Ecological and socioeconomic correlates of fruit, juice, and vegetable consumption among African-American boys

Influences of the community and consumer nutrition environment on the food purchases and dietary behaviors of adolescents: A systematic review

Adolescence is a period of increased autonomy over decision-making, including food choices, and increased exposure to influences outside the home, including the food environment. This review aims to synthesize the evidence for the influence of community nutrition environments, spatial access to food outlets, and consumer nutrition environments, environments inside food outlets, on adolescent food purchasing and dietary behaviors in high-income countries. Six databases were searched for articles published before January 2023. Results were synthesized using a vote-counting technique and effect direction plots that record the direction of the effect in relation to the anticipated relationship with health. Thirty-four observational and two intervention studies met the inclusion criteria. In the 13 studies assessing adolescent exposure to healthy community nutrition environments, results did not show clear associations with dietary and purchasing outcomes. Thirty studies assessed adolescents' exposure to unhealthy community nutrition environments with the majority (n = 17/30, 57%) reporting results showing that greater exposure to food outlets classified as unhealthy was associated with less healthy food purchases and dietary intakes. Inconsistent results were observed across the seven studies investigating associations with the consumer environment. Further research in these areas, including more high-quality intervention studies, may help to develop policy strategies to improve adolescents' dietary behaviors.

The impact of the built environment on health behaviours and disease transmission in social systems

The environment plays an important role in disease dynamics and in determining the health of individuals. Specifically, the built environment has a large impact on the prevention and containment of both chronic and infectious disease in humans and in non-human animals. The effects of the built environment on health can be direct, for example, by influencing environmental quality, or indirect by influencing behaviours that impact disease transmission and health. Furthermore, these impacts can happen at many scales, from the individual to the society, and from the design of the plates we eat from to the design of cities. In this paper, we review the ways that the built environment affects both the prevention and the containment of chronic and infectious disease. We bring examples from both human and animal societies and attempt to identify parallels and gaps between the study of humans and animals that can be capitalized on to advance the scope and perspective of research in each respective field. By consolidating this literature, we hope to highlight the importance of built structures in determining the complex dynamics of disease and in impacting the health behaviours of both humans and animals.This article is part of the theme issue 'Interdisciplinary approaches for uncovering the impacts of architecture on collective behaviour'.

Innovative Techniques for Evaluating Behavioral Nutrition Interventions

Assessing outcomes and the impact from behavioral nutrition interventions has remained challenging because of the lack of methods available beyond traditional nutrition assessment tools and techniques. With the current high global obesity and related chronic disease rates, novel methods to evaluate the impact of behavioral nutrition-based interventions are much needed. The objective of this narrative review is to describe and review the current status of knowledge as it relates to 4 different innovative methods or tools to assess behavioral nutrition interventions. Methods reviewed include 1) the assessment of stress and stress responsiveness to enhance the evaluation of nutrition interventions, 2) eye-tracking technology in nutritional interventions, 3) smartphone biosensors to assess nutrition and health-related outcomes, and 4) skin carotenoid measurements to assess fruit and vegetable intake. Specifically, the novel use of functional magnetic resonance imaging, by characterizing the brain's responsiveness to an intervention, can help researchers develop programs with greater efficacy. Similarly, if eye-tracking technology can enable researchers to get a better sense as to how participants view materials, the materials may be better tailored to create an optimal impact. The latter 2 techniques reviewed, smartphone biosensors and methods to detect skin carotenoids, can provide the research community with portable, effective, nonbiased ways to assess dietary intake and quality and more in the field. The information gained from using these types of methodologies can improve the efficacy and assessment of behavior-based nutrition interventions.

A multi-level intervention in subsidized housing sites to increase fruit and vegetable access and intake: Rationale, design and methods of the 'Live Well, Viva Bien' cluster randomized trial

BACKGROUND

Adequate fruit and vegetable (F&V) intake is important for disease prevention. Yet, most Americans, especially low-income and racial/ethnic minorities, do not eat adequate amounts. These disparities are partly attributable to food environments in low-income neighborhoods where residents often have limited access to affordable, healthful food and easy access to inexpensive, unhealthful foods. Increasing access to affordable healthful food in underserved neighborhoods through mobile markets is a promising, year-round strategy for improving dietary behaviors and reducing F&V intake disparities. However, to date, there have been no randomized controlled trials studying their effectiveness. The objective of the 'Live Well, Viva Bien' (LWVB) cluster randomized controlled trial is to evaluate the efficacy of a multicomponent mobile market intervention at increasing F&V intake among residents of subsidized housing complexes.

METHODS/DESIGN

One housing complex served as a pilot site for the intervention group and the remaining 14 demographically-matched sites were randomized into either the intervention or control group. The intervention group received bimonthly, discount, mobile, fresh F&V markets in conjunction with a nutrition education intervention (two F&V campaigns, newsletters, DVDs and cooking demonstrations) for 12 months. The control group received physical activity and stress reduction interventions. Outcome measures include F&V intake (measured by two validated F&V screeners at baseline, six-month and twelve-months) along with potential psychosocial mediating variables. Extensive quantitative and qualitative process evaluation was also conducted throughout the study.

DISCUSSION

Modifying neighborhood food environments in ways that increase access to affordable, healthful food is a promising strategy for improving dietary behaviors among low-income, racial and ethnic minority groups at increased risk for obesity and other food-related chronic diseases. Discount, mobile F&V markets address all the major barriers to eating more F&V (high cost, poor quality, limited access and limited time to shop and cook) and provide a year-round solution to limited access to healthful food in low-income neighborhoods. LWVB is the first randomized controlled trial evaluating the effectiveness of mobile markets at increasing F&V intake. If proven efficacious at increasing F&V consumption, LWVB could be disseminated widely to neighborhoods that have low access to fresh F&V.

TRIALS REGISTRATION

Clinicatrials.gov registration number: NCT02669472 First Received: January 19, 2016.

Conceptual framework of a simplified multi-dimensional model presenting the environmental and personal determinants of cardiometabolic risk behaviors in childhood

Clinical manifestations of cardiometabolic risk (CMR) may be set early in childhood due to unfavorable behaviors or lifestyle patterns related to diet and physical activity. Several factors may determine the adoption of such lifestyle-related behaviors, which researchers have tried to cluster under certain frameworks or models. In this context, the framework developed and proposed by this review gathers all the present knowledge regarding these determining factors to date and groups them into three main categories related to personal characteristics and the social and physical environment. Based on the proposed framework, a large variety of personal, social and physical environmental factors can positively or negatively influence CMR-related behaviors (either directly or indirectly via their interrelations), thus leading to decreased or increased risk, respectively. This framework could be of great value to public health policy makers and legislators for designing and implementing interventional programs tailored to the needs of susceptible population groups who are most in need for such initiatives. Targeting the correlates as potential determinants of CMR-related behaviors, and not just on the behaviors themselves, has been shown previously to be the most effective approach for tackling health issues related to CMR starting from early life stages.

Socio-economic position as a moderator of 9–13-year-old children’s non-core food intake

Objective

There is limited understanding as to why children of low socio-economic position (SEP) consume poorer diets than children of high SEP. Evidence suggests that determinants of dietary intake may differ between SEP groups. The present study aimed to determine if SEP moderated associations of personal and environmental predictors with children’s non-core food and sweetened drink intakes and unhealthy dietary behaviours.

Design

Children completed online questionnaires and parents completed computer-assisted telephone interviews to assess intrapersonal and environmental dietary predictors. Dietary intake was measured using an FFQ. Parents reported demographic information for maternal education, occupation and employment, and household income.

Setting

Twenty-six primary schools in South Australia, Australia.

Subjects

Children aged 9–13 years and their parents (n 395).

Results

Multiple personal and home environment factors predicted non-core food and sweetened drink intakes, and these associations were moderated by SEP. Maternal education moderated associations of girls’ sweetened drink intake with self-efficacy, cooking skills and pressure to eat, and boys’ non-core food intake with monitoring, parent’s self-efficacy and home environment. Maternal occupation and employment moderated associations of sweetened drink intake with attitudes, self-efficacy, pressure to eat and food availability, and non-core food intake with parents’ self-efficacy and monitoring. Income moderated associations with pressure to eat and home environment.

Conclusions

Identifying differences in dietary predictors between socio-economic groups informs understanding of why socio-economic gradients in dietary intake may occur. Tailoring interventions and health promotion to the particular needs of socio-economically disadvantaged children may produce more successful outcomes and reduce socio-economic disparities in dietary intake.

Towards a behavioral vaccine: exposure to accessible temptation when self-regulation is endorsed enhances future resistance to similar temptations in children

BACKGROUND

Access to temptation is blamed for the rising prevalence of obesity in children. A popular way to counter this is to restrict physical access to temptation. As restrictions cannot be widely applied and may have adverse long-term effects, we examine whether accessible temptations in situations that endorse self-regulation train self-regulation. Specifically, we design a method that enhances children's self-regulatory skills in the long term.

METHOD

In two studies, participants were exposed to temptation in phase one and their self-regulatory skills were measured in phase two. In Study 1, we endorsed self-regulation in the presence of accessible temptation for four consecutive days and measured consumption on the fifth day. In Study 2, we exposed children to temptation similarly and, in addition, manipulated temptation strength to show that being tempted is crucial for the skill to develop. Next, we measured saliva and preferences.

RESULTS

The findings suggest that exposure to temptation in a situation that supports self-regulation leads to better resistance to temptations in later contexts of accessible temptation in girls, but not boys.

CONCLUSIONS

Our findings suggest that interventions aiming at strengthening children's self-regulatory skills through controlled exposure to temptation might be a productive long-term strategy to reduce consumption of unhealthy food.

The role of socio-economic position as a moderator of children's healthy food intake

Children of low socio-economic position (SEP) consume poorer diets than those of high SEP; however, there is limited understanding of why socio-economic gradients in diet occur. Some evidence suggests that determinants of dietary intake may differ between SEP groups. The aim of the present study was to determine whether the associations between personal and environmental variables and children's fruit and vegetable intake, and healthy dietary behaviours are moderated by SEP. A total of 395 children aged 9 to 13 years and their parents were recruited in Adelaide, South Australia. Personal and environmental dietary predictors were measured using child-completed online questionnaires and telephone interviews with parents. Dietary intake was measured using an online FFQ. First, dietary predictors were identified using correlated component regression, and subsequently tested for moderation by four SEP indicators using partial least-squares structural equation modelling. Fruit and vegetable intake and healthy behaviours were predicted by self-efficacy, attitudes and a supportive home environment. For girls, only the associations of self-efficacy with healthy behaviours were moderated by occupation. For boys, income moderated the associations of fruit and vegetable intake with attitudes, and healthy behaviours with supportive home environments. Occupation and employment moderated the associations of boys' family environments and fruit intake, and attitudes with healthy behaviours. Reducing socio-economic disparities in children's healthy dietary intake may be more successfully achieved by tailoring health promotion policies and interventions according to variables that moderate the relationships between dietary intake and SEP.

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.

Development and Reliability Testing of a Fast-Food Restaurant Observation Form

PURPOSE

To develop a reliable observational data collection instrument to measure characteristics of the fast-food restaurant environment likely to influence consumer behaviors, including product availability, pricing, and promotion.

DESIGN

The study used observational data collection.

SETTING

Restaurants were in the Chicago Metropolitan Statistical Area.

SUBJECTS

A total of 131 chain fast-food restaurant outlets were included.

MEASURES

Interrater reliability was measured for product availability, pricing, and promotion measures on a fast-food restaurant observational data collection instrument.

ANALYSIS

Analysis was done with Cohen's κ coefficient and proportion of overall agreement for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.

RESULTS

Interrater reliability, as measured by average κ coefficient, was .79 for menu characteristics, .84 for kids' menu characteristics, .92 for food availability and sizes, .85 for beverage availability and sizes, .78 for measures on the availability of nutrition information,.75 for characteristics of exterior advertisements, and .62 and .90 for exterior and interior characteristics measures, respectively. For continuous measures, average ICC was .88 for food pricing measures, .83 for beverage prices, and .65 for counts of exterior advertisements.

CONCLUSION

Over 85% of measures demonstrated substantial or almost perfect agreement. Although some measures required revision or protocol clarification, results from this study suggest that the instrument may be used to reliably measure the fast-food restaurant environment.

Association between home availability and vegetable consumption in youth: a review

Objective

To systematically review literature examining the association between vegetable home availability and vegetable intake in youth.

Design

Articles were identified through December 2012 using a search of PubMed, PsychINFO and OVID/Medline databases, using the following keywords in varying combinations: home, environment, availability, vegetable, intake, consumption, children. Quantitative studies examining home vegetable availability and vegetable intake in children and adolescents were included. Fifteen studies were included that met inclusion criteria.

Setting

Studies were conducted in the USA (n 8), Australia (n 1), Greece (n 1), Iceland (n 1), Denmark (n 1), the UK (n 1), the Netherlands (n 1) and a combination of nine European countries (n 1).

Subjects

Various populations of children and adolescents were examined.

Results

Seven of the studies (47 %) found a positive association between vegetable availability and intake, with the others reporting null findings. There were no clear patterns of association by study design, age of subjects included, comprehensiveness of measures, or inclusion of covariates in analyses. Child report of home availability was associated with child vegetable intake (n 6, all found a positive association), while parent report of home availability was only minimally associated (n 9, one found a positive association; P=0·001 from post hoc Fisher’s exact test comparing parent v. child report).

Conclusions

Parent perception of availability may be closer to truth, given the parental role in food shopping and preparation. Therefore, to impact child vegetable intake, absolute availability may not be as important as child perception of vegetables in the home. Child perception of availability may be altered by level of familiarity with vegetables.

Associations between predictors of children's dietary intake and socioeconomic position: a systematic review of the literature

Socioeconomically disadvantaged children are at higher risk of consuming poor diets, in particular less fruits and vegetables and more non-core foods and sweetened beverages. Currently the drivers of socioeconomically related differences in children's dietary intake are not well understood. This systematic review explored whether dietary predictors vary for children of different socioeconomic circumstances. Seven databases and reference lists of included material were searched for studies investigating predictors of 9-13-year-old children's diet in relation to socioeconomic position. Individual- and population-based cross-sectional, cohort and epidemiological studies published in English and conducted in developed countries were included. Twenty-eight studies were included in this review; most were conducted in Europe (n = 12) or North America (n = 10). The most frequently used indicators of socioeconomic position were parent education and occupation. Predictors of children's dietary intake varied among children of different socioeconomic circumstances. Socioeconomic position was consistently associated with children's nutrition knowledge, parent modelling, home food availability and accessibility. Indeterminate associations with socioeconomic position were observed for parent feeding practices and food environment near school. Differences in the determinants of eating between socioeconomic groups provide a better understanding of the drivers of socioeconomic disparities in dietary intake, and how to develop targeted intervention strategies.

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.

Where are the food deserts? An evaluation of policy-relevant measures of community food access in South Carolina

Several recent United States (US) policies target spatial access to healthier food retailers. We evaluated two measures of community food access developed by two different agencies, using a 2009 food environment validation study in South Carolina as a reference. While the US Department of Agriculture Economic Research Service's (USDA ERS) measure designated 22.5% of census tracts as food deserts, the Centers for Disease Control and Prevention's (CDC) measure designated 29.0% as non-healthier retail tracts; 71% of tracts were designated consistently between USDA ERS and CDC. Our findings suggest a need for greater harmonization of these measures of community food access.

Variation in low food access areas due to data source inaccuracies

Several spatial measures of community food access identifying so called "food deserts" have been developed based on geospatial information and commercially-available, secondary data listings of food retail outlets. It is not known how data inaccuracies influence the designation of Census tracts as areas of low access. This study replicated the U.S. Department of Agriculture Economic Research Service (USDA ERS) food desert measure and the Centers for Disease Control and Prevention (CDC) non-healthier food retail tract measure in two secondary data sources (InfoUSA and Dun & Bradstreet) and reference data from an eight-county field census covering169 Census tracts in South Carolina. For the USDA ERS food deserts measure accuracy statistics for secondary data sources were 94% concordance, 50-65% sensitivity, and 60-64% positive predictive value (PPV). Based on the CDC non-healthier food retail tracts both secondary data demonstrated 88-91% concordance, 80-86% sensitivity and 78-82% PPV. While inaccuracies in secondary data sources used to identify low food access areas may be acceptable for large-scale surveillance, verification with field work is advisable for local community efforts aimed at identifying and improving food access.

Navigating the urban food environment: challenges and resilience of community-dwelling older adults

OBJECTIVE

Identify factors involved in food shopping among older urban adults.

DESIGN

A qualitative study of 30 in-depth interviews and 15 "tagalong" shopping trip observations were conducted.

SETTING

Brooklyn, New York.

PARTICIPANTS

Black, white, and Latino men and women aged 60-88 years.

MAIN OUTCOME MEASURE

Transcripts were coded inductively to identify emergent themes.

RESULTS

Older adults shopped at multiple stores to obtain the quality of foods preferred at prices that fit their food budgets. Participants often traveled outside their neighborhoods to accomplish this, and expressed dissatisfaction with the foods locally available. Adaptive food shopping behaviors included walking or the use of public transit to purchase food in small batches, as well as reliance on community resources and social network members.

CONCLUSIONS AND IMPLICATIONS

Participants identified a number of multilayered factors and challenges involved in procuring food. These factors conform to elements of ecological behavioral models described as intrapersonal, social, and environmental level influences and have resulted in adaptive behaviors for this population. These findings provide evidence that can be used to develop more effective programs, as well as promote testable interventions aimed at keeping older adults independent and capable of acquiring food that meets their age-specific needs.

Comparing the accuracy of two secondary food environment data sources in the UK across socio-economic and urban/rural divides

Background

Interest in the role of food environments in shaping food consumption behaviours has grown in recent years. However, commonly used secondary food environment data sources have not yet been fully evaluated for completeness and systematic biases. This paper assessed the accuracy of UK Points of Interest (POI) data, compared to local council food outlet data for the county of Cambridgeshire.

Methods

Percentage agreement, positive predictive values (PPVs) and sensitivities were calculated for all food outlets across the study area, by outlet type, and across urban/rural/SES divisions.

Results

Percentage agreement by outlet type (29.7-63.5%) differed significantly to overall percentage agreement (49%), differed significantly in rural areas (43%) compared to urban (52.8%), and by SES quintiles. POI data had an overall PPV of 74.9%, differing significantly for Convenience Stores (57.9%), Specialist Stores (68.3%), and Restaurants (82.6%). POI showed an overall ‘moderate’ sensitivity, although this varied significantly by outlet type. Whilst sensitivies by urban/rural/SES divides varied significantly from urban and least deprived reference categories, values remained ‘moderate’.

Conclusions

Results suggest POI is a viable alternative to council data, particularly in terms of PPVs, which remain robust across urban/rural and SES divides. Most variation in completeness was by outlet type; lowest levels were for Convenience Stores, which are commonly cited as ‘obesogenic’.

Measures of the consumer food store environment: a systematic review of the evidence 2000-2011

Description of the consumer food environment has proliferated in publication. However, there has been a lack of systematic reviews focusing on how the consumer food environment is associated with the following: (1) neighborhood characteristics; (2) food prices; (3) dietary patterns; and (4) weight status. We conducted a systematic review of primary, quantitative, observational studies, published in English that conducted an audit of the consumer food environment. The literature search included electronic, hand searches, and peer-reviewed from 2000 to 2011. Fifty six papers met the inclusion criteria. Six studies reported stores in low income neighborhoods or high minority neighborhoods had less availability of healthy food. While, four studies found there was no difference in availability between neighborhoods. The results were also inconsistent for differences in food prices, dietary patterns, and weight status. This systematic review uncovered several key findings. (1) Systematic measurement of determining availability of food within stores and store types is needed; (2) Context is relevant for understanding the complexities of the consumer food environment; (3) Interventions and longitudinal studies addressing purchasing habits, diet, and obesity outcomes are needed; and (4) Influences of price and marketing that may be linked with why people purchase certain items.

Population approaches to improve diet, physical activity, and smoking habits: a scientific statement from the American Heart Association

BACKGROUND

Poor lifestyle behaviors, including suboptimal diet, physical inactivity, and tobacco use, are leading causes of preventable diseases globally. Although even modest population shifts in risk substantially alter health outcomes, the optimal population-level approaches to improve lifestyle are not well established.

METHODS AND RESULTS

For this American Heart Association scientific statement, the writing group systematically reviewed and graded the current scientific evidence for effective population approaches to improve dietary habits, increase physical activity, and reduce tobacco use. Strategies were considered in 6 broad domains: (1) Media and educational campaigns; (2) labeling and consumer information; (3) taxation, subsidies, and other economic incentives; (4) school and workplace approaches; (5) local environmental changes; and (6) direct restrictions and mandates. The writing group also reviewed the potential contributions of healthcare systems and surveillance systems to behavior change efforts. Several specific population interventions that achieved a Class I or IIa recommendation with grade A or B evidence were identified, providing a set of specific evidence-based strategies that deserve close attention and prioritization for wider implementation. Effective interventions included specific approaches in all 6 domains evaluated for improving diet, increasing activity, and reducing tobacco use. The writing group also identified several specific interventions in each of these domains for which current evidence was less robust, as well as other inconsistencies and evidence gaps, informing the need for further rigorous and interdisciplinary approaches to evaluate population programs and policies.

CONCLUSIONS

This systematic review identified and graded the evidence for a range of population-based strategies to promote lifestyle change. The findings provide a framework for policy makers, advocacy groups, researchers, clinicians, communities, and other stakeholders to understand and implement the most effective approaches. New strategic initiatives and partnerships are needed to translate this evidence into action.

Nutrition standards for away-from-home foods in the USA

Away-from-home foods are regulated with respect to the prevention of food-borne diseases and potential contaminants, but not for their contribution to dietary-related chronic diseases. Away-from-home foods have more calories, salt, sugar and fat, and include fewer fruits and vegetables than recommended by national nutrition guidelines. Thus, frequent consumption of away-from-home foods contributes to obesity, hypertension, diabetes, heart disease, and cancer. In light of this, many localities are already adopting regulations or sponsoring programs to improve the quality of away-from-home foods. We review the rationale for developing nutritional performance standards for away-from-home foods in light of limited human capacity to regulate intake or physiologically compensate for a poor diet. We offer a set of model performance standards to be considered as a new area of environmental regulation. Models for voluntary implementation of consumer standards exist in the environmental domain and may be useful templates for implementation. Implementing such standards, whether voluntarily or via regulations, will require addressing a number of practical and ideological challenges. Politically, regulatory standards contradict the belief that adults should be able to navigate dietary risks in away-from-home settings unaided.

Neighbourhood food environments and obesity in southeast Louisiana

Supermarkets might influence food choices, and more distal outcomes like obesity, by increasing the availability of healthy foods. However, recent evidence about their effects is ambiguous, perhaps because supermarkets also increase the availability of unhealthy options. We develop an alternative measure of food environment quality that characterizes urban neighborhoods by the relative amounts of healthy (e.g. fruits and vegetables) to unhealthy foods (e.g. energy-dense snacks). Using data from 307 food stores and 1243 telephone interviews with residents in urban southeastern Louisiana, we estimate a multilevel multinomial logistic model for overweight status. We find that higher quality food environments - but not food store types - decrease the risk of obesity (RR 0.474, 95% CI 0.269-0.835) and overweight (RR 0.532, 95% CI 0.312-0.907). The findings suggest a need to move beyond a sole consideration of food store types to a more nuanced view of the food environment when planning for change.

Increasing access and affordability of produce improves perceived consumption of vegetables in low-income seniors

High cost and limited access to food have been associated with lower intake of fruits and vegetables in limited-income individuals. The Veggie Mobile is a van that carries fresh produce and travels in low-income neighborhoods, selling fruits and vegetables at a fraction of regular supermarket prices. The purpose of this study was to determine whether participation in the Veggie Mobile increases fruit and vegetable intake in a group of seniors. The intervention, buying fruits and vegetables from the Veggie Mobile, was implemented between April and October 2008 in two senior housing sites that had not previously received Veggie Mobile services. Participants were asked about fruit and vegetable intake using a modified six-item questionnaire based on the Behavioral Risk Factor Surveillance System at preintervention and again at 3 to 5 months. The post-survey also included questions about perceived benefits and barriers to using the Veggie Mobile. The two cross-sections of seniors were matched using date of birth. Wilcoxon signed rank test and paired samples t tests examined change in pre- and post-intervention variables. Seventy-nine older adults completed the baseline survey and 63 completed the post-survey. Of these, 43 participants completed both surveys (70% white [n=30], mean age 69 ± 9 years). Mean intake of fruits and vegetables after using the Veggie Mobile increased by 0.37 servings/day. Vegetable intake alone increased from 1.98 ± 1.71 servings/day to 2.58 ± 1.4 servings/day (P=0.027), half of which was potatoes. Change in fruit intake was not significant (P=0.358). At post-intervention, seniors visited the supermarket less often (P=0.001) and spent an average of $14.92 less during their last visit. The majority of participants who completed the post-survey (62 of 63) indicated being satisfied with the program. The Veggie Mobile provides an example of a simple community intervention that has potential to lead to positive behavior change among low-income seniors.

Spatial accessibility and availability measures and statistical properties in the food environment

Spatial accessibility is of increasing interest in the health sciences. This paper addresses the statistical use of spatial accessibility and availability indices. These measures are evaluated via an extensive simulation based on cluster models for local food outlet density. We derived Monte Carlo critical values for several statistical tests based on the indices. In particular we are interested in the ability to make inferential comparisons between different study areas where indices of accessibility and availability are to be calculated. We derive tests of mean difference as well as tests for differences in Moran's I for spatial correlation for each of the accessibility and availability indices. We also apply these new statistical tests to a data example based on two counties in South Carolina for various accessibility and availability measures calculated for food outlets, stores, and restaurants.

An evaluation of a neighborhood-level intervention to a local food environment

BACKGROUND

The impact of local availability of healthy foods on dietary intake and health has been established. Interventions to local environments are being evaluated for their efficacy and sustainability.

PURPOSE

The aim of this paper is to provide an evaluation of a community-driven approach to transform neighborhood healthy food availability.

METHODS

The information provided comes from minutes of monthly meetings of the partners, newsletters, media, and other store and project documentation. In addition, qualitative interviews with key stakeholders and co-op members were conducted. All of the participating individuals were interviewed during 2008 and analysis took place in 2010. Each interview was audio-taped and transcribed to form verbatim transcripts, then content analyzed for themes.

RESULTS

The implementation phase of the initiative had long-standing negative repercussions on the ability of the store to be successful because of renting too large a space; not branding the store early; early misperceptions by community members about the store; and the changing of organizational partners and personnel, which resulted in a lack of leadership for the store. Equally important, the lack of project personnel or consultants with business experience directly related to operating a food store reverberated into issues related to marketing, price structuring, decisions about stocking the store, as well as accounting.

CONCLUSIONS

Repercussions of these challenges included unmet goals in terms of attracting local residents to become members of the co-op, low sales levels, and reduced confidence in the long-term sustainability of the food cooperative. Approaches to modifications of local food environments are likely to require additional resources beyond funding in order to secure positive outcomes.

Fruit and vegetable availability enables adolescent consumption that exceeds national average

The availability of fruit, juice, and vegetables (FJV) in home and school settings is positively associated with adolescent fruit and vegetable consumption. Less is known, however, about the influence on youths' consumption of the availability of FJV in community-based settings. This study examined fruit and vegetable consumption in a sample of 156 African American adolescents (mean age, 11.89 years; range, 10-14 years; 55% female) who were provided with 3 servings each of FJV (9 servings daily) for 3 consecutive days during summer camp programming in New York City youth services agencies. It was hypothesized that youths' mean intake (measured via direct observation) would exceed the mean intake of 3.6 daily servings found among similarly aged youths in the US population given the consistently high number of servings of FJV offered. Intake differences by sex, age, and meal were also examined. Youths' mean (SD) intake of 5.41 (1.51) daily servings was higher than the population mean intake of 3.6 daily servings (P < .001). Youths aged 10 years had higher intake than did youths aged 11, 12, and 13 years. Youths' FJV intake was lower at lunch than at breakfast and dinner meals. Across meals, youths consumed more juice than fruit or vegetables. Increasing the availability of FJV in community-based settings is a promising strategy for enabling fruit and vegetable consumption among African American adolescents. Youths may also benefit from intervention to prevent age-related declines in intake, increase consumption of FJV at lunch meals, and encourage higher consumption of vegetables and fruit.

Healthy food purchasing among African American youth: associations with child gender, adult caregiver characteristics and the home food environment

Objective

To examine how factors related to the home food environment and individual characteristics are associated with healthy food purchasing among low-income African American (AA) youth.

Subjects

A total of 206 AA youth (ninety-one boys and 115 girls), aged 10–14 years, and their primary adult caregivers.

Setting

Fourteen Baltimore recreation centres in low-income neighbourhoods.

Design

Cross-sectional study. We collected information about food purchasing, the home food environment, sociodemographic and psychosocial factors drawn from social cognitive theory. Multivariable logistic regression was used to examine the factors associated with the frequency and proportion of healthy food purchases in all youth and stratified by gender. Low-fat or low-sugar foods were defined as healthy.

Results

Youth purchased an average of 1·5 healthy foods (range = 0–15) in the week before the interview, comprising an average of 11·6 % (range = 0–80 %) of total food purchases. The most commonly purchased healthy foods included water and sunflower seeds/nuts. Healthier food-related behavioural intentions were associated with a higher frequency of healthy foods purchased (OR = 1·4, P < 0·05), which was stronger in girls (OR = 1·9, P < 0·01). Greater caregiver self-efficacy for healthy food purchasing/preparation was associated with increased frequency of healthy purchasing among girls (OR = 1·3, P < 0·05). Among girls, more frequent food preparation by a family member (OR = 6·6, P < 0·01) was associated with purchasing a higher proportion of healthy foods. No significant associations were observed for boys.

Conclusions

Interventions focused on AA girls should emphasize increasing food-related behavioural intentions. For girls, associations between caregiver self-efficacy and home food preparation suggest the importance of the caregiver in healthy food purchasing.

An evaluation of edge effects in nutritional accessibility and availability measures: a simulation study

Background

This paper addresses the statistical use of accessibility and availability indices and the effect of study boundaries on these measures. The measures are evaluated via an extensive simulation based on cluster models for local outlet density. We define outlet to mean either food retail store (convenience store, supermarket, gas station) or restaurant (limited service or full service restaurants). We designed a simulation whereby a cluster outlet model is assumed in a large study window and an internal subset of that window is constructed. We performed simulations on various criteria including one scenario representing an urban area with 2000 outlets as well as a non-urban area simulated with only 300 outlets. A comparison is made between estimates obtained with the full study area and estimates using only the subset area. This allows the study of the effect of edge censoring on accessibility measures.

Results

The results suggest that considerable bias is found at the edges of study regions in particular for accessibility measures. Edge effects are smaller for availability measures (when not smoothed) and also for short range accessibility

Conclusions

It is recommended that any study utilizing these measures should correct for edge effects. The use of edge correction via guard areas is recommended and the avoidance of large range distance-based accessibility measures is also proposed.

Texas nutrition environment assessment of retail food stores (TxNEA-S): development and evaluation

OBJECTIVE

Current nutrition environment instruments are typically designed to measure a small number of healthy foods based on national trends. They lack the depth to accurately measure the unique dietary choices of subpopulations, such as Texas consumers whose food preferences are influenced by Hispanic/Latino culture. Thus the purposes of the present study were to: (i) develop a comprehensive observational tool to measure the availability of healthy foods from retail stores in Texas; and (ii) conduct a pilot test to examine the tool's reliability, as well as differences in the availability of healthy foods in stores between high- and low-income neighbourhoods.

DESIGN

Grocery and convenience stores were assessed for availability of healthy foods. Reliability was calculated using percentage agreement, and differences in availability were examined using 2 (store type) × 2 (neighbourhood income) ANOVA.

SETTING

One high-income and one low-income neighbourhood in Austin, Texas.

SUBJECTS

A sample of thirty-eight stores comprising twenty-five convenience stores and thirteen grocery stores.

RESULTS

The low-income neighbourhood had 324 % more convenience stores and 56 % fewer grocery stores than the high-income neighbourhood. High inter-rater (mean = 0·95) and test-retest reliability (mean = 0·92) and a significant interaction (P = 0·028) between store type and neighbourhood income were found.

CONCLUSIONS

The TxNEA-S tool includes 106 healthy food items, such as fruits, vegetables, dairy, proteins and grains. The tool is reliable and face validity is affirmed by the Texas Department of Health. Grocery stores have more healthy foods than convenience stores, and high-income grocery stores offer more healthy foods than low-income grocery stores.

The importance of a multi-dimensional approach for studying the links between food access and consumption

Research on neighborhood food access has focused on documenting disparities in the food environment and on assessing the links between the environment and consumption. Relatively few studies have combined in-store food availability measures with geographic mapping of stores. We review research that has used these multi-dimensional measures of access to explore the links between the neighborhood food environment and consumption or weight status. Early research in California found correlations between red meat, reduced-fat milk, and whole-grain bread consumption and shelf space availability of these products in area stores. Subsequent research in New York confirmed the low-fat milk findings. Recent research in Baltimore has used more sophisticated diet assessment tools and store-based instruments, along with controls for individual characteristics, to show that low availability of healthy food in area stores is associated with low-quality diets of area residents. Our research in southeastern Louisiana has shown that shelf space availability of energy-dense snack foods is positively associated with BMI after controlling for individual socioeconomic characteristics. Most of this research is based on cross-sectional studies. To assess the direction of causality, future research testing the effects of interventions is needed. We suggest that multi-dimensional measures of the neighborhood food environment are important to understanding these links between access and consumption. They provide a more nuanced assessment of the food environment. Moreover, given the typical duration of research project cycles, changes to in-store environments may be more feasible than changes to the overall mix of retail outlets in communities.

Measuring the food environment: state of the science

The past decades have seen an increased interest in understanding how the environment affects population health. In particular, public health practitioners and researchers alike are eager to know how the food environments of neighborhoods, schools, and worksites affect food choices and, ultimately, population risk for obesity and other diet-related chronic disease. However, the measurement tools for assessing the environment and the employed study designs have limited our ability to gain important ground. The field has not yet fully considered the psychometric properties of the environmental measurement tools, or how to deal with the copious amounts of data generated from many environmental measures. The field is dominated by research using unsophisticated study designs and has frequently failed to see the role of social and individual factors and how they interrelate with the physical environment. This paper examines some of the measurement issues to be considered as public health practitioners and researchers attempt to understand the impact of the food environment on the health of communities and takes a broad look at where the science currently is with regard to how the food environment is measured, thoughts on what issues may benefit from more deliberate inspection, and directions for future work.

Measures of the food environment: a compilation of the literature, 1990-2007

BACKGROUND

Valid and reliable measures are required to assess any effect of the food environment on individual dietary behavior, and form the foundation of research that may inform obesity-related policy. Although many methods of measuring the food environment exist, this area of research is still relatively new and there has been no systematic attempt to gather these measures, to compare and contrast them, or to report on their psychometric properties.

EVIDENCE ACQUISITION

A structured literature search was conducted to identify peer-reviewed articles published between January 1990 and August 2007 that measured the community-level food environment. These articles were categorized into the following environments: food stores, restaurants, schools, and worksites. The measurement strategies in these studies were categorized as instruments (checklists, market baskets, inventories, or interviews/questionnaires) or methodologies (geographic, sales, menu, or nutrient analyses).

EVIDENCE SYNTHESIS

A total of 137 articles were identified that included measures of the food environment. Researchers focused on assessing the accessibility, availability, affordability, and quality of the food environment. The most frequently used measure overall was some form of geographic analysis. Eighteen of the 137 articles (13.1%) tested for any psychometric properties, including inter-rater reliability, test-retest reliability, and/or validity.

CONCLUSIONS

A greater focus on testing for reliability and validity of measures of the food environment may increase rigor in research in this area. Robust measures of the food environment may strengthen research on the effects of the community-level food environment on individual dietary behavior, assist in the development and evaluation of interventions, and inform policymaking targeted at reducing the prevalence of obesity and improving diet.

Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review

Objectives

To review associations between the family environment and young people’s fruit and vegetable consumption.

Design

A systematic review. Published English-language (n60) papers were identified using electronic databases and manual searches of personal files and reference lists. Observational research reporting a measure of fruit/vegetable intake for children (aged 6–11 years) and/or adolescents (aged 12–18 years) and at least one potential family correlate of dietary intake was included.

Results

Parental modelling and parental intake were consistently and positively associated with children’s fruit and fruit, juice and vegetable (FJV) consumption. There were also positive associations between home availability, family rules and parental encouragement and children’s fruit and vegetable consumption. Parental intake was positively associated with adolescents’ fruit and vegetable consumption. There were also positive associations between parental occupational status and adolescent fruit consumption and between parental education and adolescents’ FJV consumption.

Conclusions

Our findings highlight the importance of targeting the family environment for the promotion of healthy eating behaviours among children and adolescents. Future interventions should encourage parents to be positive role models by targeting parental intake and to create a supportive home environment through increased encouragement and availability of fruits and vegetables and employing rules to govern eating behaviours. For adolescents, indicators of family circumstances (e.g. parental education) should be used to identify target groups for interventions aimed at promoting healthy eating.

Neighborhood environments: disparities in access to healthy foods in the U.S

BACKGROUND

Poor dietary patterns and obesity, established risk factors for chronic disease, have been linked to neighborhood deprivation, neighborhood minority composition, and low area population density. Neighborhood differences in access to food may have an important influence on these relationships and health disparities in the U.S. This article reviews research relating to the presence, nature, and implications of neighborhood differences in access to food.

METHODS

A snowball strategy was used to identify relevant research studies (n=54) completed in the U.S. and published between 1985 and April 2008.

RESULTS

Research suggests that neighborhood residents who have better access to supermarkets and limited access to convenience stores tend to have healthier diets and lower levels of obesity. Results from studies examining the accessibility of restaurants are less consistent, but there is some evidence to suggest that residents with limited access to fast-food restaurants have healthier diets and lower levels of obesity. National and local studies across the U.S. suggest that residents of low-income, minority, and rural neighborhoods are most often affected by poor access to supermarkets and healthful food. In contrast, the availability of fast-food restaurants and energy-dense foods has been found to be greater in lower-income and minority neighborhoods.

CONCLUSIONS

Neighborhood disparities in access to food are of great concern because of their potential to influence dietary intake and obesity. Additional research is needed to address various limitations of current studies, identify effective policy actions, and evaluate intervention strategies designed to promote more equitable access to healthy foods.

Disparities in obesity prevalence due to variation in the retail food environment: three testable hypotheses

Although the overall population in the United States has experienced a dramatic increase in obesity in the past 25 years, ethnic/racial minorities, and socioeconomically disadvantaged populations have a greater prevalence of obesity, as compared to white, and/or economically advantaged populations. Disparities in obesity are unlikely to be predominantly due to individual psychosocial or biological differences, and they may reflect differences in the built or social environment. The retail food environment is a critical aspect of the built environment that can contribute to observed disparities. This paper reviews the literature on retail food environments in the United States and proposes interrelated hypotheses that geographic, racial, ethnic, and socioeconomic disparities in obesity within the United States are the result of disparities in the retail food environment. The findings of this literature review suggest that poor-quality retail food environments in disadvantaged areas, in conjunction with limited individual economic resources, contribute to increased risk of obesity within racial and ethnic minorities and socioeconomically disadvantaged populations.

Obesity and the community food environment: a systematic review

OBJECTIVE

To examine the relationship between obesity and the community and/or consumer food environment.

DESIGN

A comprehensive literature search of multiple databases was conducted and seven studies were identified for review. Studies were selected if they measured BMI and environmental variables related to food outlets. Environmental variables included the geographic arrangement of food stores or restaurants in communities and consumer conditions such as food price and availability within each outlet. The study designs, methods, limitations and results related to obesity and the food environment were reviewed, and implications for future research were synthesized.

RESULTS

The reviewed studies used cross-sectional designs to examine the community food environment defined as the number per capita, proximity or density of food outlets. Most studies indirectly identified food outlets through large databases. The studies varied substantially in sample populations, outcome variables, units of measurement and data analysis. Two studies did not find any significant association between obesity rates and community food environment variables. Five studies found significant results. Many of the studies were subject to limitations that may have mitigated the validity of the results.

CONCLUSION

Research examining obesity and the community or consumer food environment is at an early stage. The most pertinent gaps include primary data at the individual level, direct measures of the environment, studies examining the consumer environment and study designs involving a time sequence. Future research should directly measure multiple levels of the food environment and key confounders at the individual level.

Food store types, availability, and cost of foods in a rural environment

OBJECTIVE

To characterize the built nutritional environment in terms of types and number of food stores, availability, and cost of selected food items in a rural area.

DESIGN

A cross-sectional survey of food stores conducted in 2004.

SUBJECTS/SETTING

We selected a rural county (population 91,582; 1,106 square miles). Food stores identified from a database were mapped and presence, location, and store type verified by ground-truthing. Stores were surveyed for availability and cost of selected foods.

MAIN OUTCOME MEASURES

Price and availability of a limited number of staple foods representing the main food groups.

STATISTICAL ANALYSES PERFORMED

Availability comparisons used least square means models and price comparisons used t tests.

RESULTS

Of 77 stores identified, 16% were supermarkets, 10% grocery stores, and 74% convenience stores. There were seven stores per 100 square miles and eight stores per 10,000 residents. Availability of more healthful foods was substantially higher at supermarkets and grocery stores. For instance, low-fat/nonfat milk, apples, high-fiber bread, eggs, and smoked turkey were available in 75% to 100% of supermarkets and groceries and at 4% to 29% of convenience stores. Foods that were available at both supermarkets and convenience stores tended to be substantially more expensive at convenience stores. The healthful version of a food was typically more expensive than the less healthful version.

CONCLUSIONS

In this rural environment, stores offering more healthful and lower-cost food selections were outnumbered by convenience stores offering lower availability of more healthful foods. Our findings underscore the challenges of shopping for healthful and inexpensive foods in rural areas.

Distance to food stores & adolescent male fruit and vegetable consumption: mediation effects

BACKGROUND

The physical environments in which adolescents reside and their access to food stores may influence their consumption of fruit and vegetables. This association could either be direct or mediated via psychosocial variables or home availability of fruit and vegetables. A greater understanding of these associations would aide the design of new interventions. The purpose of this study was to examine associations between distance to food stores and restaurants and fruit and vegetable consumption and the possible mediating role of psychosocial variables and home availability.

METHODS

Fruit and vegetable consumption of 204 Boy Scouts was assessed by a food frequency questionnaire in 2003. Participant addresses were geo-coded and distance to different types of food stores and restaurants calculated. Fruit and vegetable preferences, home availability and self-efficacy were measured. Regression models were run with backward deletion of non-significant environmental and psychosocial variables. Mediation tests were performed.

RESULTS

Residing further away from a small food store (SFS) (convenience store and drug store) was associated with increased fruit and juice and low fat vegetable consumption. Residing closer to a fast food restaurant was associated with increased high fat vegetable and fruit and juice consumption. Vegetable preferences partially mediated (26%) the relationship between low fat vegetable consumption and distance to the nearest SFS.

CONCLUSION

Distance to SFS and fast food restaurants were associated with fruit and vegetable consumption among male adolescents. Vegetable preferences partially mediated the distance to low fat vegetable relationship. More research is needed to elucidate how environmental variables impact children's dietary intake.

Neighbourhood fruit and vegetable availability and consumption: the role of small food stores in an urban environment

OBJECTIVE

Previous studies on the relationship of dietary intake to the neighbourhood food environment have focused on access to supermarkets, quantified by geographic distance or store concentration measures. However, in-store food availability may also be an important determinant, particularly for urban neighbourhoods with a greater concentration of small food stores. This study synthesises both types of information - store access and in-store availability - to determine their potential relationship to fruit and vegetable consumption.

DESIGN

Residents in four census tracts were surveyed in 2001 about their fruit and vegetable intake. Household distances to food stores in these and surrounding tracts were obtained using geographical information system mapping techniques. In-store fruit and vegetable availability was measured by linear shelf space. Multivariate linear regression models were used to measure the association of these neighbourhood availability measures with consumption.

SETTING

Four contiguous census tracts in central-city New Orleans.

SUBJECTS

A random sample of 102 households.

RESULTS

Greater fresh vegetable availability within 100 m of a residence was a positive predictor of vegetable intake; each additional metre of shelf space was associated with 0.35 servings per day of increased intake. Fresh fruit availability was not associated with intake, although having a small food store within this same distance was a marginal predictor of fruit consumption.

CONCLUSIONS

The findings suggest the possible importance of small neighbourhood food stores and their fresh produce availability in affecting fruit and vegetable intake.