Dietary inequalities: what is the evidence for the effect of the neighbourhood food environment?

A comparative analysis of the restaurant consumer food environment in Rochester (NY, USA) and London (ON, Canada): assessing children's menus by neighbourhood socio-economic characteristics

OBJECTIVE

To assess restaurant children's menus for content and nutritional quality; and to investigate the relationship between the restaurant consumer food environment for children and neighbourhood-level socio-economic characteristics within and between one Canadian city and one US city.

DESIGN

Cross-sectional observational study.

SETTING

London, ON, Canada and Rochester, NY, USA.ParticipantsRestaurant children's menus were assessed, scored and compared using the Children's Menu Assessment tool. We quantified neighbourhood accessibility to restaurants by calculating 800 m road-network buffers around the centroid of each city census block and created a new Neighbourhood Restaurant Quality Index for Children (NRQI-C) comprising the sum of restaurant menu scores divided by the total number of restaurants within each area. After weighting by population, we examined associations between NRQI-C and neighbourhood socio-economic characteristics using correlations and multiple regression analyses.

RESULTS

Nutritional quality of children's menus was greater, on average, in Rochester compared with London. Only one variable remained significant in the regression analyses for both cities: proportion of visible minorities had a positive effect on neighbourhood NRQI-C scores in London, whereas the reverse was true in Rochester.

CONCLUSIONS

Results suggest the presence of a socio-economic disparity within Rochester, where children in more disadvantaged areas have poorer access to better nutritional quality restaurant choices. In London, results suggest an inverse relationship across the city where children in more disadvantaged areas have better access to better nutritional quality restaurant choices. Given these disparate results, research on restaurant nutritional quality for children requires additional consideration.

Social Norms Influencing the Local Food Environment as Perceived by Residents and Food Traders: The Heart Healthy Hoods Project

Exploring subjective elements of the food environment remains key to understand why and how residents purchase food. Our aim was to explore and describe the social norms relating to the local food environment and food purchasing behaviors, as perceived by residents and food traders in Madrid, Spain. This qualitative study took place in a middle socioeconomic status neighborhood of Madrid between January 2015 and May 2016. We conducted 35 semi-structured interviews. We used stratified purposive sampling to recruit residents, neighborhood workers (N = 20) and food traders (N = 15) representing different levels of involvement with food purchasing behaviors. We analyzed these data using an interpretative phenomenological analysis approach. Participants highlighted social aspects of the food environment in relation to food purchasing behaviors. First, interpersonal and relational food environment elements were emphasized, including trust and tradition. Participants also identified generational demographic trends in relation to changes in the way residents purchased food: the new pace of life and the lack of time to buy fresh food and to cook at home. All these elements were influenced by the economic crisis. Food environment interventions aiming to improve food purchasing behaviors and residents' diets should consider intermediate social aspects of the food environment like trust and tradition and the fast pace of life of younger generations.

Higher pricing of fresh produce is more likely in SNAP-Ed eligible neighborhoods when adjacent non-program eligible neighborhoods are mixed income

This analysis describes the socioeconomic attributes of neighborhoods adjacent to low-income neighborhoods with ≥50% of households that are Supplemental Nutrition Assistance Program Education (SNAP-Ed) eligible. It compares the pricing, availability, and quality of fresh produce between these neighborhoods in Los Angeles County. The Los Angeles County Department of Public Health utilized 2013–2014 community-level data from the Communities of Excellence in Nutrition, Physical Activity and Obesity Prevention (CX3) Project to examine the geographic patterns of fresh produce purchases and accessibility in SNAP-Ed eligible census tracts. Community indicators collected by CX3 included information on pricing, availability, and quality of fruits and vegetables from grocery stores (n = 108) in these eligible neighborhoods (n = 21). Correlation statistics were generated to explore the effects of adjacent neighborhoods' socioeconomic status on fruit and vegetable pricing, availability, and quality in the selected neighborhoods (“CX3 neighborhoods”). Poverty data were obtained from the United States Census' American Community Survey. Residents of CX3 neighborhoods that were surrounded by mixed income neighborhoods paid 43% more for fresh produce than CX3 neighborhoods surrounded by other similarly low-income neighborhoods (median produce price, $1.50 versus $1.05). Study results suggest that while quality of produce remains an issue, it is the higher pricing of fresh produce in CX3 neighborhoods – i.e., in the presence of other surrounding mixed income neighborhoods (those with relatively higher income) – that appeared to potentiate food access barriers. Future SNAP-Ed efforts should take this pricing pattern under consideration when designing, planning, and/or implementing nutrition-related programs in these neighborhoods.

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CX3 assessments provide environmental context to the delivery of SNAP-Ed services.

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Produce quality remains an issue in Los Angeles County's low-income neighborhoods.

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Low-income neighborhoods near mixed-income neighborhoods have higher priced produce.

Examination of how food environment and psychological factors interact in their relationship with dietary behaviours: test of a cross-sectional model

BACKGROUND

To improve population diet environmental strategies have been hailed the panacea because they require little agency or investment of personal resources; this contrasts with conventional strategies that rely on individuals to engage high levels of agency and make deliberate choices. There is an immediate need to improve understanding of the synergy between the psychological and environmental determinants of diet in order to optimise allocation of precious public health resources. This study examined the synergistic and relative association between a number of food environment and psychological factors and the dietary behaviours of a population sample of women with young children.

METHODS

Women in Hampshire were recruited from children's centres and asked about their demographic characteristics, psychological resources, dietary behaviours (food frequency questionnaire) and perceptions of healthy food access and affordability. Three local food environment factors were objectively assessed: i) spatial access to food outlets using activity spaces; ii) healthfulness of the supermarket where women did their main food shop, (based on nine in-store factors including price, placement and promotion on seven healthy and five less healthy foods); iii) nutrition environment of children's centres visited frequently by the women, assessed via staff-administered questionnaire. A theoretical model linking environmental factors to dietary behaviours, both directly and indirectly through three factors representing individual agency (psychological resources, perceived food affordability, perceived food accessibility), was tested using Structural Equation Modelling.

RESULTS

Complete data were available for 753 women. The environment of women's main supermarket was indirectly related to their dietary behaviours through psychological resources and perceived food affordability. Shopping at supermarkets classified as having a healthier in-store environment was associated with having greater psychological resources associated with healthy eating (standardised regression weight β = 0.14SD, p = 0.03) and fewer food affordability concerns (β = - 0.14SD, p = 0.01), which in turn related to healthier dietary behaviours (β = 0.55SD, < 0.001 and β = - 0.15, p = 0.01 respectively). The three food environment factors were not directly associated with dietary behaviour (p > 0.3). The overall model fit was good (CFI = 0.91, RMSEA = 0.05 [0.05, 0.06]).

CONCLUSIONS

This pathway analysis identified three focal points for intervention and suggests that high-agency interventions targeting individual psychological resources when combined with low-agency supermarket environment interventions may confer greater benefits on dietary behaviours than either intervention alone.

Food safety and nutrition for low-income urbanites: exploring a social justice dilemma in consumption policy

Equitable access to healthy food is a critical challenge in urban Asia. Food safety governance promotes modern supermarkets over more traditional markets, but supermarkets are associated with unequal access to food. This study investigates how retail policies driven by food safety impact the diets of the urban poor in Hanoi, Vietnam. We do this by linking food retail infrastructures with the food shopping practices and measured dietary intake of 400 women. Our results reveal sub-optimal dietary diversity and reliance on foods sourced through traditional markets, which do not provide formal food safety guarantees. Modern channels supply formal food safety guarantees, but are mainly frequented for purchasing ultra-processed foods. The paper uncovers a conflicting duality governing food security and suggests that the public responsibility for ensuring access of the poor to nutritious and safe foods requires a more diverse retail policy approach.

Ethnic Differences in Magnesium Intake in U.S. Older Adults: Findings from NHANES 2005⁻2016

Magnesium plays a crucial role in hundreds of bodily processes relevant to aging, but consumption of dietary magnesium intake has been shown to be inadequate in a large proportion of older adults. Identifying groups at risk of low magnesium intake is important for informing targeted advice. Using data from the National Health and Nutrition Examination Survey (NHANES) 2005–2016, we examined the association between ethnicity (Caucasian/African American/Hispanic/other) and magnesium intake in a large representative sample of U.S. older adults (≥65 y, n = 5682, mean (SD) 72.9 (0.10) y). Analyses adjusted for total energy intake and a range of relevant covariates. Overall, 83.3% of participants were not meeting the recommended level of dietary magnesium intake, ranging from 78.1% of other ethnic groups to 90.6% of African Americans. In the fully adjusted model, magnesium intake was lower among African American older adults (−13.0 mg/d, 95% CI: −18.8 to −7.2), and higher among Hispanics (14.0 mg/d, 95% CI: 7.5 to 20.5) and those from other ethnic groups (17.2, 95% CI: 3.8 to 30.5) compared with Caucasian older adults. These results highlight the need for targeted interventions to increase magnesium intake in U.S. older adults, with a focus on African Americans, in order to reduce the burden of morbidity and ethnic inequalities in health in later life.

Bringing Healthy Retail to Urban "Food Swamps": a Case Study of CBPR-Informed Policy and Neighborhood Change in San Francisco

In urban "food swamps" like San Francisco's Tenderloin, the absence of full-service grocery stores and plethora of corner stores saturated with tobacco, alcohol, and processed food contribute to high rates of chronic disease. We explore the genesis of the Tenderloin Healthy Corner Store Coalition, its relationship with health department and academic partners, and its contributions to the passage and implementation of a healthy retail ordinance through community-based participatory research (CBPR), capacity building, and advocacy. The healthy retail ordinance incentivizes small stores to increase space for healthy foods and decrease tobacco and alcohol availability. Through Yin's multi-method case study analysis, we examined the partnership's processes and contributions to the ordinance within the framework of Kingdon's three-stage policymaking model. We also assessed preliminary outcomes of the ordinance, including a 35% increase in produce sales and moderate declines in tobacco sales in the first four stores participating in the Tenderloin, as well as a "ripple effect," through which non-participating stores also improved their retail environments. Despite challenges, CBPR partnerships led by a strong community coalition concerned with bedrock issues like food justice and neighborhood inequities in tobacco exposure may represent an important avenue for health equity-focused research and its translation into practice.

Neighborhood socioeconomic status and adherence to dietary recommendations among Finnish adults: A retrospective follow-up study

Neighborhood socioeconomic status (SES) is associated with dietary habits among the residents, but few studies have examined this association separately among long-term residents and movers. We calculated cumulative neighborhood SES score weighted by residential time in each address over 6 years for non-movers (n = 7704) and movers (n = 8818) using national grid database. Increase in average neighborhood SES was associated with higher adherence to dietary recommendations in both groups. Among the movers, an upward trajectory from low to high neighborhood SES was also associated with better adherence. Our findings suggest high SES areas might offer healthier food environments than low SES areas.

The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers

OBJECTIVE

To evaluate the secondary impact of a multilevel, child-focused, obesity intervention on food-related behaviours (acquisition, preparation, fruit and vegetable (FV) consumption) on youths' primary caregivers.

DESIGN

B'More Healthy Communities for Kids (BHCK) group-randomized controlled trial promoted access to healthy foods and food-related behaviours through wholesaler and small store strategies, peer mentor-led nutrition education aimed at youths, and social media and text messaging targeting their adult caregivers. Measures included caregivers' (n 516) self-reported household food acquisition frequency for FV, snacks and grocery items over 30 d, and usual FV consumption in a sub-sample of 226 caregivers via the NCI FV Screener. Hierarchical models assessed average treatment effects (ATE). Treatment-on-the-treated-effect (TTE) analyses evaluated correlation between behavioural change and exposure to BHCK. Exposure scores at post-assessment were based on self-reported viewing of BHCK materials and participating in activities.

SETTING

Thirty Baltimore City low-income neighbourhoods, USA.ParticipantsAdult caregivers of youths aged 9-15 years.

RESULTS

Of caregivers, 90·89 % were female; mean age 39·31 (sd 9·31) years. Baseline mean (sd) intake (servings/d) was 1·30 (1·69) fruits and 1·35 (1·05) vegetables. In ATE, no significant intervention effect was found on caregivers' food-related behaviours. In TTE, each point increase in BHCK exposure score (range: 0-6·9) increased caregivers' daily fruit consumption by 0·2 servings (0·24 (se 0·11); 95 % CI 0·04, 0·47). Caregivers reporting greater social media exposure tripled their daily fruit intake (3·16 (se 0·92); 95 % CI 1·33, 4·99) and increased their frequency of unhealthy food purchasing v. baseline.

CONCLUSIONS

Child-focused community-based nutrition interventions may also benefit family members' fruit intake. Child-focused interventions should involve adult caregivers and intervention effects on family members should be assessed. Future multilevel studies should consider using social media to improve reach and engage caregiver participants.

Does cultural capital contribute to educational inequalities in food consumption in the Netherlands? A cross-sectional analysis of the GLOBE-2011 survey

BACKGROUND

The importance of culture for food consumption is widely acknowledged, as well as the fact that culture-based resources ("cultural capital") differ between educational groups. Since current explanations for educational inequalities in healthy and unhealthy food consumption (e.g. economic capital, social capital) are unable to fully explain this gradient, we aim to investigate a new explanation for educational inequalities in healthy food consumption, i.e. the role of cultural capital.

METHODS

Data were obtained cross-sectionally by a postal survey among participants of the GLOBE study in the Netherlands in 2011 (N = 2953; response 67.1%). The survey measured respondents' highest attained educational level, food-related cultural capital (institutionalised, objectivised and incorporated cultural capital), economic capital (e.g. home ownership, financial strain), social capital (e.g. social support, health-related social leverage, interpersonal relationships), and frequency of consumption of healthy and unhealthy food products. Two general outcomes (overall healthy food consumption, and overall unhealthy food consumption), and seven specific food consumption outcomes were constructed, and prevalence ratios (PR) were estimated in Poisson regression models with robust variance.

RESULTS

Cultural capital was significantly associated with all food outcomes, also when social and economic capital were taken into account. Those with low levels of cultural capital were more likely to have a lower overall healthy food consumption (PR 1.35, 95% CI 1.22-1.49), a lower consumption of whole wheat bread (PR 1.21, 95% CI 1.05-1.38), vegetables (PR 1.55, 95% CI 1.40-1.71), and meat-substitutes and fish (PR 1.74, 95% CI 1.53-1.97), and a higher consumption of fried food (PR 1.59, 95% CI 1.31-1.93). Social capital was positively associated with overall healthy food consumption, whole wheat bread consumption, and the consumption of fish and meat-substitutes, and economic capital with none of the outcomes. The PR of the lowest educational group to have a low overall healthy food consumption decreased from 1.48 (95% CI 1.28-1.73) to 1.22 (95% CI 1.04-1.43) when cultural, social and economic capital were taken into account.

CONCLUSIONS

Cultural capital contributed to the explanation of educational inequalities in food consumption in The Netherlands, over and above economic and social capital. The socialisation processes through which cultural capital is acquired could offer new entry-points for the promotion of healthy food consumption among low educational groups.

Neighborhood food environment, dietary fatty acid biomarkers, and cardiac arrest risk

We explored links between food environments, dietary intake biomarkers, and sudden cardiac arrest in a population-based longitudinal study using cases and controls accruing between 1990 and 2010 in King County, WA. Surprisingly, presence of more unhealthy food sources near home was associated with a lower 18:1 trans-fatty acid concentration (-0.05% per standard deviation higher count of unhealthy food sources, 95% Confidence Interval [CI]: 0.01, 0.09). However, presence of more unhealthy food sources was associated with higher odds of cardiac arrest (Odds Ratio [OR]: 2.29, 95% CI: 1.19, 4.41 per standard deviation in unhealthy food outlets). While unhealthy food outlets were associated with higher cardiac arrest risk, circulating 18:1 trans fats did not explain the association.

Using spatial analysis to examine best placement of electronic benefit transfer services at farmers' markets in Honolulu County, Hawaii, USA

OBJECTIVE

Farmers' market interventions are a popular strategy for addressing chronic disease disparities in low-income neighbourhoods. With limited resources, strategic targeting of interventions is critical. The present study used spatial analysis to identify where market interventions have the greatest impact on healthy food access within a geographic region.

DESIGN

All farmers' markets in a mixed urban/rural county were mapped and those that accepted Supplemental Nutrition Assistance Program (SNAP) electronic benefit transfer (EBT) cards identified. Households were grouped into small neighbourhoods and mapped. The area of 'reasonable access' around each market (walking distance (0·8 km; 0·5mile) in urban areas, driving distance (15 min) in rural areas) was calculated using spatial analysis. The percentage of county low-income households within a market's access area, and the percentage of county SNAP-participating households within an EBT-accepting market's access area, were calculated. The ten neighbourhoods with the most low-income households and with the most SNAP-participating households were then identified, their access areas calculated and mapped, and those lacking access identified. County-level gains resulting from improving market accessibility in these areas were calculated.

SUBJECTS

None.

SETTING

Honolulu County, Hawaii, USA.

RESULTS

Only 44 % of SNAP-participating households had EBT-market access. Six of the ten highest SNAP-participant neighbourhoods lacked access. Improving access for these neighbourhoods increased county-level access by 23 %. Market access for low-income households was 74 %. Adding markets to these low-income neighbourhoods without market access increased county-level access by 4 %.

CONCLUSIONS

Geographic identification of market access demographics, and strategic targeting of EBT interventions, could improve regional access to healthy foods.

Promoting access to fresh fruits and vegetables through a local market intervention at a subway station

OBJECTIVE

Alternative food sources (AFS) such as local markets in disadvantaged areas are promising strategies for preventing chronic disease and reducing health inequalities. The present study assessed how sociodemographic characteristics, physical access and fruit and vegetable (F&V) consumption are associated with market use in a newly opened F&V market next to a subway station in a disadvantaged neighbourhood.

DESIGN

Two cross-sectional surveys were conducted among adults: (i) on-site, among shoppers who had just bought F&V and (ii) a telephone-based population survey among residents living within 1 km distance from the market.

SETTING

One neighbourhood in Montreal (Canada) with previously limited F&V offerings.

SUBJECTS

Respectively, 218 shoppers and 335 residents completed the on-site and telephone-based population surveys.

RESULTS

Among shoppers, 23 % were low-income, 56 % did not consume enough F&V and 54 % did not have access to a car. Among all participants living 1 km from the market (n 472), market usage was associated (OR; 95 % CI) with adequate F&V consumption (1·86; 1·10, 3·16), living closer to the market (for distance: 0·86; 0·76, 0·97), having the market on the commute route (2·77; 1·61, 4·75) and not having access to a car (2·96; 1·67, 5·26).

CONCLUSIONS

When implemented in strategic locations such as transport hubs, AFS like F&V markets offer a promising strategy to improve F&V access among populations that may be constrained in their food acquisition practices, including low-income populations and those relying on public transportation.

Examining the interaction of fast-food outlet exposure and income on diet and obesity: evidence from 51,361 UK Biobank participants

BACKGROUND

Household income (as a marker of socioeconomic position) and neighbourhood fast-food outlet exposure may be related to diet and body weight, which are key risk factors for non-communicable diseases. However, the research evidence is equivocal. Moreover, understanding the double burden of these factors is a matter of public health importance. The purpose of this study was to test associations of neighbourhood fast-food outlet exposure and household income, in relation to frequency of consumption of processed meat and multiple measures of adiposity, and to examine possible interactions.

METHODS

We employed an observational, cross-sectional study design. In a cohort of 51,361 adults aged 38-72 years in Greater London, UK, we jointly classified participants based on household income (£/year, four groups) and GIS-derived neighbourhood fast-food outlet proportion (counts of fast-food outlets as a percentage of all food outlets, quartiles). Multivariable regression models estimated main effects and interactions (additive and multiplicative) of household income and fast-food outlet proportion on odds of self-reported frequent processed meat consumption (> 1/week), measured BMI (kg/m2), body fat (%), and odds of obesity (BMI ≥ 30).

RESULTS

Income and fast-food proportion were independently, systematically associated with BMI, body fat, obesity and frequent processed meat consumption. Odds of obesity were greater for lowest income participants compared to highest (OR = 1.54, 95% CI: 1.41, 1.69) and for those most-exposed to fast-food outlets compared to least-exposed (OR = 1.51, 95% CI: 1.40, 1.64). In jointly classified models, lowest income and highest fast-food outlet proportion in combination were associated with greater odds of obesity (OR = 2.43, 95% CI: 2.09, 2.84), with relative excess risk due to interaction (RERI = 0.03). Results were similar for frequent processed meat consumption models. There was no evidence of interaction on a multiplicative scale between fast-food outlet proportion and household income on each of BMI (P = 0.230), obesity (P = 0.054) and frequent processed meat consumption (P = 0.725).

CONCLUSIONS

Our study demonstrated independent associations of neighbourhood fast-food outlet exposure and household income, in relation to diet and multiple objective measures of adiposity, in a large sample of UK adults. Moreover, we provide evidence of the double burden of low income and an unhealthy neighbourhood food environment, furthering our understanding of how these factors contribute jointly to social inequalities in health.

Associations between home and school neighbourhood food environments and adolescents’ fast-food and sugar-sweetened beverage intakes: findings from the Olympic Regeneration in East London (ORiEL) Study

Objective

To examine associations between availability of fast-food restaurants and convenience stores in the home and school neighbourhoods, considered separately and together, and adolescents’ fast-food and sugar-sweetened beverage (SSB) intakes.

Design

Cross-sectional observational study.

Setting

East London, UK.

Subjects

Adolescents (n3089; aged 13–15 years) from the Olympic Regeneration in East London (ORiEL) Study self-reported their weekly frequency of fast-food and SSB consumption. We used food business addresses collected from local authority registers to derive absolute (counts) and relative (proportions) exposure measures to fast-food restaurants and convenience stores within 800 m from home, school, and home and school combined. Associations between absolute and relative measures of the food environment and fast-food and SSB intakes were assessed using Poisson regression models with robust standard errors.

Results

Absolute exposure to fast-food restaurants or convenience stores in the home, school, or combined home and school neighbourhoods was not associated with any of the outcomes. High SSB intake was associated with relative exposure to convenience stores in the residential neighbourhood (risk ratio=1·45; 95 % CI 1·08, 1·96) and in the home and school neighbourhoods combined (risk ratio=1·69; 95 % CI 1·11, 2·57).

Conclusions

We found no evidence of an association between absolute exposure to fast-food restaurants and convenience stores around home and school and adolescents’ fast-food and SSB intakes. Relative exposure, which measures the local diversity of the neighbourhood food environment, was positively associated with SSB intake. Relative measures of the food environment may better capture the environmental risks for poor diet than absolute measures.

Food environments and dietary intakes among adults: does the type of spatial exposure measurement matter? A systematic review

BACKGROUND

The relationships between food environments and dietary intake have been assessed via a range of methodologically diverse measures of spatial exposure to food outlets, resulting in a largely inconclusive body of evidence, limiting informed policy intervention.

OBJECTIVE

This systematic review aims to evaluate the influence of methodological choice on study outcomes by examining the within-study effect of availability (e.g., counts) versus accessibility (e.g., proximity) spatial exposure measures on associations with diet.

METHODS

(PROSPERO registration: CRD42018085250). PubMed, Web of Science, Scopus and ScienceDirect databases were searched for empirical studies from 1980 to 2017, in the English language, involving adults and reporting on the statistical association between a dietary outcome and spatial exposure measures of both availability and accessibility. Studies were appraised using an eight-point quality criteria with a narrative synthesis of results.

RESULTS

A total of 205 associations and 44 relationships (i.e., multiple measures of spatial exposure relating to a particular food outlet type and dietary outcome) were extracted from 14 eligible articles. Comparative measures were dominated by counts (availability) and proximity (accessibility). Few studies compared more complex measures and all counts were derived from place-based measures of exposure. Sixteen of the 44 relationships had a significant effect involving an availability measure whilst only 8 had a significant effect from an accessibility measure. The largest effect sizes in relationships were mostly for availability measures. After stratification by scale, availability measure had the greatest effect size in 139 of the 176 pairwise comparisons. Of the 33% (68/205) of associations that reached significance, 53/68 (78%) were from availability measures. There was no relationship between study quality and reported study outcomes.

CONCLUSIONS

The limited evidence suggests that availability measures may produce significant and greater effect sizes than accessibility measures. However, both availability and accessibility measures may be important concepts of spatial exposure depending on the food outlet type and dietary outcome examined. More studies reporting on multi-method effects are required to differentiate findings by the type of spatial exposure assessment and build an evidence base regarding the appropriateness and robustness of measures under different circumstances.

A Census of Midsize to Large Supermarkets in Toronto: A Cross-Sectional Analysis of the Consumer Nutrition Environment

OBJECTIVE

Assess the consumer nutrition environment in midsize to large supermarkets by supermarket type and area-level socioeconomic variables.

DESIGN

Cross-sectional census of 257 supermarkets using the Toronto Nutrition Environment Measures Survey in Stores.

SETTING

Toronto, Canada.

VARIABLES MEASURED

Availability; price and linear shelf space of fruits and vegetables vs energy-dense snack foods by supermarket type; after-tax, low-income measure; and neighborhood improvement area.

ANALYSIS

Multivariate linear regression.

RESULTS

There was a high availability of fruits (7.7 of 8) and vegetables (9.5 of 11). There was similar linear shelf space for fruits and vegetables vs energy-dense snack foods (ratio, 1.1 m). Adjusted fruit prices were lowest in quintiles 1 (β = -$1.30; P = .008), 2 (β = -$1.41; P = .005), and 3 (β = -$1.89; P < .001) vs quintile 5 (lowest percentage of people living with low income) and in ethnic (β = -$3.47; P < .001) and discount stores (β = -$5.64; P < .001) vs conventional. Adjusted vegetable prices were lowest in quintiles 2 (β = -$1.87; P = .04), 3 (β = -$1.78; P = .03), and 4 (β = -$2.65; P = .001) vs quintile 5 and in ethnic (β = -$7.10; P < .001) and discount (β = -$5.49; P < .001) stores. They were highest in other (β = + $3.08; P = .003) vs conventional stores. Adjusted soda and chips prices were lower in discount (β = -$1.16; P < .001) and higher in other stores (β = + $0.67; P < .001) vs conventional.

CONCLUSIONS AND IMPLICATIONS

Findings do not indicate inequities in shelf space, availability, or price across diverse neighborhoods. Practitioners can use findings to help consumers navigate supermarkets to make healthy choices.

Examining community and consumer food environments for children: An urban-suburban-rural comparison in Southwestern Ontario

The aim of this study is to evaluate how retail food environments for children in the City of London and Middlesex County, Ontario, Canada, vary according to level of urbanicity and level of socioeconomic distress. Urbanicity in this study is defined as a neighbourhood's designation as urban, suburban, or rural. We assessed community food environments (e.g., the type, location, and accessibility of food outlets) using 800m and 1600m network buffers (school zones) around all public and private elementary schools, and we calculated and compared density of junk food opportunities (JFO) (e.g., fast food and full-service restaurants, grocery stores, and convenience stores) within each school zone in urban, suburban and rural settings. The study also assessed consumer food environments (e.g., the price, promotion, placement, and availability of healthy options and nutrition information) through restaurant children's menu audits using the Children's Menu Assessment tool. Results suggest JFO density is greater around elementary schools in areas with higher levels of socioeconomic distress and urbanicity, while urbanicity is also associated with greater use of branded marketing and inclusion of an unhealthy dessert on children's menus.

Evaluation of an Educational Initiative to Promote Shopping at Farmers' Markets Among the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants in New York City

Public Health Solutions' (PHS) Neighborhood WIC (The Special Supplemental Nutrition Program for Women, Infants, and Children) serves approximately 43,000 women and families at eight locations in high-need communities in New York City. Farmers' markets (FMs) exist in many low-income areas, and, coupled with incentives and benefits, are viable venues for WIC participants to purchase affordable produce. During the 2015 FM season (July-November), PHS launched a campaign to change participants' knowledge, attitudes, and shopping habits at FMs. WIC center staff were provided with educational materials, were trained to educate participants on FM locations and how to use their benefits at FMs, and provided tours for participants at nearby markets. To assess changes in knowledge, attitudes, and behaviors, staff administered surveys to 404 matched participants before and after the initiative. For all variables below, McNemar's test was conducted and demonstrated statistically significant increases from pre-season to post-season (p < 0.001 for all variables). After the initiative compared to before, a higher percentage of participants had heard of FM Nutrition Program (FMNP) checks (51% pre-74% post) and of Health Bucks (13-24%). Additionally, a higher percentage knew that WIC checks can be used at FMs (38-53%), knew that Supplemental Nutrition Assistance Program (SNAP/EBT) can be used at FMs (20-32%), had shopped at a FM (58-75%), and had used their FMNP checks at a FM (48-66%). These results suggest that promoting the use of WIC and SNAP benefits at FMs resulted in positive change.

Neighborhood social and economic change and retail food environment change in Madrid (Spain): The heart healthy hoods study

This study explores the association between neighborhood social and economic change from 2009 to 2013 and changes in the retail food environment from 2013 to 2017 in Madrid (Spain). We classified neighborhoods into four types: decreasing SES, new housing/gentrifying, increasing SES, and aging (population and housing). Food store data was obtained from a retail spaces census and classified as supermarket, specialized small store, or fruit and vegetable store. Compared to aging areas, new housing/gentrifying and areas with increasing SES had a higher baseline presence and proportion of supermarkets and a lower proportion of specialized stores and fruit and vegetable stores. Areas with decreasing SES had an initially higher presence and proportion of fruit and vegetable stores but showed a declining trend in both presence and proportion of fruit and vegetable stores.

Is in utero exposure to maternal socioeconomic disadvantage related to offspring ovarian reserve in adulthood?

BACKGROUND

Because the ovarian follicle pool is established in utero, adverse exposures during this period may be especially impactful on the size and health of the initial follicle endowment, potentially shaping trajectories of ovarian follicle loss and the eventual onset of menopause. Building on a robust literature linking socioeconomic status (SES) and menopausal timing, the current study examined adverse prenatal exposures related to maternal SES, hypothesizing that greater maternal socioeconomic disadvantage would be associated with lower ovarian reserve in the adult offspring.

METHODS

In a healthy, community-based sub-sample (n = 350) of reproductive age participants in the OVA Study (2006-2011), prenatal maternal SES was examined in relation to two biomarkers of ovarian reserve, antimullerian hormone (AMH) and antral follicle count (AFC). Prenatal maternal SES was assessed indirectly using maternal addresses abstracted from participant birth certificates, geocoded, and linked to US Census-derived variables, including neighborhood-level characteristics: education (% of individuals with a HS diploma); poverty (% of families below the poverty line); unemployment (% of individuals > 16 years who are unemployed); and income (median family income).

RESULTS

In separate covariate-adjusted linear regression models (following the backward elimination of main effects with P > .10), greater maternal neighborhood education was related to higher ovarian reserve as marked by higher levels of offspring AMH (beta = .142, P < .001) and AFC (beta = .092, P < .10) with models accounting for 19.6% and 21.5% of the variance in AMH and AFC, respectively. In addition, greater maternal neighborhood poverty was related to lower ovarian reserve as marked by lower offspring AMH (beta = -.144, P < .01), with the model accounting for 19.5% of the variance in AMH.

CONCLUSIONS

Maternal socioeconomic disadvantage measured indirectly at the neighborhood level was associated with lower ovarian reserve among the adult offspring, independently of offspring SES and other potential confounding factors. This suggests SES-related adversity exposures may have a detrimental impact on the size or health of the initial follicle endowment, leading to accelerated follicle loss over time.

Growth In SNAP Retailers Was Associated With Increased Client Enrollment In Georgia During The Great Recession

Policies to improve food accessibility in underserved areas often use direct financial incentives to attract new food retailers. Our analysis of data on the Supplemental Nutrition Assistance Program (SNAP) in Georgia before and after the Great Recession suggests that increased program enrollment improves access to food for SNAP beneficiaries by acting as an indirect subsidy to retailers. We divided food stores into four categories: large, midsize, small, and specialty retailers. Between 2008 and 2011 the number of SNAP enrollees increased by 87 percent, and between 2007 and 2014 the number of SNAP retailers in Georgia increased by 82 percent, primarily because of growth in the number of authorized small retailers. Inside metropolitan Atlanta, changes in the numbers of SNAP enrollees and authorized retailers were positively and significantly associated for small retailers. For the areas outside of metropolitan Atlanta, the association between changes in numbers of enrollees and authorized retailers was strongest for small retailers; more modest associations were also seen for large and specialty retailers. Policy makers should consider how retailers' sensitivity to and reliance on SNAP funding can be leveraged to improve not only food availability, but also access to healthy foods.

Frequency of Intake and Type of Away-from- Home Foods Consumed Are Associated with Diet Quality in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Background

Away-from-home foods (AFHFs) influence diet quality, a modifiable obesity risk factor, with limited generalizable evidence in Hispanic/Latino adults.

Objective

We investigated associations between AFHF intake with diet quality and overweight or obesity among US Hispanic/Latino adults.

Methods

Cross-sectional baseline (2008-2011) analyses included adults (n = 16,045) aged 18-74 y in the national Hispanic Community Health Study/Study of Latinos. Participants self-reported AFHF consumption frequency from 10 different settings and dietary intake (2-d 24-h recall). The Alternate Healthy Eating Index-2010 (AHEI-2010) was used to measure diet quality; higher scores indicated a healthier diet and scores were categorized into tertiles. WHO classifications categorized overweight [body mass index (BMI; kg/m2): 25.0-29.9] and obesity (BMI ≥30). Multivariate-adjusted associations of AFHF frequency or type with AHEI-2010, overweight, or obesity were assessed by using complex survey logistic regression (ORs and 95% CIs).

Results

Almost half of participants (47.1%) reported eating AFHFs ≥5 times/wk. The mean ± SE AHEI-2010 score was 47.5 ± 0.2. More than one-third (37.2%) were classified as overweight and 39.6% classified as obese. Compared with consuming AFHFs ≥5 times/wk, consuming AFHFs <1 time/wk or 1-2 times/wk was associated with greater odds of being in higher AHEI-2010 tertiles, indicating a healthier diet [<1 time/wk-tertile 2: OR (95% CI): 1.6 (1.4, 1.9); tertile 3: 2.5 (2.1, 3.1); 1-2 times/wk-tertile 2: OR (95% CI): 1.4 (1.2, 1.6); tertile 3: 1.5 (1.2, 1.8)]. Consumption of AFHFs ≥1 time/wk from each AFHF setting, compared with consumption of any AFHFs <1 time/wk was associated with lower odds of being in higher AHEI-2010 tertiles. Increasing AFHF intake frequency was not associated with odds of overweight or obesity. Eating from on-street vendors ≥1 time/wk was associated with obesity (OR: 1.5; 95% CI: 1.1, 2.0).

Conclusions

Consumption of AFHFs was prevalent among Hispanic/Latino adults and was associated with poorer diet quality. Findings may help to identify dietary targets to improve diet quality and prevent obesity in US Hispanics/Latinos.

Spatial access to food: Retiring the food desert metaphor

The food desert metaphor has been widely used over the past few decades as a way to identify regions as being at risk for having little or no access to healthy food. While the simplicity of the metaphor is attractive, this article argues that its usefulness to researchers interested in understanding the relationship between the geography of healthy food opportunities and dietary behaviours is limited. More nuanced approaches to incorporating geography into food access studies, like including transportation, economic factors, and time use, in addition to considering other dimensions of accessibility, are warranted.

Mobile produce market influences access to fruits and vegetables in an urban environment

Objective

To assess the influence of a mobile produce market (MPM) on fruit and vegetable access.

Design

Novel application of a structured assessment (five dimensions of access framework) to examine fruit and vegetable access through self-administered surveys on shopping behaviours, and perceptions and experiences of shopping at the MPM.

Setting

Low-income neighbourhoods with limited access to fruits and vegetables.

Subjects

Older (≥60 years) and younger (18–59·9 years) shoppers.

Results

Participants were more likely to be women and non-White, one-third lived alone and nearly half were older adults. Compared with younger, older participants had different shopping behaviours: tended to purchase food for one person (P < 0·001), be long-term shoppers (P=0·002) and use electronic benefit transfer (EBT) cards (P=0·012). Older adults were more likely to like the market location (P=0·03), while younger adults were more likely to want changes in location (P=0·04), more activities (P=0·04), taste sampling (P=0·05) and nutritional counselling (P=0·01). The MPM captured all dimensions of access: availability, indicated by satisfaction with the produce variety for nearly one-third of all participants; accessibility, indicated by participants travelling <1 mile (<1·6 km; 72·2 %) and appreciation of location (72·7 %); affordability, indicated by satisfaction with price (47·6 %); acceptability, indicated by appreciation of produce quality (46·2 %); and accommodation, indicated by satisfaction with safety of location (30·1 %) and high EBT use among older adults (41·8 %).

Conclusions

MPM may influence fruit and vegetable access in low-income urban neighbourhoods by facilitating the five dimensions of access and may especially benefit older adults and individuals living alone.

A spatial analysis of dietary patterns in a large representative population in the north of The Netherlands - the Lifelines cohort study

BACKGROUND

Diet is an important modifiable risk factor for chronic diseases. In the search for effective strategies to improve dietary patterns in order to promote healthy ageing, new approaches considering contextual factors in public health medicine are warranted. The aim of this study is to examine the spatial clustering of dietary patterns in a large representative sample of adults.

METHODS

Dietary patterns were defined on the basis of a 111 item Food Frequency Questionnaire among n = 117,570 adults using principal components analysis. We quantified the spatial clustering of dietary pattern scores at the neighborhood level using the Global Moran's I spatial statistic, taking into consideration individual demographic and (neighborhood) socioeconomic indicators.

RESULTS

Four dietary patterns explaining 27% of the variance in dietary data were extracted in this population and named the "bread and cookies" pattern, the "snack" pattern, the "meat and alcohol" pattern and the "vegetable, fruit and fish" pattern. Significant spatial clustering of high (hot spot) and low (cold spot) dietary pattern scores was found for all four dietary patterns irrespective of age and gender differences. Educational attainment and neighborhood income explained the global clustering to some extent, although clustering at smaller regional scales persisted.

CONCLUSION

The significant region-specific hot and cold spots of the four dietary patterns illustrate the existence of regional "food cultures" and underscore the need for interventions targeted at the sub-national level in order to tackle unhealthy dietary behavior and to stimulate people to make healthy dietary choices.

Understanding bias in relationships between the food environment and diet quality: the Coronary Artery Risk Development in Young Adults (CARDIA) study

BACKGROUND

The relationship between food environment exposures and diet behaviours is unclear, possibly because the majority of studies ignore potential residual confounding.

METHODS

We used 20 years (1985-1986, 1992-1993 2005-2006) of data from the Coronary Artery Risk Development in Young Adults (CARDIA) study across four US cities (Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; Oakland, California) and instrumental variables (IV) regression to obtain causal estimates of longitudinal associations between the percentage of neighbourhood food outlets (per total food outlets within 1 km network distance of respondent residence) and an a priori diet quality score, with higher scores indicating higher diet quality. To assess the presence and magnitude of bias related to residual confounding, we compared results from causal models (IV regression) to non-causal models, including ordinary least squares regression, which does not account for residual confounding at all and fixed-effects regression, which only controls for time-invariant unmeasured characteristics.

RESULTS

The mean diet quality score across follow-up was 63.4 (SD=12.7). A 10% increase in fast food restaurants (relative to full-service restaurants) was associated with a lower diet quality score over time using IV regression (β=-1.01, 95% CI -1.99 to -0.04); estimates were attenuated using non-causal models. The percentage of neighbourhood convenience and grocery stores (relative to supermarkets) was not associated with diet quality in any model, but estimates from non-causal models were similarly attenuated compared with causal models.

CONCLUSION

Ignoring residual confounding may generate biased estimated effects of neighbourhood food outlets on diet outcomes and may have contributed to weak findings in the food environment literature.

Accessibility of fast food outlets is associated with fast food intake. A study in the Capital Region of Denmark

Literature suggests that people living in areas with a wealth of unhealthy fast food options may show higher levels of fast food intake. Multilevel logistic regression analyses were applied to examine the association between GIS-located fast food outlets (FFOs) and self-reported fast food intake among adults (+ 16 years) in the Capital Region of Denmark (N = 48,305). Accessibility of FFOs was measured both as proximity (distance to nearest FFO) and density (number of FFOs within a 1km network buffer around home). Odds of fast food intake ≥ 1/week increased significantly with increasing FFO density and decreased significantly with increasing distance to the nearest FFO for distances ≤ 4km. For long distances (>4km), odds increased with increasing distance, although this applied only for car owners. Results suggest that Danish health promotion strategies need to consider the contribution of the built environment to unhealthy eating.

Diabetes prevention among American Indians: the role of self-efficacy, risk perception, numeracy and cultural identity

Background

According to the Risk Perception Attitude (RPA) framework, classifying people according to their perceptions of disease risk and their self-efficacy beliefs allows us to predict their likelihood for engaging in preventive behaviors. Health interventions can then be targeted according to RPA group. We applied the framework to type 2 diabetes prevention behaviors among American Indians and expanded it to include culture and numeracy.

Methods

Using a cross-sectional study design, we surveyed a sample of Northern Plains American Indians in a reservation community setting on self-reported perceptions of diabetes risk, objective diabetes risk, self-efficacy, engagement in healthy behaviors, knowledge of diabetes risk factors, and covariates including demographics, numeracy, and cultural identity. We used the RPA framework to classify participants into four groups based on their perceptions of risk and self-efficacy. Analyses of variance and covariance estimated inter-group differences in behaviors associated with type 2 diabetes prevention.

Results

Among 128 participants, our only finding consistent with the RPA framework was that self-efficacy and risk perception predicted knowledge about diabetes risk factors. We found limited evidence for the influence of cultural identity within the RPA framework. Overall, participants had lower numeracy skills which tended to be associated with inaccurate perceptions of higher levels of risk.

Conclusions

The theoretical framework may benefit from inclusion of further contextual factors that influence these behaviors. Attention to numeracy skills stands out in our study as an important influence on the RPA framework, highlighting the importance of attending to numeracy when targeting and tailoring risk information to participants segmented by the RPA framework.

Investigating the importance of the local food environment for fruit and vegetable intake in older men and women in 20 UK towns: a cross-sectional analysis of two national cohorts using novel methods

BACKGROUND

Local neighbourhood environments can influence dietary behavior. There is limited evidence focused on older people who are likely to have greater dependence on local areas and may suffer functional limitations that amplify any neighbourhood impact.

METHODS

Using multi-level ordinal regression analysis we investigated the association between multiple dimensions of neighbourhood food environments (captured by fine-detail, foot-based environmental audits and secondary data) and self-reported frequency of fruit and vegetable intake. The study was a cross-sectional analysis nested within two nationally representative cohorts in the UK: the British Regional Heart Study and the British Women's Heart and Health Study. Main exposures of interest were density of food retail outlets selling fruits and vegetables, the density of fast food outlets and a novel measure of diversity of the food retail environment.

RESULTS

A total of 1124 men and 883 women, aged 69 - 92 years, living in 20 British towns were included in the analysis. There was strong evidence of an association between area income deprivation and fruit and vegetable consumption, with study members in the most deprived areas estimated to have 27% (95% CI: 7, 42) lower odds of being in a higher fruit and vegetable consumption category relative to those in the least deprived areas. We found no consistent evidence for an association between fruit and vegetable consumption and a range of other food environment domains, including density of shops selling fruits and vegetables, density of premises selling fast food, the area food retail diversity, area walkability, transport accessibility, or the local food marketing environment. For example, individuals living in areas with greatest fruit and vegetable outlet density had 2% (95% CI: -22, 21) lower odds of being in a higher fruit and vegetable consumption category relative to those in areas with no shops.

CONCLUSIONS

Although small effect sizes in environment-diet relationships cannot be discounted, this study suggests that older people are less influenced by physical characteristics of neighbourhood food environments than is suggested in the literature. The association between area income deprivation and diet may be capturing an important social aspect of neighbourhoods that influence food intake in older adults and warrants further research.

Supermarket access, transport mode and BMI: the potential for urban design and planning policy across socio-economic areas

OBJECTIVE

To investigate dietary intake, BMI and supermarket access at varying geographic scales and transport modes across areas of socio-economic disadvantage, and to evaluate the implementation of an urban planning policy that provides guidance on spatial access to supermarkets.

DESIGN

Cross-sectional study used generalised estimating equations to investigate associations between supermarket density and proximity, vegetable and fruit intake and BMI at five geographic scales representing distances people travel to purchase food by varying transport modes. A stratified analysis by area-level disadvantage was conducted to detect optimal distances to supermarkets across socio-economic areas. Spatial distribution of supermarket and transport access was analysed using a geographic information system.

SETTING

Melbourne, Australia.

SUBJECTS

Adults (n 3128) from twelve local government areas (LGA) across Melbourne.

RESULTS

Supermarket access was protective of BMI for participants in high disadvantaged areas within 800 m (P=0·040) and 1000 m (P=0·032) road network buffers around the household but not for participants in less disadvantaged areas. In urban growth area LGA, only 26 % of dwellings were within 1 km of a supermarket, far less than 80-90 % of dwellings suggested in the local urban planning policy. Low public transport access compounded disadvantage.

CONCLUSIONS

Rapid urbanisation is a global health challenge linked to increases in dietary risk factors and BMI. Our findings highlight the importance of identifying the most appropriate geographic scale to inform urban planning policy for optimal health outcomes across socio-economic strata. Urban planning policy implementation in disadvantaged areas within cities has potential for reducing health inequities.

Does exposure to the food environment differ by socioeconomic position? Comparing area-based and person-centred metrics in the Fenland Study, UK

Background

Retail food environments (foodscapes) are a recognised determinant of eating behaviours and may contribute to inequalities in diet. However, findings from studies measuring socioeconomic inequality in the foodscape have been mixed, which may be due to methodological differences. The aim of this cross-sectional study was to compare exposure to the foodscape by socioeconomic position using different measures, to test whether the presence, direction or amplitude of differences was sensitive to the choice of foodscape metric or socioeconomic indicator.

Methods

A sample of 10,429 adults aged 30–64 years with valid home address data were obtained from the Fenland Study, UK. Of this sample, 7270 participants also had valid work location data. The sample was linked to data on food outlets obtained from local government records. Foodscape metrics included count, density and proximity of takeaway outlets and supermarkets, and the percentage of takeaway outlets relative to all food outlets. Exposure metrics were area-based (lower super output areas), and person-centred (proximity to nearest; Euclidean and Network buffers at 800 m, 1 km, and 1 mile). Person-centred buffers were constructed using home and work locations. Socioeconomic status was measured at the area-level (2010 Index of Multiple Deprivation) and the individual-level (highest educational attainment; equivalised household income). Participants were classified into socioeconomic groups and average exposures estimated. Results were analysed using the statistical and percent differences between the highest and lowest socioeconomic groups.

Results

In area-based measures, the most deprived areas contained higher takeaway outlet densities (p < 0.001). However, in person-centred metrics lower socioeconomic status was associated with lower exposure to takeaway outlets and supermarkets (all home-based exposures p < 0.001) and socioeconomic differences were greatest at the smallest buffer sizes. Socioeconomic differences in exposure was similar for home and combined home and work measures. Measuring takeaway exposure as a percentage of all outlets reversed the socioeconomic differences; the lowest socioeconomic groups had a higher percentage of takeaway outlets compared to the middle and highest groups (p < 0.001).

Conclusions

We compared approaches to measuring socioeconomic variation in the foodscape and found that the association was sensitive to the metric used. In particular, the direction of association varied between area- and person-centred measures and between absolute and relative outlet measures. Studies need to consider the most appropriate measure for the research question, and may need to consider multiple measures as a single measure may be context dependent.

Greater access to healthy food outlets in the home and school environment is associated with better dietary quality in young children

OBJECTIVE

To explore associations between dietary quality and access to different types of food outlets around both home and school in primary school-aged children.

DESIGN

Cross-sectional observational study.

SETTING

Hampshire, UK.

SUBJECTS

Children (n 1173) in the Southampton Women's Survey underwent dietary assessment at age 6 years by FFQ and a standardised diet quality score was calculated. An activity space around each child's home and school was created using ArcGIS. Cross-sectional observational food outlet data were overlaid to derive four food environment measures: counts of supermarkets, healthy specialty stores (e.g. greengrocers), fast-food outlets and total number of outlets, and a relative measure representing healthy outlets (supermarkets and specialty stores) as a proportion of total retail and fast-food outlets.

RESULTS

In univariate multilevel linear regression analyses, better diet score was associated with exposure to greater number of healthy specialty stores (β=0·025 sd/store: 95 % CI 0·007, 0·044) and greater exposure to healthy outlets relative to all outlets in children's activity spaces (β=0·068 sd/10 % increase in healthy outlets as a proportion of total outlets, 95 % CI 0·018, 0·117). After adjustment for mothers' educational qualification and level of home neighbourhood deprivation, the relationship between diet and healthy specialty stores remained robust (P=0·002) while the relationship with the relative measure weakened (P=0·095). Greater exposure to supermarkets and fast-food outlets was associated with better diet only in the adjusted models (P=0·017 and P=0·014, respectively).

CONCLUSIONS

The results strengthen the argument for local authorities to increase the number of healthy food outlets to which young children are exposed.

The relationship between dietary quality and the local food environment differs according to level of educational attainment: A cross-sectional study

There is evidence that food outlet access differs according to level of neighbourhood deprivation but little is known about how individual circumstances affect associations between food outlet access and diet. This study explored the relationship between dietary quality and a measure of overall food environment, representing the balance between healthy and unhealthy food outlet access in individualised activity spaces. Furthermore, this study is the first to assess effect modification of level of educational attainment on this relationship. A total of 839 mothers with young children from Hampshire, United Kingdom (UK) completed a cross-sectional survey including a 20-item food frequency questionnaire to measure diet and questions about demographic characteristics and frequently visited locations including home, children’s centre, general practitioner, work, main food shop and physical activity location. Dietary information was used to calculate a standardised dietary quality score for each mother. Individualised activity spaces were produced by creating a 1000m buffer around frequently visited locations using ArcGIS. Cross-sectional observational food outlet data were overlaid onto activity spaces to derive an overall food environment score for each mother. These scores represented the balance between healthy and unhealthy food outlets using weightings to characterise the proportion of healthy or unhealthy foods sold in each outlet type. Food outlet access was dominated by the presence of unhealthy food outlets; only 1% of mothers were exposed to a healthy overall food environment in their daily activities. Level of educational attainment moderated the relationship between overall food environment and diet (mid vs low, p = 0.06; high vs low, p = 0.04). Adjusted stratified linear regression analyses showed poorer food environments were associated with better dietary quality among mothers with degrees (β = -0.02; 95%CI: -0.03, -0.001) and a tendency toward poorer dietary quality among mothers with low educational attainment, however this relationship was not statistically significant (β = 0.01; 95%CI: -0.01, 0.02). This study showed that unhealthy food outlets, like takeaways and convenience stores, dominated mothers’ food outlet access, and provides some empirical evidence to support the concept that individual characteristics, particularly educational attainment, are protective against exposure to unhealthy food environments. Improvements to the imbalance of healthy and unhealthy food outlets through planning restrictions could be important to reduce dietary inequalities.

Creating Integrated Strategies for Increasing Access to Healthy Affordable Food in Urban Communities: A Case Study of Intersecting Food Initiatives

In New York and other cities, substantial evidence documents that community food environments interact with inequitable allocation of power, wealth, and services to shape the distribution of diet-related diseases and food insecurity. This case study shows how one Central Brooklyn community organization, Bedford Stuyvesant Restoration Corporation, has launched multiple coordinated food initiatives in order to reduce the burden of food-related health problems and boost community development. The report used standard case study methods to document the implementation of the New York City Food and Fitness Partnership in Central Brooklyn. The case study shows how two distinct strands of activities, a Farm to Early Care Program that ultimately brought fresh food to 30 child care centers, and a food hub that sought to make fresh local food more available in Central Brooklyn, intersected and reinforced each other. It also shows how organizational, community, and municipal resources and policies in some cases supported these initiatives and in others served as obstacles. Finally, the case study shows that multiple coordinated strategies have the potential to empower low-income Black and Latino communities to act to make local food environments healthier and more equitable.

Higher densities of fast-food and full-service restaurants are not associated with obesity prevalence

Background: The obesity epidemic in the United States has been mirrored by an increase in calories consumed outside of the home and by expansions in the numbers of, and portion sizes at, both fast-food restaurants (FFRs) and full-service restaurants (FSRs), leading some to blame the epidemic on the restaurant industry. If this were indeed true, one would predict that greater per capita densities of FFRs and FSRs would lead to greater obesity prevalence.Objective: We evaluated the population-level association between both FSRs and FFRs and the prevalence of obesity and calculated the proportion of calories consumed in these establishments.Design: In this ecological cross-sectional study, we used county-level data (aggregate-level data) for obesity prevalence across the mainland United States in 2012 and matched these data to county-level per capita densities of FFRs and FSRs in the same year. Multiple linear regression was used to determine the relation between the prevalence of obesity and the densities of FFRs and FSRs after adjustment for confounding factors.Results: Contrary to expectations, obesity prevalence was highly significantly negatively related to the densities of both FFRs and FSRs (combined-effect R² = 0.195). This was principally because greater numbers of both FFRs and FSRs were located in areas in which individuals were on average wealthier and more educated. When we normalized for these factors (and additional socioeconomic variables), the associations between restaurant densities and obesity effectively disappeared (pooled R² = 0.008). Our calculations showed that the percentage of total calories consumed in FFRs and FSRs is a mean of only 15.9% of the total intake (maximum: 22.6%).Conclusions: Variations in the densities of FFRs and FSRs are not linked to the prevalence of obesity in the United States, and food consumed in these establishments is responsible for <20% of total energy intake. This finding has implications for policy decisions regarding how we aim to tackle the obesity epidemic.

The moderating role of food cue sensitivity in the behavioral response of children to their neighborhood food environment: a cross-sectional study

Background

Neighborhood food cues have been inconsistently related to residents’ health, possibly due to variations in residents’ sensitivity to such cues. This study sought to investigate the degree to which children’s predisposition to eat upon exposure to food environment and food cues (external eating), could explain differences in strength of associations between their food consumption and the type of food outlets and marketing strategies present in their neighborhood.

Methods

Data were obtained from 616 6–12 y.o. children recruited into a population-based cross-sectional study in which food consumption was measured through a 24-h food recall and responsiveness to food cues measured using the external eating scale. The proportion of food retailers within 3 km of residence considered as “healthful” was calculated using a Geographical Information System. Neighborhood exposure to food marketing strategies (displays, discount frequency, variety, and price) for vegetables and soft drinks were derived from a geocoded digital marketing database. Adjusted mixed models with spatial covariance tested interaction effects of food environment indicators and external eating on food consumption.

Results

In children with higher external eating scores, healthful food consumption was more positively related to vegetable displays, and more negatively to the display and variety of soft drinks. No interactions were observed for unhealthful food consumption and no main effects of food environment indicators were found on food consumption.

Conclusions

Children differ in their responsiveness to marketing-related visual food cues on the basis of their external eating phenotype. Strategies aiming to increase the promotion of healthful relative to unhealthful food products in stores may be particularly beneficial for children identified as being more responsive to food cues.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0540-9) contains supplementary material, which is available to authorized users.

Association between distance to nearest supermarket and provision of fruits and vegetables in English nurseries

With 796,500 places available for children in England, pre-school nurseries could serve as an important setting for population-wide dietary intervention. It is critical to understand the determinants of healthy food provision in this setting, which may include access to food stores. This study examined the association between objective, GIS-derived supermarket proximity and fruit and vegetable serving frequency, using data from 623 English nurseries. Overall, 116 (18%) nurseries served fruits and vegetables infrequently (<2-3 times/week), but provision differed by supermarket proximity. In adjusted multivariable regression models, nurseries farthest from their nearest supermarket (Q5, 1.7-19.8km) had 2.38 (95% CI 1.01-5.63) greater odds of infrequent provision. Our results suggest that supermarket access may be important for nurseries in meeting fruit and vegetable provision guidelines. We advance a growing body of international literature, for the first time linking the food practices of institutions to their neighbourhood food retail context.

Exploring the influence of local food environments on food behaviours: a systematic review of qualitative literature

Objective

Systematic reviews investigating associations between objective measures of the food environment and dietary behaviours or health outcomes have not established a consistent evidence base. The present paper aims to synthesise qualitative evidence regarding the influence of local food environments on food and purchasing behaviours.

Design

A systematic review in the form of a qualitative thematic synthesis.

Setting

Urban localities.

Subjects

Adults.

Results

Four analytic themes were identified from the review including community and consumer nutrition environments, other environmental factors and individual coping strategies for shopping and purchasing decisions. Availability, accessibility and affordability were consistently identified as key determinants of store choice and purchasing behaviours that often result in less healthy food choices within community nutrition environments. Food availability, quality and food store characteristics within consumer nutrition environments also greatly influenced in-store purchases. Individuals used a range of coping strategies in both the community and consumer nutrition environments to make optimal purchasing decisions, often within the context of financial constraints.

Conclusions

Findings from the current review add depth and scope to quantitative literature and can guide ongoing theory, interventions and policy development in food environment research. There is a need to investigate contextual influences within food environments as well as individual and household socio-economic characteristics that contribute to the differing use of and views towards local food environments. Greater emphasis on how individual and environmental factors interact in the food environment field will be key to developing stronger understanding of how environments can support and promote healthier food choices.

A corner store intervention to improve access to fruits and vegetables in two Latino communities

OBJECTIVE

Investments have been made to alter the food environment of neighbourhoods that have a disproportionate number of unhealthy food venues. Corner store conversions are one strategy to increase access to fruits and vegetables (F&V). Although the literature shows modest success, the effectiveness of these interventions remains equivocal. The present paper reports on the evaluation of Proyecto MercadoFRESCO, a corner store conversion intervention in two Latino communities.

DESIGN

A repeated cross-sectional design was employed. Data were stratified by intervention arm and bivariate tests assessed changes over time. Logistic and multiple regression models with intervention arm, time and the interaction of intervention and time were conducted. Supplementary analyses account for clustering of patrons within stores and staggering of store conversions.

SETTING

Three stores were converted and five stores served as comparisons in East Los Angeles and Boyle Heights, California, USA.

SUBJECTS

Store patrons were interviewed before (n550) and after (n407) the intervention.

RESULTS

Relative to patrons of comparison stores, patrons of intervention stores demonstrated more favourable perceptions of corner stores and increased purchasing of F&V during that store visit. Changes were not detected in store patronage, percentage of weekly dollars spent on food for F&V or daily consumption of F&V.

CONCLUSIONS

Consistent with some extant food environment literature, findings demonstrate limited effects. Investments should be made in multilevel, comprehensive interventions that target a variety retail food outlets rather than focusing on corner stores exclusively. Complementary policies limiting the availability, affordability and marketing of energy-dense, nutrient-poor foods should also be pursued.

Social media indicators of the food environment and state health outcomes

OBJECTIVES

Contextual factors can influence health through exposures to health-promoting and risk-inducing factors. The aim of this study was to (1) build, from geotagged Twitter and Yelp data, a national food environment database and (2) to test associations between state food environment indicators and health outcomes.

STUDY DESIGN

This is a cross-sectional study based upon secondary analyses of publicly available data.

METHODS

Using Twitter's Streaming Application Programming Interface (API), we collected and processed 4,041,521 food-related, geotagged tweets between April 2015 and March 2016. Using Yelp's Search API, we collected data on 505,554 unique food-related businesses. In linear regression models, we examined associations between food environment characteristics and state-level health outcomes, controlling for state-level differences in age, percent non-Hispanic white, and median household income.

RESULTS

A one standard deviation increase in caloric density of food tweets was related to higher all-cause mortality (+46.50 per 100,000), diabetes (+0.75%), obesity (+1.78%), high cholesterol (+1.40%), and fair/poor self-rated health (2.01%). More burger Yelp listings were related to higher prevalence of diabetes (+0.55%), obesity (1.35%), and fair/poor self-rated health (1.12%). More alcohol tweets and Yelp bars and pub listings were related to higher state-level binge drinking and heavy drinking, but lower mortality and lower percent reporting fair/poor self-rated health. Supplemental analyses with county-level social media indicators and county health outcomes resulted in finding similar but slightly attenuated associations compared to those found at the state level.

CONCLUSIONS

Social media can be utilized to create indicators of the food environment that are associated with area-level mortality, health behaviors, and chronic conditions.

Local descriptive body weight and dietary norms, food availability, and 10-year change in glycosylated haemoglobin in an Australian population-based biomedical cohort

BACKGROUND

Individual-level health outcomes are shaped by environmental risk conditions. Norms figure prominently in socio-behavioural theories yet spatial variations in health-related norms have rarely been investigated as environmental risk conditions. This study assessed: 1) the contributions of local descriptive norms for overweight/obesity and dietary behaviour to 10-year change in glycosylated haemoglobin (HbA1c), accounting for food resource availability; and 2) whether associations between local descriptive norms and HbA1c were moderated by food resource availability.

METHODS

HbA1c, representing cardiometabolic risk, was measured three times over 10 years for a population-based biomedical cohort of adults in Adelaide, South Australia. Residential environmental exposures were defined using 1600 m participant-centred road-network buffers. Local descriptive norms for overweight/obesity and insufficient fruit intake (proportion of residents with BMI ≥ 25 kg/m2 [n = 1890] or fruit intake of <2 serves/day [n = 1945], respectively) were aggregated from responses to a separate geocoded population survey. Fast-food and healthful food resource availability (counts) were extracted from a retail database. Separate sets of multilevel models included different predictors, one local descriptive norm and either fast-food or healthful food resource availability, with area-level education and individual-level covariates (age, sex, employment status, education, marital status, and smoking status). Interactions between local descriptive norms and food resource availability were tested.

RESULTS

HbA1c concentration rose over time. Local descriptive norms for overweight/obesity and insufficient fruit intake predicted greater rates of increase in HbA1c. Neither fast-food nor healthful food resource availability were associated with change in HbA1c. Greater healthful food resource availability reduced the rate of increase in HbA1c concentration attributed to the overweight/obesity norm.

CONCLUSIONS

Local descriptive health-related norms, not food resource availability, predicted 10-year change in HbA1c. Null findings for food resource availability may reflect a sufficiency or minimum threshold level of resources such that availability poses no barrier to obtaining healthful or unhealthful foods for this region. However, the influence of local descriptive norms varied according to food resource availability in effects on HbA1c. Local descriptive health-related norms have received little attention thus far but are important influences on individual cardiometabolic risk. Further research is needed to explore how local descriptive norms contribute to chronic disease risk and outcomes.

Urban Place and Health Equity: Critical Issues and Practices

Urban places and health equity are two of the most challenging concepts for 21st century environmental health. More people live in cities than at any other time in human history and health inequities are increasing. Health inequities are avoidable differences in the social, environmental and political conditions that shape morbidity and mortality, and disproportionately burden the poor, racial, ethnic and religious minorities and migrants. By linking urban place and health inequities, research and action brings into sharp relief the challenges of achieving urban environmental justice. This article briefly reviews the complex definitions of urban places and how they can shape health equity in cities. I suggest that a more relational or integrated approach to defining urban places and acting on health equity can complement other approaches and improve the ability of public health to meet 21st century challenges. I close with suggestions for research and practice that might focus environmental public health on healthy urban place making. The practices include community driven map making, Health in All Policies (HiAP), promoting urban ecosystem services for health, and participatory and integrated approaches to urban slum upgrading. I conclude that if the global community is serious about the sustainable development goals (SDGs), greater attention must be paid to understanding and acting to improve urban places, living conditions and the social and economic conditions that can promote health equity.

Baltimore City Stores Increased The Availability Of Healthy Food After WIC Policy Change

As part of a 2009 revision to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program, the Department of Agriculture required WIC-authorized stores to stock additional varieties of healthy food. The long-term effects of this policy on access to healthy food are unknown. Using surveys conducted in 118 Baltimore City, Maryland, food stores in 2006 and 2012, we examined associations of the change in healthy food availability with store type, neighborhood demographics, and the 2009 WIC policy change. Overall, healthy food availability improved significantly between 2006 and 2012, with the greatest increases in corner stores and in census tracts with more than 60 percent black residents. On an 11-point scale measuring availability of fruit (3 points), vegetables (4 points), bread (2 points), and milk (2 points), the WIC policy change was associated with a 0.72-point increase in WIC-relevant healthy food availability, while joining WIC was associated with a 0.99-point increase. Stores that carry a limited variety of food items may be more receptive to stocking healthier food than previously thought, particularly within neighborhoods with a majority of black residents. Policies targeting healthy food availability have the potential to increase availability and decrease health disparities.

Between exposure, access and use: Reconsidering foodscape influences on dietary behaviours

Good accessibility to both healthy and unhealthy food outlets is a greater reality than food deserts. Yet, there is a lack of conceptual insights on the contextual factors that push individuals to opt for healthy or unhealthy food outlets when both options are accessible. Our comprehension of foodscape influences on dietary behaviours would benefit from a better understanding of the decision-making process for food outlet choices. In this paper, we build on the fundamental position that outlet choices are conditioned by how much outlets' attributes accommodate individuals' constraints and preferences. We further argue that food outlets continuously experienced within individuals' daily-path help people re-evaluate food acquisition possibilities, push them to form intentions, and shape their preferences for the choices they will subsequently make. Doing so, we suggest differentiating access, defined as the potential for the foodscape to be used at the time when individuals decide to do so, from exposure, which acts as a constant catalyst for knowledge, intention, preferences and routine tendency. We conclude with implications for future research, and discuss consequences for public policy.