can be applied to practice. The indicators describe three skill levels (competent, proficient, and expert) for Registered Dietitian Nutritionists working in sustainable, resilient, and healthy food and water systems.

Objective and self-reported factors associated with food-environment perceptions and fruit-and-vegetable consumption: a multilevel analysis

Introduction

Few studies have assessed how people’s perceptions of their neighborhood environment compare with objective measures or how self-reported and objective neighborhood measures relate to consumption of fruits and vegetables.

Methods

A telephone survey of 4,399 residents of Philadelphia, Pennsylvania, provided data on individuals, their households, their neighborhoods (self-defined), their food-environment perceptions, and their fruit-and-vegetable consumption. Other data on neighborhoods (census tracts) or “extended neighborhoods” (census tracts plus 1-quarter–mile buffers) came from the US Census Bureau, the Philadelphia Police Department, the Southeastern Pennsylvania Transportation Authority, and the federal Supplemental Nutrition Assistance Program. Mixed-effects multilevel logistic regression models examined associations between food-environment perceptions, fruit-and-vegetable consumption, and individual, household, and neighborhood characteristics.

Results

Perceptions of neighborhood food environments (supermarket accessibility, produce availability, and grocery quality) were strongly associated with each other but not consistently or significantly associated with objective neighborhood measures or self-reported fruit-and-vegetable consumption. We found racial and educational disparities in fruit-and-vegetable consumption, even after adjusting for food-environment perceptions and individual, household, and neighborhood characteristics. Having a supermarket in the extended neighborhood was associated with better perceived supermarket access (adjusted odds ratio for having a conventional supermarket, 2.04 [95% CI, 1.68–2.46]; adjusted odds ratio for having a limited-assortment supermarket, 1.28 [95% CI, 1.02–1.59]) but not increased fruit-and-vegetable consumption. Models showed some counterintuitive associations with neighborhood crime and public transportation.

Conclusion

We found limited association between objective and self-reported neighborhood measures. Sociodemographic differences in individual fruit-and-vegetable consumption were evident regardless of neighborhood environment. Adding supermarkets to urban neighborhoods might improve residents’ perceptions of supermarket accessibility but might not increase their fruit-and-vegetable consumption.

Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study

OBJECTIVES

To examine the association between environmental exposure to takeaway food outlets, takeaway food consumption, and body weight, while accounting for home, work place, and commuting route environments.

DESIGN

Population based, cross sectional study, using data on individual participants' diet and weight, and objective metrics of food environment exposure.

PARTICIPANTS

Working adults participating in the Fenland Study, Cambridgeshire, UK (n = 5442, aged 29-62 years), who provided home and work addresses and commuting preferences. Takeaway food outlet exposure was derived using data from local authorities for individual environmental domains (at home, at work, and along commuting routes (the shortest route between home and work)), and for exposure in all three domains combined. Exposure was divided into quarters (Q); Q1 being the least exposed and Q4 being the most exposed.

MAIN OUTCOME MEASURES

Self reported consumption of takeaway type food (g/day; pizza, burgers, fried foods, and chips) using food frequency questionnaires, measured body mass index, and cut-offs for body mass index as defined by the World Health Organization.

RESULTS

In multiple linear regression models, exposure to takeaway food outlets was positively associated with consumption of takeaway food. Among domains at home, at work, and along commuting routes, associations were strongest in work environments (Q4 v Q1; β coefficient = 5.3 g/day, 95% confidence interval 1.6 to 8.7; P<0.05), with evidence of a dose-response effect. Associations between exposure in all three domains combined and consumption were greater in magnitude across quarters of exposure (Q4 v Q1; 5.7 g/day, 2.6 to 8.8; P<0.001), with evidence of a dose-response effect. Combined exposure was especially strongly associated with increased body mass index (Q4 v Q1; body mass index 1.21, 0.68 to 1.74; P<0.001) and odds of obesity (Q4 v Q1; odds ratio 1.80, 1.28 to 2.53; P<0.05). There was no evidence of effect modification by sex.

CONCLUSIONS

Exposure to takeaway food outlets in home, work, and commuting environments combined was associated with marginally higher consumption of takeaway food, greater body mass index, and greater odds of obesity. Government strategies to promote healthier diets through planning restrictions for takeaway food could be most effective if focused around the workplace.

Development and evaluation of a food environment survey in three urban environments of Kunming, China

BACKGROUND

Given the rapid pace of urbanization and Westernization and the increasing prevalence of obesity, there is a need for research to better understand the influence of the built environment on overweight and obesity in world's developing regions. Culturally-specific food environment survey instruments are important tools for studying changing food availability and pricing. Here, we present findings from an effort to develop and evaluate food environment survey instruments for use in a rapidly developing city in southwest China.

METHODS

We developed two survey instruments (for stores and restaurants), each designed to be completed within 10 minutes. Two pairs of researchers surveyed a pre-selected 1-km stretch of street in each of three socio-demographically different neighborhoods to assess inter-rater reliability. Construct validity was assessed by comparing the food environments of the neighborhoods to cross-sectional height and weight data obtained on 575 adolescents in the corresponding regions of the city.

RESULTS

273 food establishments (163 restaurants and 110 stores) were surveyed. Sit-down, take-out, and fast food restaurants accounted for 40%, 21% and 19% of all restaurants surveyed. Tobacco and alcohol shops, convenience stores and supermarkets accounted for 25%, 12% and 11%, respectively, of all stores surveyed. We found a high percentage of agreement between teams (>75%) for all categorical variables with moderate kappa scores (0.4-0.6), and no statistically significant differences between teams for any of the continuous variables. More developed inner city neighborhoods had a higher number of fast food restaurants and convenience stores than surrounding neighborhoods. Adolescents who lived in the more developed inner neighborhoods also had a higher percentage of overweight, indicating well-founded construct validity. Depending on the cutoff used, 19% to 36% of male and 10% to 22% of female 16-year old adolescents were found to be overweight.

CONCLUSIONS

The prevalence of overweight Chinese adolescents, and the food environments they are exposed to, deserve immediate attention. To our knowledge, these are the first food environment surveys developed specifically to assess changing food availability, accessibility, and pricing in China. These instruments may be useful in future systematic longitudinal assessments of the changing food environment and its health impact in China.

What does SNAP benefit usage tell us about food access in low-income neighborhoods?

Current GIS based research on food access has focused primarily on the proximity of food sources to places of residence in low-income communities, with relatively little attention given to actual practices of food procurement. This project addresses this issue by using dasymetric mapping techniques to develop fine scale estimates of benefit usage for the Supplemental Nutrition Assistance Program (SNAP) in the Twin Cities of Minneapolis and St. Paul, Minnesota, drawing from existing zip code level data on benefit distribution and redemptions. Based on this data, this research shows that while supermarkets receive almost all SNAP benefits in suburban areas, these stores have a smaller share of all SNAP redemptions in low-income core neighborhoods. In these latter areas, both convenience stores and mid-sized grocers (e.g., discount grocers, food cooperatives, ethnic markets) play a much larger role in residents' food shopping, even when supermarkets are also present. In addition, these core neighborhoods have a net "outflow" of SNAP dollars, meaning that residents of these areas receive more in benefits than is spent at neighborhood food retailers. This finding confirms existing research showing that low-income residents often travel outside their neighborhoods to get food, regardless of the presence or absence of supermarkets. Rather than simply increasing the number of large food outlets in low-access areas, this research suggests that efforts to improve food access and community health must take into account the geographically complex ways residents interact with the food system.

Construct validation of 4 food-environment assessment methods: adapting a multitrait-multimethod matrix approach for environmental measures

Few studies have assessed the construct validity of measures of neighborhood food environment, which remains a major challenge in accurately assessing food access. In this study, we adapted a psychometric tool to examine the construct validity of 4 such measures for 3 constructs. We used 4 food-environment measures to collect objective data from 422 Ontario, Canada, food stores in 2010. Residents' perceptions of their neighborhood food environment were collected from 2,397 households between 2009 and 2010. Objective and perceptual data were aggregated within buffer zones around respondents' homes (at 250 m, 500 m, 1,000 m, and 1,500 m). We constructed multitrait-multimethod matrices for each scale to examine construct validity for the constructs of food availability, food quality, and food affordability. Convergent validity between objective measures decreased with increasing geographic scale. Convergent validity between objective and subjective measures increased with increasing geographic scale. High discriminant validity coefficients existed between food availability and food quality, indicating that these two constructs may not be distinct in this setting. We conclude that the construct validity of food environment measures varies over geographic scales, which has implications for research, policy, and practice.