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

Food Swamps and Food Deserts Impact on Metabolic Dysfunction-Associated Steatotic Liver Disease Mortality in US Counties

BACKGROUND AND AIMS

Lacking access to quality food may increase the risk of metabolic dysfunction-associated steatotic liver disease (MASLD). We investigated associations between food environment factors (food deserts and food swamps) and MASLD-related mortality across the United States.

METHODS

MASLD-related deaths were obtained from the National Vital Statistics System (2016-2020) and food environment factors from Food Environment Atlas. Food deserts are areas where low-income residents have limited access to affordable and nutritious food due to a scarcity of nearby grocery stores. Food swamps are areas oversaturated with outlets offering limited healthy food options.

RESULTS

Counties in the highest mortality quartile (fourth quartile) compared with the lowest mortality quartile (first quartile) were predominantly located in the South region (78.7% vs 23.5%) and rural areas (76.1% vs 26.6%). These counties also had higher rates of elderly residents (19.4% vs 16.5%), Hispanic residents (13.1% vs 10.5%), household crowding (2.83% vs 2.37%), no broadband Internet subscription (23.9% vs 12.7%), no high school diploma (16.1% vs 9.0%), poverty (30.2% vs 18.5%), unemployment (6.4% vs 4.7%), food deserts (8.7% vs 5.8%), and food swamp ratio (5.69 vs 4.28) (all P values <.001). After adjusting for county sociodemographic and clinical factors and regions, mixed-effects linear regression models showed significant differences in mortality rates (per 100,000) between counties with the highest vs lowest quartiles of food deserts (25.65 vs 12.75, adjusted difference = 3.66 [95% confidence interval, 2.66-4.72]) and food swamps (27.13 vs 20.15 per 100,000, adjusted difference = 3.57 [95% confidence interval, 2.44-4.71]).

CONCLUSIONS

In the United States, addressing sociodemographic and food environment disparities is paramount to reduce MASLD-related mortality.

Food outlet availability differs according to area socioeconomic status in Denmark

BACKGROUND

Disparities in access to specific foods may contribute to inequalities in diet-related diseases seen at a global and National level.

METHODS

Based on aggregated population data on income, education, and employment, area-level socioeconomic differences in food outlet availability were analyzed for 53,368 study participants residing across parishes in the Capital Region of Denmark. Validated data on fast-food outlets, convenience stores, supermarkets, and restaurants were used. Information on individual characteristics, home address and corresponding parishes were linked to the participants through the Danish Civil Registration System. Three multilevel hurdle models were applied for each food outlet type to analyze food outlet density (count/km²) within an 800-meter network buffer around participants' homes across four levels of parish socioeconomic status (SES). Model 1 provided a basic examination of the association between density and area SES. Model 2 adjusted for individual characteristics while Model 3 further included urbanity at the area level. The structure of the chosen hurdle models included was Part (1) a logistic multilevel regression modelling the probability of food outlet presence by using the entire dataset and, Part (2) a standard linear multilevel regression modelling the 10 base logarithmic transformation of only positive food outlet densities with a lognormal distribution.

RESULTS

No statistically significant spatial patterning of food outlets across area SES was found in Model 1 and 2, however positive and strong significant odds were seen in part 1 of Model 3 for supermarkets, convenience stores and fast-food outlets. Thus, residents in more disadvantaged SES areas had higher odds of having a supermarket, convenience store, or fast-food outlet near their homes compared to those living in the most advantaged areas. No differences were seen in the density across area SES.

CONCLUSION

Area SES influenced the presence of supermarkets, convenience stores, and fast-food outlets, but not the density of these establishments.

Association between neighbourhood food environment and dietary quality among adolescents in Kuala Lumpur, Malaysia

The neighbourhood food environment has been found to influence the dietary quality of adolescents. Therefore, this study aims to investigate the association between neighbourhood food environment and dietary quality among adolescents that come from low-income families in Kuala Lumpur. This cross-sectional study involves 184 adolescents from six public secondary schools in Kuala Lumpur. The online self-administered questionnaire through Google Forms was used to obtain information regarding adolescents' sociodemographic characteristics, dietary quality, and perceived availability, accessibility, and affordability of the neighbourhood food environment. Food stores and home addresses were geocoded using Google Earth. Geographic Information System (GIS) was used to identify the status of neighbourhood food environment, map the food stores and home addresses, and determine 1000m buffer zones around respondents' addresses. Associations between neighbourhood food environment statuses and dietary quality were examined using Pearson correlation, Chi-Square Test and Multivariable Linear Regression (MLR). The most reported response for dietary quality status is it 'requires improvement' (62.0 %), compared to having a 'poor diet' (23.9 %) and 'good' (14.1 %). The majority (60.3 %) resided in a healthy food environment, while the minority lived in food swamps (37.0 %) and food deserts (2.7 %). Although the majority of respondents perceived While a higher number of them perceived high food availability (76.6 %) and affordability (64.7 %) of healthy food stores in their neighbourhood, over half (51.7 %) reported low accessibility to these stores. About 33.2 % of them never use food delivery services, followed by at least once per month (31.5 %), once every two weeks (16.3 %), and once per week (19.0 %). Age (rs = -0.19), ethnicity (X 2 = 5.75), fathers' educational level (rs = 0.15), non-fast-food restaurants (r = -0.16) and convenience stores (rs = -0.20) were significantly correlated with adolescents' dietary quality (p < 0.05). However, after adjustment for covariates, ethnicity (β = 0.180, t = 2.283, p = 0.020), father's educational level (β = 0.177, t = 2.113, p = 0.036) and monthly household income (β = -0.169, t = -2.160, p = 0.032) were identified as significantly associated with dietary quality. The dietary quality of urban poor adolescents in Kuala Lumpur requires further improvement in terms of awareness and intervention. Interventions should focus on increasing fathers' awareness of healthy food choices and addressing ethnic dietary. Enhancing nutrition education in schools may also help improve dietary habits among low-income urban adolescents.

A linear tessellation model for the identification of "food desert": A case study of Shanghai, China

The "food desert" problem has been treated under a national strategy in the United States and other countries. At present, there is little research on the phenomenon of "food desert" in China. This study takes Shanghai as the research area and proposes a multiscale analysis method using a linear tessellation model that splits the street network into homogeneous linear units. Firstly, the network kernel density estimation using a linear tessellation model is used to measure the travel-mode-based food accessibility. Considering the actual travel constraints, the GPS trajectory data of four travel modes (walking, bicycle, metro and taxi) are applied to calculate the speed of each linear unit. Secondly, the "food desert" phenomenon in Shanghai are identified combing with the results of the network K-function. Finally, the resident income conditions in different modes are fitted based on the housing price data and the spatial distribution of four "food desert" patterns are detected by the overlay analysis of food accessibility and resident income conditions. The experimental results show that fifty percent of Shanghai is characterized by low food accessibility, and half of these areas are disadvantaged and low-income areas in suburbs, which are the locations experiencing the "food desert" phenomenon. Comparing the results of the proposed method and that of the traditional planar method, the identification results for all modes based on the traditional planar method underestimate the severity of the "food desert", especially for the bicycle and taxi modes. This study also provides corresponding decision-making reference for the alleviation and resolution of "food desert" issues. Moreover, the proposed method provides a new research perspective for urban research under the street network space.

Understanding the dynamics driving obesity in socioeconomically deprived urban neighbourhoods: an expert-based systems map

BACKGROUND

Over the past decades, the prevalence of obesity among adults has rapidly increased, particularly in socioeconomically deprived urban neighbourhoods. To better understand the complex mechanisms behind this trend, we created a system map exposing the underlying system driving obesity prevalence in socioeconomically deprived urban neighbourhoods over the last three decades in the Netherlands.

METHODS

We conducted Group Model Building (GMB) sessions with a group of thirteen interdisciplinary experts to develop a Causal Loop Diagram (CLD) of the obesogenic system. Using system-based analysis, the underlying system dynamics were interpreted.

RESULTS

The CLD demonstrates the food environment, physical activity environment, socioeconomic environment and socio-political environment, and their interactions. We identified the following overarching reinforcing dynamics in the obesogenic system in socioeconomically deprived urban neighbourhoods: (1) adverse socioeconomic conditions and an unhealthy food environment reinforced each other, (2) increased social distance between social groups and adverse socioeconomic conditions reinforced each other and (3) increased social distance between institutions and communities and the normalisation of unhealthy behaviours reinforced each other. These deeper system dynamics further reinforced chronic stress, sedentary behaviour, sleeping problems, unhealthy diets and reduced physical activity over time. In turn, these dynamics led to the emergent result of rising obesity prevalence in socioeconomically deprived urban neighbourhoods over the past decades.

CONCLUSIONS

Our study sheds light on the system dynamics leading to neighbourhoods with an unhealthy food environment, challenging socioeconomic conditions, a widening distance between social groups and an infrastructure that discouraged physical activity while promoting sedentary behaviour. Our insights can form the basis for the development of an integrated approach aimed at reshaping the obesogenic system in socioeconomically deprived urban neighbourhoods.

Measuring associations between the food environment and dietary habits: comparing the proportion and density of food outlets

BACKGROUND

The food environment plays a crucial role in shaping our dietary choices and overall health. Spatial measures provide distinct perspectives on the physical food environment and its impact on diet. While proportion measures are theoretically considered to provide a more accurate representation of the overall physical food environment than density measures, it is important to recognize that the association between food environments and diet can vary depending on the context. Therefore, relying solely on one measure may not be appropriate.

METHODS

We systematically assessed the density and proportion of multiple food outlet types (fast-food outlets, convenience stores, supermarkets, and restaurants) around individuals homes using a large cross-sectional Danish study (N = 71,840). Densities were modeled in separate multilevel linear regression models, incorporating random intercepts from linear splines for each of the four food outlet types. Proportions were modeled without splines. Through the association with a dietary quality score (DQS), we examined the impact of quantifying the foodscape from density versus proportion measures. Associations were compared using parameter estimates, p-values, Akaike Information Criterion (AIC) values, and Akaike weights.

RESULTS

AIC values and Akaike weights were in favor of models including density measures. Across all outlet types, density measures were consistently negatively associated with the DQS until reaching densities of 3-5 (count/km2), at which point the direction of association became positive, indicating a shift towards a healthier DQS. After correcting for multiple comparisons, the most significant effect was observed for the sole significant proportion measure. A 10% increase in the proportion of fast-food outlets among "eating out options" was associated with a 7% decrease in the DQS, towards poorer dietary quality.

CONCLUSIONS

The associations highlight that choosing food outlet density versus proportions to quantify the foodscape impact findings of substantial importance when considering the significance level and direction of association. Findings suggests a threshold effect when using density measures indicating abundance of many food outlets, at which the association with dietary quality alters significantly towards healthier diet quality.

Can nudge interventions targeting healthy food purchases in real-world grocery stores reduce diet-related health disparities? A pooled analysis of four controlled trials

BACKGROUND

Healthy food nudges may be more, or especially, effective among groups experiencing socioeconomic disadvantage. We investigated the modifying role of socioeconomic and demographic characteristics in the effectiveness of nudge interventions targeting healthy foods in real-world grocery store settings on food purchasing patterns.

METHODS

We pooled individual participant data from multiple trials. Eligible trials were identified via a PubMed search and selected based on having a controlled real-world design, testing a nudging intervention promoting healthy purchases, while collecting participants' sociodemographic and purchasing data. Out of four eligible trials, three had longitudinal measurements, one consisted of a single time point, two were randomised and two were not. Applied nudges consisted of a combination of placement nudges (focussing on availability or positioning) and property nudges (presentation and/or information). Harmonised data included dichotomised socioeconomic and demographic variables and the percentage of purchased fruits and vegetables of total purchases. Multilevel meta-regression based on linear mixed-effects models were used to explore modifying effects using two approaches: longitudinal and cross-sectional analyses.

RESULTS

The analytical sample in the longitudinal analysis comprised of 638 participants, who were predominantly female (76.3%), had a lower education attainment (67.7%), and a mean age of 46.6 years (SD 13.5). These characteristics were similar in the cross-sectional analysis (n = 855). Compared to control group participants, there was no main effect of healthy food nudges on the percentage of fruit and vegetable purchases by intervention group participants in the longitudinal analysis (β = 0.00; 95%CI -0.03, 0.09). This main effect was not modified by educational attainment (βgroup*higher education = -0.06; -0.40, 0.02), sex (βgroup*females = 0.13; -0.00, 0.61) nor age (βgroup*older adults = -0.05; -0.39, 0.02). Results from the cross-sectional analysis were comparable.

CONCLUSIONS

This pooled analyses of four controlled trials did not find evidence supporting the hypothesis that grocery store nudge interventions of healthy foods work more effectively among groups experiencing socioeconomic disadvantage. Future studies are needed to address the identified limitations through rigorous trial design using comprehensive interventional strategies, standardised outcome measures, while also evaluating context-specific approaches. Such insights will help to better understand the equity of nudging interventions in grocery store settings and the potential for reducing diet-related health disparities.

TRIAL REGISTRATIONS

The trial of Ayala et al. (2022) was retrospectively registered at ClinicalTrials.gov (NCT01475526; at 14 November 2011, https://clinicaltrials.gov/study/NCT01475526 ), the of Huitink et al. (2020) was retrospectively registered in the ISRCTN registry (ISRCTN39440735; at 5 September 2018, https://doi.org/10.1186/ISRCTN39440735 ), the of Vogel et al. (2024) was retrospectively registered at ClinicalTrials.gov (NCT03518151; at 24 April 2018, https://clinicaltrials.gov/study/NCT03518151 ), and finally of Stuber et al. (2024) was registered in the Dutch Trial Register (ID NL7064, at 30 May 2018, https://www.onderzoekmetmensen.nl/en/trial/20990 ).

The moderating effect of access to food facilities and recreational activity space on mHealth multiple health behavior change intervention

OBJECTIVE

To evaluate whether the neighborhood social and built environment moderates response to a mobile health multiple health behavior change intervention targeting fruit/vegetable intake, sedentary behavior, and physical activity.

METHODS

Participants were 156 Chicago-residing adults with unhealthy lifestyle behaviors. Using linear mixed models, we evaluated whether access to food facilities (fast food restaurants and grocery stores) and recreational activity spaces (gyms and parks) moderated the difference in behavior change between the active intervention condition relative to control. Using spatial data analysis (cross K functions), we also assessed whether participants who achieved goal levels of behaviors ("responders") were more or less likely than those who did not achieve intervention goals ("non-responders") to reside near fast food restaurants, grocery stores, gyms, or parks.

RESULTS

According to linear mixed models, none of the neighborhood social and built environment factors moderated the difference in behavior change between the active intervention condition and the control condition (Likelihood Ratio (χ²[1] = 0.02-2.33, P-values > 0.05). Cross K functions showed that diet behavior change responders were more likely than non-responders to reside near fast food restaurants, but not grocery stores. The results for activity behavior change were more variable. Sedentary screen time responders were more likely to reside around recreational activity spaces than non-responders. Moderate-vigorous physical activity responders had greater and lesser clustering than non-responders around parks, dependent upon distance from the park to participant residence.

CONCLUSIONS

A complex relationship was observed between residential proximity to Chicago facilities and response to multiple health behavior change intervention. Replication across diverse geographic settings and samples is necessary.

Influence of Socioeconomic Status on the Retail Food Environment in Alicante

BACKGROUND/OBJECTIVES

Unhealthy dietary habits are associated with chronic non-communicable diseases and may contribute to increased mortality in all countries of the world. Food environments determine the accessibility, availability, and promotion of food, thus playing an important role in people's diets, but they are context-dependent. The aim of this study was to evaluate the availability and accessibility of food in food outlets in different neighborhoods of the city of Alicante.

METHODS

Cross-sectional study. Trained researchers conducted food store audits using the validated Nutrition Environment Measures Survey in Stores for Mediterranean contexts (NEMS-S-MED) tool. Data were collected from food stores within a socioeconomically diverse sample in Alicante (n = 63). We compared the availability and affordability of "healthier-less healthy" food pairs, scores between food store types (supermarkets, specialized, convenience stores, and others), and socioeconomic levels in Alicante in 2022.

RESULTS

The present study highlights that the food stores with the greatest availability and accessibility to healthy foods are supermarkets, as opposed to specialized stores and convenience stores. In addition, differences were found in the accessibility and availability of healthy foods by neighborhoods with different income levels, being more accessible in the residential neighborhood with the highest income level. Tourism could explain the differences in the food retail environment, with a high-income neighborhood showing similar results to low-income neighborhoods.

CONCLUSIONS

The results obtained invite reflection on the development and adoption of policy strategies that promote the availability and accessibility of healthy food in the most disadvantaged areas.

Can digitalization improve the equality and equity of food environment? Evidence from greengrocers in central Shanghai

Introduction

Online food shopping has a profound impact on people's food acquisition behavior, the current study aims to understand how online food shopping may affect the accessibility of the local food environment and further influence the health equity among different populations.

Methods

Taking 8512 traditional and online greengrocers in central Shanghai as an example, this paper uses Gini coefficient, location quotient and spatial clustering method to compare the equality and equity of food environment between physical and digital food outlets.

Results

It finds that spatial equality is more significantly improved as a result of online food stores than are population equality and social equity of the food environment; older populations are not disadvantaged in terms of healthy food access but lower-income people are; the impact of online stores varies for different regions and different types of stores; depot-based stores have the most positive impact on health equity.

Discussion

Policy implications are discussed to promote the environmental justice of healthy food accessibility.

National school food standards in England: a cross-sectional study to explore compliance in secondary schools and impact on pupil nutritional intake

BACKGROUND

Many countries have introduced school food standards to improve the dietary intakes of school-aged children. England has school food standards (SFS) legislation in place but little is known about how well secondary schools comply with this. We aimed to assess compliance with the SFS legislation in English secondary schools and explore the impact of the SFS on pupils' nutritional intake.

METHODS

We conducted a cross-sectional study with English secondary schools from 2019 to 2022. We compared SFS compliance and pupil nutritional intake in schools mandated or not mandated to comply with the SFS legislation, and explored the association between school compliance and pupil nutritional intake. We assessed the percentage of SFS (%SFS) complied with by reviewing school food menus and observing food served in school canteens. We assessed pupil nutritional intake using a 24-hour dietary recall measure (Intake24) and estimated intakes of free sugar (primary outcome) and other nutrients/foods. We used adjusted multilevel models to compare pupil intakes in the SFS-mandated and SFS-non-mandated schools, and to explore the association between school SFS compliance and pupil intakes.

RESULTS

36 schools (23 not mandated and 13 mandated to comply with the SFS) and 2,273 pupils participated. The median %SFS complied with was 63.9% (interquartile range 60.0-70.0%). This was similar for SFS-non-mandated (64.5%) and SFS-mandated schools (63.3%). Compliance was highest for standards applying to lunchtime (median = 81.3%) and lowest for those applying across the whole school day (median = 41.7%). It was also lower for standards restricting high fat, sugar and energy-dense items (median = 26.1%) than for standards aiming to increase dietary variety (median = 92.3%). Pupils from SFS-mandated schools had a lower mean lunchtime intake of free sugar (g) (adjusted mean difference: -2.78g; 95% CI: -4.66g to -0.90g). There were few significant associations between %SFS complied with and pupil nutritional intake.

CONCLUSIONS

English secondary schools do not fully comply with SFS legislation regardless of whether they are mandated to comply. Schools and caterers may require monitoring and support to fully comply. There is little evidence that SFS compliance is associated with better pupil nutritional intake. Food environments outside of school also need to be considered.

STUDY REGISTRATION

ISRCTN68757496 (17-10-2019).

Support for Policies and Strategies to Promote Healthy Food Retail In-Store and Online: Perspectives From a National Sample of Supplemental Nutrition Assistance Program Participants

OBJECTIVE

Gather perspectives on healthy retail policies and strategies from a national sample of Supplemental Nutrition Assistance Program (SNAP) participants.

DESIGN

Anonymous web-based survey fielded in English and Spanish. The survey measured support for healthy retail policies and strategies.

SETTING

National Qualtrics panel fielded on September 30 and October 19, 2022.

PARTICIPANTS

A total of 1,559 adult SNAP participants (in the last 12 months) participated in the Qualtrics SNAP survey panel.

VARIABLES MEASURED

Overall support for retail policies and strategies was calculated using response frequencies and proportions.

ANALYSIS

Cross-tabulations and chi-square tests of independence assessed differences in policy support by online shopping behavior and nutrition security status. Significance was determined at P < 0.05.

RESULTS

Most SNAP participants were broadly supportive of policies and strategies to improve the healthy food retail environment. More restrictive policies were less popular than policies that expanded consumer choice. Support also varied by online shopping status and nutrition security status.

CONCLUSIONS AND IMPLICATIONS

Policies and strategies that improve the healthy food retail environment are popular among a national sample of SNAP participants. Policy discussions must understand SNAP participants' perspectives regarding changes to the retail environment that may impact their ability to access healthy foods.

Implementation of health-promoting retail initiatives in the Healthier Choices in Supermarkets Study-qualitative perspectives from a feasibility study

BACKGROUND

Improving food environments like supermarkets has the potential to affect customers' health positively. Scholars suggest researchers and retailers collaborate closely on implementing and testing such health-promoting interventions, but knowledge of the implementation of such interventions is limited. We explore the implementation of four health-promoting food retail initiatives selected and developed by a partnership between a research institution, a large retail group, and a non-governmental organisation.

METHODS

The four initiatives included downsizing of bags for pick'n' mix sweets and soda bottles at the check-out registers, shelf tags promoting healthier breakfast cereal options, and replacing a complimentary bun with a banana offered to children. The initiatives were implemented for 6 weeks (or longer if the store manager allowed it) in one store in Copenhagen, Denmark. Data were collected through observations, informal interviews with customers, and semi-structured interviews with retailers. We conducted a thematic analysis of transcripts and field notes inspired by process evaluation concepts and included quantitative summaries of selected data.

RESULTS

Two out of four initiatives were not implemented as intended. The implementation was delayed due to delivery issues, which also resulted in soda bottles not being downsized as intended. The maintenance of the shelf tags decreased over time. Retailers expressed different levels of acceptability towards the initiatives, with a preference for the complimentary banana for children. This was also the only initiative noticed by customers with both positive and negative responses. Barriers and facilitators of implementation fell into three themes: Health is not the number one priority, general capacity of retailers, and influence of customers and other stakeholders on store operation.

CONCLUSIONS

The retailers' interests, priorities, and general capacity influenced the initiative implementation. Retailers' acceptability of the initiatives was mixed despite their involvement in the pre-intervention phase. Our study also suggests that customer responses towards health-promoting initiatives, as well as cooperation with suppliers and manufacturers in the development phase, may be determining to successful implementation. Future studies should explore strategies to facilitate implementation, which can be applied prior to and during the intervention.

Neighborhood Racial Segregation Predict the Spatial Distribution of Supermarkets and Grocery Stores Better than Socioeconomic Factors in Cleveland, Ohio: a Bayesian Spatial Approach

INTRODUCTION

The food environment influences the availability and affordability of food options for consumers in a given neighborhood. However, disparities in access to healthy food options exist, affecting Black and low-income communities disproportionately. This study investigated whether racial segregation predicted the spatial distribution of supermarkets and grocery stores better than socioeconomic factors or vice versa in Cleveland, Ohio.

METHOD

The outcome measure was the count of supermarket and grocery stores in each census tract in Cleveland. They were combined with US census bureau data as covariates. We fitted four Bayesian spatial models. The first model was a baseline model with no covariates. The second model accounted for racial segregation alone. The third model looked at only socioeconomic factors, and the final model combined both racial and socioeconomic factors.

RESULTS

Overall model performance was better in the model that considered only racial segregation as a predictor of supermarkets and grocery stores (DIC = 476.29). There was 13% decrease in the number of stores for a census tract with a higher majority of Black people compared to areas with a lower number of Black people. Model 3 that considered only socioeconomic factors was less predictive of the retail outlets (DIC = 484.80).

CONCLUSIONS

These findings lead to the conclusion that structural racism evidenced in policies like residential segregation has a significant influence on the spatial distribution of food retail in the city of Cleveland.

Neighborhood-level social determinants of health and cardioprotective behaviors among church members in New Orleans, Louisiana

BACKGROUND

Favorable neighborhood-level social determinants of health (SDoH) are associated with lower cardiovascular disease risk. Less is known about their influence on cardioprotective behaviors. We evaluated the associations between neighborhood-level SDoH and cardioprotective behaviors among church members in Louisiana.

METHODS

Participants were surveyed between November 2021 to February 2022, and were asked about health behaviors, aspects of their neighborhood, and home address (to link to census tract and corresponding social deprivation index [SDI] data). Logistic regression models were used to assess the relation of neighborhood factors with the likelihood of engaging in cardioprotective behaviors: 1) a composite of healthy lifestyle behaviors [fruit and vegetable consumption, physical activity, and a tobacco/nicotine-free lifestyle], 2) medication adherence, and 3) receipt of routine medical care within the past year.

RESULTS

Participants (n = 302, mean age: 63 years, 77% female, 99% Black) were recruited from 12 churches in New Orleans. After adjusting for demographic and clinical factors, perceived neighborhood walkability or conduciveness to exercise (odds ratio [OR]=1.25; 95% CI: 1.03, 1.53), availability of fruits and vegetables (OR=1.23; 95% CI: 1.07, 1.42), and social cohesion (OR=1.55; 95% CI: 1.22, 1.97) were positively associated with the composite of healthy lifestyle behaviors. After multivariable adjustment, SDI was in the direction of association with all three cardioprotective behavior outcomes, but associations were not statistically significant.

CONCLUSIONS

In this predominantly Black, church-based population, neighborhood-level SDoH including the availability of fruits and vegetables, walkability or conduciveness to exercise, and social cohesion were associated with cardioprotective behaviors. Findings reiterate the need to address adverse neighborhood-level SDoH in the design and implementation of health interventions.

Social and environmental stressors of cardiometabolic health

Exposures to social and environmental stressors arise individual behavioural response and thus indirectly affect cardiometabolic health. The aim of this study was to investigate several social and environmental stressors and the paths of their influence on cardiometabolic health. The data of 2154 participants (aged 25-64 years) from the cross-sectional population-based study were analysed. The composite score of metabolic disorders (MS score) was calculated based on 5 biomarkers: waist circumference, blood pressure, fasting blood glucose, HDL-cholesterol, triglycerides. The effects of social stressors (education level, income), environmental stressors (NO2, noise) and behavioural factors (unhealthy diet, smoking, alcohol consumption, sedentary behaviours) on MS score were assessed using a structural model. We observed a direct effect of education on MS score, as well as an indirect effect mediated via an unhealthy diet, smoking, and sedentary behaviours. We also observed a significant indirect effect of income via sedentary behaviours. The only environmental stressor predicting MS was noise, which also mediated the effect of education. In summary, the effect of social stressors on the development of cardiometabolic risk had a higher magnitude than the effect of the assessed environmental factors. Social stressors lead to an individual's unhealthy behaviour and might predispose individuals to higher levels of environmental stressors exposures.

GIS-Based Assessments of Neighborhood Food Environments and Chronic Conditions: An Overview of Methodologies

The industrial revolution and urbanization fundamentally restructured populations' living circumstances, often with poor impacts on health. As an example, unhealthy food establishments may concentrate in some neighborhoods and, mediated by social and commercial drivers, increase local health risks. To understand the connections between neighborhood food environments and public health, researchers often use geographic information systems (GIS) and spatial statistics to analyze place-based evidence, but such tools require careful application and interpretation. In this article, we summarize the factors shaping neighborhood health in relation to local food environments and outline the use of GIS methodologies to assess associations between the two. We provide an overview of available data sources, analytical approaches, and their strengths and weaknesses. We postulate next steps in GIS integration with forecasting, prediction, and simulation measures to frame implications for local health policies.

Local retail food environment exposure and diet quality in rural and urban adults: A longitudinal analysis of the ORISCAV-LUX cohort study

Despite growing interest in understanding how food environments shape dietary behaviors, European longitudinal evidence is scarce. We aimed to investigate the associations of 9-year average and change in exposure to local retail food environments with the diet quality of residents in Luxembourg. We used data from 566 adults enrolled in both waves of the nationwide ORISCAV-LUX study (2007-2017). Dietary quality was assessed by the Diet Quality Index-International (DQI-I). Exposure to "healthy" and "less healthy" food outlets was assessed by both absolute and relative GIS-based measurements. The results showed a 56.3% increase in less healthy food outlets over the period. In adjusted linear mixed models, high (vs. low) 9-year average exposure to less healthy food outlets was associated with lower DQI-I, when examining spatial access (β = -1.25, 95% CI: -2.29, -0.22) and proportions (β = -1.24, 95% CI: -2.15, -0.33). Stratified analyses showed these associations to be significant only among urban residents. There was no association between change in exposure to less healthy food outlets and DQI-I. Increased exposure to healthy outlets in rural areas, using absolute measurements, was associated with worsened DQI-I. Neighborhood socioeconomic status did not moderate the above associations. Findings suggest that the proliferation of less healthy food outlets may have contributed to the deterioration of the diet quality of urban residents, and support the use of relative measurements to fully capture the healthiness of food environments.

Social inequities in food deserts and food swamps in a northeastern Brazilian capital

This study identified food deserts and swamps, investigating their associations with socioeconomic and demographic conditions. This ecological study was conducted using data from urban census tracts in the city of Recife, which were considered the unit of analysis. Information on food retail was obtained from government sources in 2019. Census tracts below the 25th percentile in the density of healthy food retail (i.e., those that predominantly sell natural or minimally processed foods, mixed businesses, and super- and hypermarkets) were classified as food deserts. Census tracts above the 25th percentile in the density of unhealthy food retail (i.e., those selling primarily ultra-processed foods) were considered food swamps. The socioeconomic and demographic conditions of the census tracts were evaluated using variables from the 2010 census (per capita income, average income, race, literacy of the head of household, and the availability of essential services) and the Health Vulnerability Index. Census tracts considered food deserts (28.5%) were more vulnerable, characterized by lower income and access to essential services, more illiterate residents and more minorities (Black/Indigenous/mixed race). Food swamps (73.47%) were more prevalent in less vulnerable neighbourhoods characterized by higher percentages of literate residents and Whites, greater purchasing power, and better basic sanitation. The characteristics of Recife's food deserts and swamps demonstrate social inequalities in the food environment. Public facilities could play a vital role in promoting healthy eating within food deserts. Additionally, future implementation of taxes on ultra-processed foods and the provision of tax subsidies to natural or minimally processed food sellers might contribute to fostering healthier dietary choices.

Social inequities in neighborhood health amenities over time in the Wasatch Front Region of Utah: Historical inequities, population selection, or differential investment?

Socially disadvantaged groups generally are more likely to reside in areas with less desirable conditions. We examined longitudinal relationships between neighborhood resident characteristics and amenities from 1990 to 2010 in an urban area of Utah, U.S. Four temporal patterns of social inequities are described using mixed-effects models: historical inequities; differential selection into amenity-rich tracts; differential investment in amenities; and simultaneous twenty-year change. Results indicate historical differences by neighborhood socioeconomic status, with lower status tracts having fewer green/natural amenities and higher air pollution in 1990 but also greater walkability and more food stores. Differences in amenities by neighborhood socioeconomic status widened over time as aggregate socioeconomic status disproportionately increased in tracts with more green/natural amenities, less air pollution, and lower walkability in 1990, consistent with differential selection. Tract percentage non-Hispanic White did not predict historical differences, but tracts that were less walkable and had fewer healthy food stores in 1990 experienced larger subsequent increases in racial/ethnic diversity. Tracts with higher relative to lower percentage non-Hispanic White in 1990 had larger decreases in air pollution but declining green/natural amenities. This study shows how social inequities in neighborhood amenities change over time, providing evidence of historical socioeconomic differences increasing from differential resident selection.

Assessing the association between food environment and dietary inflammation by community type: a cross-sectional REGARDS study

BACKGROUND

Communities in the United States (US) exist on a continuum of urbanicity, which may inform how individuals interact with their food environment, and thus modify the relationship between food access and dietary behaviors.

OBJECTIVE

This cross-sectional study aims to examine the modifying effect of community type in the association between the relative availability of food outlets and dietary inflammation across the US.

METHODS

Using baseline data from the REasons for Geographic and Racial Differences in Stroke study (2003-2007), we calculated participants' dietary inflammation score (DIS). Higher DIS indicates greater pro-inflammatory exposure. We defined our exposures as the relative availability of supermarkets and fast-food restaurants (percentage of food outlet type out of all food stores or restaurants, respectively) using street-network buffers around the population-weighted centroid of each participant's census tract. We used 1-, 2-, 6-, and 10-mile (~ 2-, 3-, 10-, and 16 km) buffer sizes for higher density urban, lower density urban, suburban/small town, and rural community types, respectively. Using generalized estimating equations, we estimated the association between relative food outlet availability and DIS, controlling for individual and neighborhood socio-demographics and total food outlets. The percentage of supermarkets and fast-food restaurants were modeled together.

RESULTS

Participants (n = 20,322) were distributed across all community types: higher density urban (16.7%), lower density urban (39.8%), suburban/small town (19.3%), and rural (24.2%). Across all community types, mean DIS was - 0.004 (SD = 2.5; min = - 14.2, max = 9.9). DIS was associated with relative availability of fast-food restaurants, but not supermarkets. Association between fast-food restaurants and DIS varied by community type (P for interaction = 0.02). Increases in the relative availability of fast-food restaurants were associated with higher DIS in suburban/small towns and lower density urban areas (p-values < 0.01); no significant associations were present in higher density urban or rural areas.

CONCLUSIONS

The relative availability of fast-food restaurants was associated with higher DIS among participants residing in suburban/small town and lower density urban community types, suggesting that these communities might benefit most from interventions and policies that either promote restaurant diversity or expand healthier food options.

Women Consumers' Views on Legislation to Restrict Prominent Placement and Multibuy Promotions of High Fat, Sugar, and Salt Products in England: A Qualitative Perspective

BACKGROUND

As part of the childhood obesity strategy, the UK Government has introduced regulations to restrict the ways high fat salt and sugar (HFSS) products can be promoted in retail settings from October 2022. This study explored (i) consumers' views on the likely impact of the UK legislation restricting the placement and promotion of HFSS products on their shopping behaviours and (ii) consumers' beliefs about who is responsible for healthy eating.

METHODS

Using a cross-sectional study design, qualitative semi-structured telephone interviews were conducted with a purposive sample of women who shopped at a discount supermarket. Thematic analysis was employed to identify key themes.

RESULTS

Participants' (n = 34) had a median age of 35 years and over half were in paid employment. Five themes were identified: (1) The legislation is acceptable, but people can still (and should be able to) buy HFSS items; (2) The legislation is likely to have more impact on shoppers who do not plan their shopping; (3) Affordability of healthy food is just as, or more, important than the legislation; (4) It's up to the individual to eat healthily; and (5) Government and retailers can better support consumers to make healthy choices.

CONCLUSION

Most participants were optimistic about the incoming regulations and believed that it would support consumers to make healthier food choices. Many raised concerns, however, that the high price of healthy foods and continued availability of unhealthy foods within the stores could undermine the legislation's benefits. Coupling the legislation with interventions to promote and reduce the costs of healthier products would go some way to ensure its success. Raising awareness about marketing strategies that play into consumer concerns for cost and autonomy could further increase acceptance of the policy.

The interplay between social and food environments on UK adolescents' food choices: implications for policy

Factors from social and food environments can influence the food choices of adolescents in ways not experienced during childhood. Evidence suggests these two environments influence adolescents' food choices independently, but there is limited knowledge of how the interplay between these environments influence adolescents' diets. An enhanced understanding of this interplay surrounding adolescent food choice could aid the development of more nuanced interventions and policies. This qualitative study involved 13 online focus groups with adolescents (n = 45) aged 11-18 years, attending secondary school or college in England, UK. Data were analysed using thematic analysis. Social experiences which accompanied eating were perceived as more important than the food itself, and fast-food outlets were described as uniquely suited to facilitating these interactions. Young people wanted to spend their money on foods they considered worthwhile, but this did not always relate to the most affordable foods. Adolescents wanted to put little effort into making food decisions and appreciated factors that helped them make quick decisions such as prominent placement and eye-catching promotions on foods they wanted to buy. Chain food outlets were valued as they offered familiar and frequently advertised foods, which minimized the effort needed for food decisions. Adolescents' sense of autonomy underpinned all themes. Participants described having limited opportunities to make their own food choices and they did not want to waste these buying unappealing 'healthy' foods. Interventions and government policies should align with adolescents' experiences and values relating to food choice to ensure that they are effective with this important age group.

How to enable healthier and more sustainable food practices in collective meal contexts: A scoping review

Collective meal contexts such as restaurants, cafeterias and canteens can help accelerate transitions to healthier and more sustainable diets. However, evidence from intervention studies on these contexts lacks integration. This scoping review aimed to map determinants of dietary change in collective meal contexts across multiple settings, interventions, target groups, and target behaviors. The review provided two main outcomes: (i) identifying intervention components to promote dietary change in collective meal contexts, based on the existing body of evidence; and (ii) classifying and integrating these intervention components into an overarching framework of behavior change (i.e., COM-B system). The review encompassed twenty-eight databases via two indexing services and extracted information from 232 primary sources (27,458 records selected for title and abstract screening, 574 articles selected for full-text screening). We identified a total of 653 intervention activities, which were classified into intervention components and grouped under three broad themes, namely contextual and environmental changes, social influence, and knowledge and behavioral regulation. Multi-component interventions tended to report overall positive outcomes. The review proposes several directions for future research, including: (i) moving toward more theory-based interventions in collective meal contexts; (ii) providing more detailed information about intervention settings, implementation, target groups, activities, and materials; and (iii) improving the use of open science practices in the field. Furthermore, the review offers a free, original, open-access list and synthesis of 277 intervention studies in collective meal contexts, which can help intervention planners and evaluators optimize their efforts to promote healthier and more sustainable food practices in these contexts.

Beyond Plants: The Ultra-Processing of Global Diets Is Harming the Health of People, Places, and Planet

Global food systems are a central issue for personal and planetary health in the Anthropocene. One aspect of major concern is the dramatic global spread of ultra-processed convenience foods in the last 75 years, which is linked with the rising human burden of disease and growing sustainability and environmental health challenges. However, there are also calls to radically transform global food systems, from animal to plant-derived protein sources, which may have unintended consequences. Commercial entities have moved toward this "great plant transition" with vigor. Whether motivated by profit or genuine environmental concern, this effort has facilitated the emergence of novel ultra-processed "plant-based" commercial products devoid of nutrients and fiber, and sometimes inclusive of high sugar, industrial fats, and synthetic additives. These and other ingredients combined into "plant-based" foods are often assumed to be healthy and lower in calorie content. However, the available evidence indicates that many of these products can potentially compromise health at all scales-of people, places, and planet. In this viewpoint, we summarize and reflect on the evidence and discussions presented at the Nova Network planetary health meeting on the "Future of Food", which had a particular focus on the encroachment of ultra-processed foods into the global food supply, including the plant-sourced animal protein alternatives (and the collective of ingredients therein) that are finding their way into global fast-food chains. We contend that while there has been much uncritical media attention given to the environmental impact of protein and macronutrient sources-meat vs. novel soy/pea protein burgers, etc.-the impact of the heavy industrial processing on both human and environmental health is significant but often overlooked, including effects on cognition and mental health. This calls for a more nuanced discourse that considers these complexities and refocuses priorities and value systems towards mutualistic solutions, with co-benefits for individuals, local communities, and global ecology.

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.

Simply Dinner: A Randomized Controlled Trial of Home Meal Delivery

OBJECTIVE

To determine the effect of a bundled intervention (home meal delivery and provision of cooking/serving resources) on preschoolers' body mass index z-score (BMIz), dietary quality, and family meal frequency.

METHODS

Participants (299 families; mean child age 4.4 years, 47% male, 55% White, 18% Black, 27% Hispanic or other race and ethnicity, and 25% were overweight or obese) were randomized to a control group or to provision of cooking/serving resources plus home meal delivery for 12 weeks (meals provided by Meals on Wheels [MOW cohort, n = 83] or a commercial service [COM cohort, n = 216]). Outcomes were child dietary quality, family meal frequency, and child BMIz.

RESULTS

The intervention increased dinnertime intake of red and orange vegetables in the full sample (MOW cohort+COM cohort) (0.10 pre- to 0.15 cup equivalents (CE) post-in the intervention group vs 0.10 pre- to 0.09 post- in the control group; P = .01) and the COM cohort (0.11 pre- to 0.17 CE post- vs 0.11 pre- to 0.09 post-; P = .002), and typical daily dietary intake of fruit and fruit juice in the MOW cohort (1.50 CE pre- to 1.66 post- vs 1.48 pre- to 1.19 post-; P = .05). The intervention did not change meal frequency or BMIz.

CONCLUSIONS

Short-term home meal delivery with provision of cooking/serving resources improved dietary quality among preschool-aged children but did not change meal frequency or BMIz. Expansion of Meals on Wheels programs to preschool-aged children may be a promising intervention to improve dietary quality. Family meals, when already frequent, are not further increased by reducing the burden of meal preparation.

Adult food choices in association with the local retail food environment and food access in resource-poor communities: a scoping review

BACKGROUND

There is a growing body of research on local retail food environments globally in both urban and rural settings. Despite this, little research has been conducted on adult food choices, local retail environments, and healthy food access in resource-poor communities. The purpose of this study is therefore to provide an overview of the evidence on adult food choices (measured as dietary intake) in association with the local retail food environment and food access in resource-poor communities (defined as low-income communities and/or households).

METHODS

We searched nine databases for studies published from July 2005 to March 2022 and identified 2426 records in the primary and updated search. Observational studies, empirical and theoretical studies, focused on adults ≤ 65 years, published in English peer-reviewed journals, examining local retail food environments and food access, were included. Two independent reviewers screened identified articles using the selection criteria and data extraction form. Study characteristics and findings were summarized for all studies and relevant themes summarized for qualitative and mixed methods studies.

RESULTS

A total of 47 studies were included in this review. Most studies were cross sectional (93.6%) and conducted in the United States of America (70%). Nineteen (40.4%) studies assessed the association between food choice outcomes and local retail food environment exposures, and evidence on these associations are inconclusive. Associations of certain food choice outcomes with healthy food retail environments were positive for healthy foods (in 11 studies) and unhealthy foods (in 3 studies). Associations of certain food choice outcomes with unhealthy retail food environment exposures were positive for unhealthy foods in 1 study and negative for healthy foods in 3 studies. In 9 studies, some of the food choice outcomes were not associated with retail food environment exposures. A healthy food store type and lower food prices were found to be major facilitators for healthy food access in resource-poor communities, while cost and transportation were the main barriers.

CONCLUSIONS

More research is needed on the local retail food environment in communities in low- and middle-income countries to develop better interventions to improve food choices and access to healthy foods in resource-poor communities.

Inequalities in Environmental Cancer Risk and Carcinogen Exposures: A Scoping Review

Background: Cancer is the leading cause of death in Canada and a major cause of death worldwide. Environmental exposure to carcinogens and environments that may relate to health behaviors are important to examine as they can be modified to lower cancer risks. Built environments include aspects such as transit infrastructure, greenspace, food and tobacco environments, or land use, which may impact how people move, exercise, eat, and live. While environments may play a role in overall cancer risk, exposure to carcinogens or healthier environments is not equitably spread across space. Exposures to carcinogens commonly concentrate among socially and/or economically disadvantaged populations. While many studies have examined inequalities in exposure or cancer risk, this has commonly been for one exposure. Methods: This scoping review collected and synthesized research that examines inequities in carcinogenic environments and exposures. Results: This scoping review found that neighborhoods with higher proportions of low-income residents, racialized people, or same-sex couples had higher exposures to carcinogens and environments that may influence cancer risk. There are currently four main themes in research studying inequitable exposures: air pollution and hazardous substances, tobacco access, food access, and other aspects of the built environment, with most research still focusing on air pollution. Conclusions: More work is needed to understand how exposures to these four areas intersect with other factors to reduce inequities in exposures to support longer-term goals toward cancer prevention.

Neighborhood deprivation, built environment, and overweight in adolescents in the city of Oslo

BACKGROUND

Even though the social and built environment characteristics of neighborhoods have been studied as potential determinants of social inequalities in obesity among adults, fewer studies have focused on children. Our first aim was to investigate whether there were differences in the food and physical activity environments between different neighborhood deprivation levels in the city of Oslo. We also explored whether there was an association between the prevalence of overweight (including obesity) among adolescents and (i) neighborhood deprivation levels and (ii) food and physical activity environments of the neighborhoods they live in.

METHODS

We conducted a food and physical activity environment mapping (using ArcGIS Pro) in all neighborhoods of Oslo, which were defined by administrative boundaries (sub-districts). The neighborhood deprivation score was calculated based on the percentage of households living in poverty, unemployment in the neighborhood, and residents with low education. A cross-sectional study including 802 seventh graders from 28 primary schools in Oslo residing in 75 out of 97 sub-districts in Oslo was also performed. MANCOVA and partial correlations were ran to compare the built environment distribution between different neighborhood deprivation levels, and multilevel logistic regression analyses were used to explore the effect of neighborhood deprivation and the food and physical activity environments on childhood overweight.

RESULTS

We found that deprived neighborhoods had greater availability of fast food restaurants and fewer indoor recreational facilities compared to low-deprived neighborhoods. Additionally, we observed that the residential neighborhoods of the adolescents with overweight had greater availability of grocery and convenience stores when compared to the residential neighborhoods of the adolescents without overweight. Adolescents living in neighborhoods with high deprivation had a two-fold higher odds (95% CI = 1.1-3.8) to have overweight compared to adolescents living in neighborhoods with low deprivation, regardless of participants' ethnicity and parental education. However, the built environment did not determine the relationship between neighborhood deprivation and overweight in adolescents.

CONCLUSION

The neighborhoods in Oslo with higher deprivation levels had more obesogenic characteristics than the low-deprived neighborhoods. Adolescents living in high-deprived neighborhoods were more likely to have overweight than their counterparts from low-deprived neighborhoods. Thus, preventive measures targeting adolescents from high-deprived neighborhoods should be put in place in order to reduce incidence of overweight.

Association Between County-Level Food Retail and Socioeconomic Environment and Nutritional Quality of Household Food Purchases, 2015

BACKGROUND

About 40 million Americans do not have easy access to affordable nutritious foods. Healthier foods are less likely to be available to those living in rural and/or lower-income communities.

OBJECTIVE

The objective of this study was to analyze the association between nutritional quality of household food purchases and county-level food retail environment; county-level demographic, health, and socioeconomic indicators; and household composition, demographic characteristics, and socioeconomic characteristics.

DESIGN

This study is a secondary analysis of the 2015 Information Resources Inc Consumer Network panel; Purchase-to-Plate Crosswalk, which links US Department of Agriculture nutrition databases to Information Resources Inc scanner data; County Health Rankings; and the Food Environment Atlas data.

PARTICIPANTS AND SETTINGS

A total of 63,285 households, representative of the contiguous US population, consistently provided food purchase scanner data from retail stores throughout 2015.

MAIN OUTCOME MEASURES

Nutritional quality of retail food purchases was assessed using the Healthy Eating Index 2015 (HEI-2015).

STATISTICAL ANALYSIS

Multivariate linear regression analysis was used to simultaneously test the relationship between the main outcome and household-level demographic and socioeconomic characteristics as well as the county-level demographic, health, socioeconomic, and retail food environment.

RESULTS

Household heads who had higher education and households with higher incomes purchased food of better nutritional quality (ie, higher HEI-2015 scores). Also, the association between retail food purchase HEI-2015 scores and the food environment was weak. Higher density of convenience stores was associated with lower retail food purchase nutritional quality for higher-income households and households living in urban counties, whereas low-income households in counties with higher specialty (including ethnic) store density purchased higher nutritional quality food. Both in the full sample and when stratified by household income or county rural vs urban status, no association was found between grocery store, supercenters, fast-food outlets, and full-service restaurant densities and retail food purchase HEI-2015 scores. HEI-2015 scores were negatively correlated with the county average number of mental health days for higher income and urban households.

CONCLUSIONS

The study findings suggest that availability of healthier food alone may not improve healthfulness of retail food purchases. Future studies examining the influence of demand-side factors/interventions, such as habits, cultural preferences, nutrition education, and cost/affordability, on household purchasing patterns could provide complementary evidence to inform effective intervention strategies.

Cross-sectional and prospective associations between household socioeconomic resources, appetite traits, and body size among Samoan infants

In high-income countries, household socioeconomic resources (as measured by education, occupation, income, and/or household assets) and childhood obesity risk tend to be negatively associated. This association may arise in part because children from households with fewer resources are exposed to obesogenic environments that shape appetite trait development. In contrast, many low- and middle-income countries (LMICs) exhibit a positive association between socioeconomic resources and child body size. There is less evidence from LMIC settings about when during development this association emerges and whether appetite traits play a mediatory role. To explore these questions, we examined cross-sectional and longitudinal associations between socioeconomic resources, appetite traits, and body size among infants in Samoa, an LMIC in Oceania. Data were from the Foafoaga O le Ola prospective birth cohort of 160 mother-infant dyads. Appetite traits were characterized using the Baby and Child Eating Behavior Questionnaires and household socioeconomic resources were quantified using an asset-based measure. While infant body size and household socioeconomic resources were positively associated in both cross-sectional and prospective analyses, we found no evidence that appetite traits mediate this relationship. These results suggest that other aspects of the food environment, such as food security and feeding style, may explain the positive association between socioeconomic resources and body size observed in many LMICs.

AHA Life's essential 8 and ideal cardiovascular health among young adults

Objective

This study assessed cardiovascular health (CVH) in young adults using the 2022 AHA Life's Essential 8 (LE8) score and compared it with the Life's Simple 7 (LS7) score.

Methods

Individuals aged 18 to 44 years without a history of cardiovascular disease in the National Health and Nutrition Examination Survey (NHANES) cycles were included. Data from 2007-2008 to 2017-2018 were combined to create 3 groups (2007-2010, 2011-2014, and 2015-2018) for analysis. The LE8 score and its components were computed in the overall population and stratified by sex and race/ethnicity. Trends for the LE8 score were analyzed using adjusted linear regression models.

Results

Among 12,197 young adults, representing an estimated 89.4 million individuals, from the NHANES 2007-2018, the CVH in the overall population and across all subgroups was stable (Ptrend >0.05). The blood lipid score improved across all subgroups (Ptrend:<0.05). The mean LE8 score was 69.2±0.3. Females (71.4±0.4) had better CVH compared with males (67.2±0.4). Non-Hispanic Black individuals (65.1± 0.3) had the lowest CVH compared with Non-Hispanic White individuals (69.9±0.5), Mexican American individuals (67.3±0.3), and other race individuals (71.2±0.4). Of the 46.1 million individuals categorized as intermediate CVH by the LS7 score, 8.1 million (17.6%) and 2.3 million (5.0%) were reclassified to poor and ideal CVH by the LE8 score, respectively. Of the 40.1 million individuals categorized as ideal CVH by the LS7 score, 18.9 million (47.1%) and 0.1 million (0.2%) were reclassified to poor CVH and intermediate CVH by the LE8 score, respectively.

Conclusion

Among US young adults, there has been no improvement in CVH over the last decade with notable sex and race/ethnicity-associated differences in the LE8 score. Nearly 1 in 4 young adults had ideal CVH using the LE8 score compared with 1 in 2 individuals using the LS7 score.

Associations between area deprivation and changes in the digital food environment during the COVID-19 pandemic: Longitudinal analysis of three online food delivery platforms

Online food delivery services facilitate access to unhealthy foods and have proliferated during the COVID-19 pandemic. This study explores associations between neighbourhood deprivation and exposure to online food delivery services and changes in exposure by deprivation during the first year of the pandemic. Data on food outlets delivering to 661 postcode districts in London and the North of England in 2020 and 2021 were collected from three online delivery platforms. The association between area deprivation and overall exposure to online food delivery services was moderated by region, with evidence of a positive relationship between count of outlets and deprivation in the North of England, and a negative relationship in London. There was no association between area deprivation and growth of online food delivery services. Associations between neighbourhood deprivation and exposure to the digital food environment vary geographically. Consequently, policies aimed at the digital food environment need to be tailored to the local context.

Proximity to High/Moderate vs Low Diversity Selection Food Stores and Patient Weight loss through 24 Months

PURPOSE

Explorations into the neighborhood food environment have not adequately extended to adults with obesity who undergo bariatric surgery. The objective of this study is to determine how diversity of food selection at food retail stores within proximities of 5- and 10-min walks associate with patient postoperative weight loss over 24 months.

MATERIALS AND METHODS

Eight hundred eleven patients (82.1% female; 60.0% White) who had primary bariatric surgery (48.6% gastric bypass) from 2015 to 2019 at The Ohio State University were included. EHR variables included race, insurance, procedure, and percent total weight loss (%TWL) at 2, 3, 6, 12, and 24 months. Proximity from patients' home addresses to food stores within a 5- (0.25 mile)- and 10-min (0.50 mile) walk were totaled for low (LD) and moderate/high (M/HD) diversity food selections. Bivariate analyses were conducted with %TWL at all visits and LD and M/HD selections within 5- (0, ≥ 1) and 10-min (0, 1, ≥ 2) walk proximities. Four mixed multilevel models were conducted with dependent variable %TWL over 24 months with visits as the between subjects factor and covariates: race, insurance, procedure, and interaction between proximity to type of food store selections with visits to determine association with %TWL over 24 months.

RESULTS

There were no significant differences for patients living within a 5- (p = 0.523) and 10-min (p = 0.580) walk in proximity to M/HD food selection stores and weight loss through 24 months. However, patients living in proximity to at least 1 LD selection store within a 5- (p = 0.027) and 1 or 2 LD stores within a 10-min (p = 0.015) walk had less weight loss through 24 months.

CONCLUSION

Overall, living in proximity to LD selection stores was a better predictor of postoperative weight loss over 24 months than living within proximity of M/HD selection stores.

Food availability and affordability in a Mediterranean urban context: associations by store type and area-level socio-economic status

OBJECTIVE

Although food environments have been highlighted as potentially effective targets to improve population diets, evidence on Mediterranean food environments is lacking. We examined differences in food availability and affordability in Madrid (Spain) by store type and area-level socio-economic status (SES).

DESIGN

Cross-sectional study. Trained researchers conducted food store audits using the validated Nutrition Environment Measures Survey in Stores for Mediterranean contexts (NEMS-S-MED) tool to measure the availability and price of twelve food groups (specific foods = 35). We computed NEMS-S-MED scores and summarised price data with a Relative Price Index (RPI, comparing prices across stores) and an Affordability Index (normalising prices by area-level income). We compared the availability and affordability of 'healthier-less healthy' food pairs, scores between food store types (supermarkets, specialised, convenience stores and others) and area-level SES using ANOVA and multi-level regression models.

SETTING

City of Madrid. 2016 and 2019 to cover a representative sample.

PARTICIPANTS

Food stores within a socio-economically diverse sample of sixty-three census tracts (n 151).

RESULTS

Supermarkets had higher food availability (37·5/49 NEMS-S-MED points), compared to convenience stores (13·5/49) and specialised stores (8/49). Supermarkets offered lower prices (RPI: 0·83) than specialised stores (RPI: 0·97) and convenience stores (RPI: 2·06). Both 'healthy' and 'less healthy' items were more available in supermarkets. We found no differences in food availability or price by area-level SES, but affordability was higher in higher-income areas.

CONCLUSIONS

Supermarkets offered higher food availability and affordability for healthy and less healthy food items. Promoting healthy food availability through supermarkets and specialised stores and/or limiting access to convenience stores are promising policy options to achieve a healthier food environment.

Retail Food Environment around Schools in Barcelona by Neighborhood Socioeconomic Status: Implications for Local Food Policy

Childhood obesity is a relevant public health problem. The school food environment has been identified as an important factor for promoting healthy eating behaviors. This study assessed the availability of and proximity to unhealthy food stores around schools (n = 22) in the city of Barcelona and its association with neighborhood socioeconomic status (NSES). We conducted this cross-sectional study between 2019 and 2020. First, we identified all food retailers (n = 153) within a 400-m buffer around each school and identified those selling unhealthy food products. Then, we used Poison regression models to measure the association between NSES and the healthy food availability index (HFAI), adjusting for population density and distance. A total of 95% of the food establishments studied were classified as unhealthy (n = 146). In all, 90% of schools that had, at least, two unhealthy retailers in their proximity. There were significant differences in the mean distance to unhealthy establishments according to neighborhood SES and population density (p < 0.05). We found a positive association between schools located in higher SES neighborhoods and a higher availability and affordability of healthy food products (IIR = 1.67, 95% CI = 1.45−1.91 p = 0.000). We found strong social inequalities in the supply of healthy foods in Barcelona. Local food policy interventions addressing retail food environment around schools should consider socioeconomic inequalities.

Disparities in Childhood Obesity Prevalence and Spatial Clustering Related to Socioeconomic Factors in Isaan, Thailand

Globally, rapid economic growth has contributed to an overall increase in the incidence of childhood obesity. Although the prevalence of obesity has been well recognized, the disparities related to a region's socioeconomic environment in terms of the incidence of obesity are still less understood. Therefore, the purpose of this study was to examine the spatial pattern of childhood obesity and identify the potential associations between childhood obesity and socioeconomic environment in the northeastern region of Thailand, Isaan. Using nationally collected obesity data from children aged 0-5 years in 2019, we employed a geographic information system (GIS) to perform obesity cluster analysis at the smaller regional level, investigating a total of 322 districts in study area. Global and local statistical approaches were applied to calculate spatial associations between the socioeconomic status of neighborhoods and childhood obesity. The study revealed that 12.42% of the total area showed significant clusters at the district level, with high values observed in the western and northeastern areas. The results of the spatial statistical model revealed that childhood obesity was significantly positively associated with areas exhibiting high levels of socioeconomic environment factors. Identifying the associated factors and highlighting geographic regions with significant spatial clusters is a powerful approach towards understanding the role of location and expanding the knowledge on the factors contributing to childhood obesity. Our findings, as a first step, offer valuable references that could support policy-makers and local authorities in enhancing policy development with the aim of reducing childhood obesity and improving public health.

The community food environment and its association with diet, health or weight status in Australia: A systematic review with recommendations for future research

ISSUE ADDRESSED

This study systematically reviewed Australian literature to determine if an association exists between geospatial exposure to food outlets and diet, health or weight status. Recommendations for future research are provided.

METHODS

A systematic literature search was conducted in December 2021 using CINAHL Plus, PubMed and Web of Science databases. Data were extracted, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using an eight-item checklist. A descriptive synthesis of study characteristics and findings was carried out, stratified via study outcomes.

RESULTS

Of the 36 included articles, the majority were from Victoria (n = 19), involving adult participants (n = 30) and cross-sectional in design (n = 27). Overall, associations were mainly null (nonsignificant) for diet (80%), weight status (75%) and health outcomes (90%). Significant findings were mixed with no positive trend with study quality.

CONCLUSIONS

Six recommendations are suggested to address current knowledge gaps and limitations in the Australian evidence base: (1) Conduct research on different populations; (2) Employ robust study designs that can test the impact of change over time; (3) Improve the accuracy of food outlet data sources; (4) Improve food outlet geospatial exposure measures; (5) Improve measurement of outcome variables; and (6) Incorporate theoretical models into study design and data analysis. SO WHAT?: Improving the quality and consistency of research will be critical to informing locally relevant policy. Despite the present limitations in the evidence base, it is reasonable to assume that decisions to purchase and consume food are driven by availability and access. Thus, policy and planning aimed at improving the overall "healthiness" of the community food environment by increasing access to healthy food outlets is warranted to ensure that healthy options are easier choice for all.

The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics

INTRODUCTION

Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington.

METHODS

We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile.

RESULTS

Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents.

CONCLUSION

We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

Regional Difference in the Effect of Food Accessibility and Affordability on Vegetable and Fruit Acquisition and Healthy Eating Behaviors for Older Adults

The food environment has been determined to affect a range of healthy eating and health indicators, but the study on the regional difference of food environment effects on these outcomes is limited. This study aimed to examine whether food environment factors influence vegetable and fruit acquisition and healthy eating behaviors in urban and rural areas using a nationwide dataset. The study participants were community-dwelling older adults aged 65 years and older (n = 830) who participated in the 2019 Consumer Behavior Survey for Food provided by the Korea Rural Economic Institute. Food environment factors were assessed using questionnaires measuring perceived food accessibility and affordability. The negative perceptions of food environment were related to lower vegetable and fruit acquisitions and poor healthy eating behaviors. The higher risks of low vegetable and fruit acquisitions in older rural adults were related to a negative perception of food accessibility only (odds ratio [OR]: 2.34, 95% confidence interval [CI]: 1.27-4.32 for vegetable; OR: 1.96, 95% CI: 1.02-3.75 for fruit). For older urban adults, negative perceptions of both food accessibility and food affordability were related to the increased risk of low vegetable acquisition (OR: 2.03, 95% CI: 1.07-3.83 for food accessibility; OR: 2.52, 95% CI: 1.26-5.04 for food affordability). In terms of healthy eating behaviors, for those who perceived that either food accessibility or affordability was poor, older urban adults were less likely to have various and healthy food eating behaviors when they had a negative perception of affordability (OR: 0.47, 95% CI: 0.25-0.90 for variety; OR: 0.23, 95% CI: 0.11-0.46 for eating healthy foods); however, older rural adults were less likely to have the behaviors when they had a negative perception of accessibility (OR: 0.49, 95% CI: 0.21-0.97 for variety; OR: 0.28, 95% CI: 0.13-0.63 for eating healthy foods). In conclusion, the negative perceptions of food accessibility and affordability were related to low vegetable acquisition and poor healthy eating behaviors. The effects of food accessibility and affordability on vegetable and fruit acquisitions and healthy eating behaviors were different between urban and rural areas.

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample

Background

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data.

Methods

We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17.

Results

Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients.

Conclusions

In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Giving Families a Voice for Equitable Healthy Food Access in the Wake of Online Grocery Shopping

Understanding the views of families from low-income backgrounds about inequities in healthy food access and grocery purchase is critical to food access policies. This study explored perspectives of families eligible for the Supplemental Nutrition Assistance Program (SNAP) on healthy food access in physical and online grocery environments. The qualitative design used purposive sampling of 44 primary household food purchasers with children (aged ≤ 8), between November 2020-March 2021, through 11 online focus groups and 5 in-depth interviews. Grounded theory was used to identify community-level perceived inequities, including influences of COVID-19 pandemic, SNAP and online grocery services. The most salient perceived causes of inequitable food access were neighborhood resource deficiencies and public transportation limitations. Rural communities, people with disabilities, older adults, racially and ethnically diverse groups were perceived to be disproportionately impacted by food inequities, which were exacerbated by the pandemic. The ability to use SNAP benefits to buy foods online facilitated healthy food access. Delivery fees and lack of control over food selection were barriers. Barriers to healthy food access aggravated by SNAP included social stigma, inability to acquire cooked meals, and inadequate amount of monthly funds. Findings provide a foundation for policy redesign to promote equitable healthy food systems.

Towards healthy urbanism: inclusive, equitable and sustainable (THRIVES) - an urban design and planning framework from theory to praxis

The globally distributed health impacts of environmental degradation and widening population inequalities require a fundamental shift in understandings of healthy urbanism - including policies and decisions that shape neighbourhood and building design. The built environment tends to disadvantage or exclude women, children, the elderly, disabled, poor and other groups, starting from design and planning stages through to occupation, and this results in avoidable health impacts. Although these concepts are not new, they are rapidly emerging as built environment research and practice priorities without clear understanding of the interconnected aims of healthy environments that are sustainable, equitable and inclusive. This article promotes a new framework - Towards Healthy uRbanism: InclusiVe Equitable Sustainable (THRIVES) - that extends previous conceptualisations and reorients focus towards the existential threat of environmental breakdown and the social injustice created through inequitable and exclusive urban governance and design processes and outcomes. The Framework was developed through synthesising knowledge from research and practice, and by testing this new conceptualisation in a participatory workshop. Ongoing research is exploring implementation of the Framework in practice. If widely adopted, this Framework may contribute towards achieving the goals of sustainable development through a focus on increasing human health and wellbeing in urban development.

Enhancing the Retail Food Environment Index (RFEI) with Neighborhood Commuting Patterns: A Hybrid Human-Environment Measure

The Retail Food Environment Index (RFEI) and its variants have been widely used in public health to measure people's accessibility to healthy food. These indices are purely environmental as they only concern the geographic distribution of food retailers, but fail to include human factors, such as demographics, socio-economy, and mobility, which also shape the food environment. The exclusion of human factors limits the explanatory power of RFEIs in identifying neighborhoods of the greatest concern. In this study, we first proposed a hybrid approach to integrate human and environmental factors into the RFEI. We then demonstrated this approach by incorporating neighborhood commuting patterns into a traditional RFEI: we devised a multi-origin RFEI (MO_RFEI) that allows people to access food from both homes and workplaces, and further an enhanced RFEI (eRFEI) that allows people to access food with different transportation modes. We compared the traditional and proposed RFEIs in a case study of Florida, USA, and found that the eRFEI identified fewer and more clustered underserved populations, allowing policymakers to intervene more effectively. The eRFEI depicts more realistic human shopping behaviors and better represents the food environment. Our study enriches the literature by offering a new and generic approach for assimilating a neighborhood context into food environment measures.

Heterogeneity in grocery shopping patterns among low-income minority women in public housing

BACKGROUND

Public housing residents, who tend to be predominantly female and racial/ethnic minorities, are at a particularly high risk for chronic health conditions. Prior studies have suggested that a lack of access to healthy and affordable food may be an important barrier in public housing communities, but evidence is mixed on the association between the neighborhood food environment and dietary quality, suggesting the need to examine food access patterns in low-income, minority communities more deeply. The purpose of this study was to examine the variability in grocery shopping patterns, and the factors that predict them, among low-income minority women in public housing.

METHODS

Interviewer-administered surveys and body composition measurements were collected in the Watts Neighborhood Health Study, an ongoing longitudinal cohort study of low-income urban public housing residents located in South Los Angeles. Descriptive analyses were conducted to understand the variation in grocery shopping patterns among women. Logistic and ordered logistic regression models were estimated to examine the association between resident characteristics and grocery shopping patterns.

RESULTS

There was considerable variability in grocery shopping patterns, including the types of grocery stores accessed, distance travelled, frequency of shopping, and reasons behind grocery store choice. Grocery shopping patterns were associated with several participant characteristics, including race/ethnicity, working status, access to a car, income, and education. Hispanic participants were less likely to shop at a supermarket, travel further distances to shop, shop more frequently, and were more likely to prioritize price in their choice of primary grocery store than non-Hispanic Black women participants.

CONCLUSIONS

There was considerable variability in grocery shopping patterns, even within this low-income, minority community despite access to the same neighborhood food environment. Convenience and quality, in addition to price, were priorities for choice of primary grocery store, and differences by race/ethnicity suggest that initiatives to improve the neighborhood food environment should consider quality of food, cultural factors, and availability of foods desired by the surrounding community, in addition to price and proximity of grocery stores.

Sources of food ready to consume around the Health Academy Program units: an analysis according to inequality

The aim of this study was to spatially examine the distribution of establishments for the acquisition of food that is ready to consume around the Health Academy Program (PAS) in Belo Horizonte, Minas Gerais, Brazil, according to the Municipal Human Development Index (IDH-M).This is an ecological study with the PAS as the unit of analysis. The establishments contained in a circular buffer with a radius of 900 meters from the 77 units of the PAS in operation were evaluated. Address and type of establishment data were obtained from a public list and verified in a virtual audit. Thematic kernel maps were used. A total of 3,050 establishments were identified around the PAS units. Higher densities were observed around units located in the city's south-central region and in areas with high and very high IDH-M. There was a high density of establishments selling ready-to-consume foods around the PAS units, especially in the wealthier parts of the city. These results are useful in supporting the planning of actions aimed at strengthening the PAS as a promoter of healthy eating environments. Further, it reinforces the need for equitable public policies for supply and regulation, aiming to promote access to adequate and healthy food for all.

Sources of food ready to consume around the Health Academy Program units: an analysis according to inequality

Abstract The aim of this study was to spatially examine the distribution of establishments for the acquisition of food that is ready to consume around the Health Academy Program (PAS) in Belo Horizonte, Minas Gerais, Brazil, according to the Municipal Human Development Index (IDH-M).This is an ecological study with the PAS as the unit of analysis. The establishments contained in a circular buffer with a radius of 900 meters from the 77 units of the PAS in operation were evaluated. Address and type of establishment data were obtained from a public list and verified in a virtual audit. Thematic kernel maps were used. A total of 3,050 establishments were identified around the PAS units. Higher densities were observed around units located in the city’s south-central region and in areas with high and very high IDH-M. There was a high density of establishments selling ready-to-consume foods around the PAS units, especially in the wealthier parts of the city. These results are useful in supporting the planning of actions aimed at strengthening the PAS as a promoter of healthy eating environments. Further, it reinforces the need for equitable public policies for supply and regulation, aiming to promote access to adequate and healthy food for all.

Systematic literature review of instruments that measure the healthfulness of food and beverages sold in informal food outlets

BACKGROUND

Informal food outlets, defined as vendors who rarely have access to water and toilets, much less shelter and electricity, are a common component of the food environment, particularly in many non-Western countries. The purpose of this study was to review available instruments that measure the quality and particularly the healthfulness of food and beverages sold within informal food outlets.

METHODS

PubMed, LILACS, Web of Science, and Scopus databases were used. Articles were included if they reported instruments that measured the availability or type of healthy and unhealthy foods and beverages by informal food outlets, were written in English or Spanish, and published between January 1, 2010, and July 31, 2020. Two trained researchers reviewed the title, abstract and full text of selected articles; discrepancies were solved by two independent researchers. In addition, the list of references for selected articles was reviewed for any additional articles of relevance. The quality of published articles and documents was evaluated using JBI Critical appraisal checklist for analytical cross-sectional studies.

RESULTS

We identified 1078 articles of which 14 were included after applying the selection criteria. Three additional articles were considered after reviewing the references from the selected articles. From the final 17 articles, 13 measurement tools were identified. Most of the instruments were used in low- and middle-income countries (LMIC). Products were classified as healthy/unhealthy or produce/non-produce or processed/unprocessed based on availability and type. Six studies reported psychometric tests, whereas one was tested within the informal food sector.

CONCLUSIONS

Few instruments can measure the healthfulness of food and beverages sold in informal food outlets, of which the most valid and reliable have been used to measure formal food outlets as well. Therefore, it is necessary to develop an instrument that manages to measure, specifically, the elements available within an informal one. These actions are extremely important to better understand the food environment that is a central contributor to poor diets that are increasingly associated with the obesity and Non-communicable disease (NCD) pandemic.