Body mass index in elementary school children, metropolitan area food prices and food outlet density

Effects of food price on nutrition outcomes among women in Nigeria

Nutrition outcomes (undernutrition, overweight, and obesity) among women are growing concerns across the globe. Currently, the rate of undernutrition and overweight among women in Nigeria is ranked among the highest in Africa. A major contributory factor reported is unstable food prices in the country. This study, therefore, examined the effects of food prices on nutrition outcomes among women in Nigeria. Secondary datasets retrieved from two different sources were used for this study. Cross-sectional data on weight and height for women were obtained from Nigeria Health Demographic Survey (NHDS). Data on monthly prices of the selected food items were obtained from the Nigeria Bureau of Statistics (NBS). The data were categorized into energy dense (yam tuber, garri, rice, and maize) and nutrient dense (egg, beef, and chicken). Multinomial logit regression was used to estimate the relationship between the prices of energy and nutrient-dense food prices concerning respondents' personal and environmental characteristics such as age, wealth status, and region; as well as the three nutrition outcomes for women (undernutrition, overnutrition, and obesity). This study revealed that the prevalence of overweight and obesity among women was 19.9% and 10.3%, respectively. Nutrition outcomes (obesity and overweight) were positively correlated with the price of energy-dense food with 0.2% and 0.3%, respectively. Nutrient-dense food price is negatively correlated with undernutrition with a probability of 0.1%. The study recommends that food policy instruments such as food prices and subsidies can be introduced to favor the consumption of healthier food to stem the prevalence of overweight and obesity in Nigeria.

Spatial scale analysis for the relationships between the built environment and cardiovascular disease based on multi-source data

To examine what built environment characteristics improve the health outcomes of human beings is always a hot issue. While a growing literature has analyzed the link between the built environment and health, few studies have investigated this relationship across different spatial scales. In this study, eighteen variables were selected from multi-source data and reduced to eight built environment attributes using principal component analysis. These attributes included socioeconomic deprivation, urban density, street walkability, land-use diversity, blue-green space, transportation convenience, ageing, and street insecurity. Multiscale geographically weighted regression was then employed to clarify how these attributes relate to cardiovascular disease at different scales. The results indicated that: (1) multiscale geographically weighted regression showed a better fit of the association between the built environment and cardiovascular diseases than other models (e.g., ordinary least squares and geographically weighted regression), and is thus an effective approach for multiscale analysis of the built environment and health associations; (2) built environment variables related to cardiovascular diseases can be divided into global variables with large scales (e.g., socioeconomic deprivation, street walkability, land-use diversity, blue-green space, transportation convenience, and ageing) and local variables with small scales (e.g., urban density and street insecurity); and (3) at specific spatial scales, global variables had trivial spatial variation across the area, while local variables showed significant gradients. These findings provide greater insight into the association between the built environment and lifestyle-related diseases in densely populated cities, emphasizing the significance of hierarchical and place-specific policy formation in health interventions.

Perceived Availability of Healthy and Unhealthy Foods in the Community, Work, and Higher Education Settings across Five Countries: Findings from the International Food Policy Study 2018

BACKGROUND

Food environments play a key role in dietary behavior and vary due to different contexts, regulations, and policies.

OBJECTIVES

This study aimed to characterize the perceived availability of healthy and unhealthy foods in 3 different settings in 5 countries.

METHODS

We analyzed data from the 2018 International Food Policy Study, a cross-sectional survey of adults (18-100 y, n = 22,824) from Australia, Canada, Mexico, the United Kingdom (UK), and the USA. Perceived availability of unhealthy (junk food and sugary drinks) and healthy foods (fruit or vegetables, healthy snacks, and water) in the community, workplace, and university settings were measured (i.e. not available, available for purchase, or available for free). Differences in perceived availability across countries were tested using adjusted multinomial logistic regression models.

RESULTS

Across countries, unhealthy foods were perceived as highly available in all settings; in university and work settings unhealthy foods were perceived as more available than healthy foods. Australia and Canada had the highest perceived availability of unhealthy foods (range 87.5-90.6% between categories), and the UK had the highest perceived availability of fruits and vegetables for purchase (89.3%) in the community. In university and work settings, Mexico had the highest perceived availability for purchase of unhealthy foods (range 69.9-84.9%). The USA and the UK had the highest perceived availability of fruits and vegetables for purchase (65.3-66.3%) or for free (21.2-22.8%) in the university. In the workplace, the UK had high perceived availability of fruits and vegetables for purchase (40.2%) or for free (18.5%), and the USA had the highest perceived availability of junk food for free (17.3%).

CONCLUSIONS

Across countries, unhealthy foods were perceived as highly available in all settings. Variability between countries may reflect differences in policies and regulations. Results underscore the need for the continuation and improvement of policy efforts to generate healthier food environments.

Retail food outlets and metabolic syndrome: a systematic review of longitudinal studies

CONTEXT

The community food environment covers the type, quantity, density, location, and access to retail food outlets, and its influence on eating behavior, obesity, and metabolic syndrome has been investigated.

OBJECTIVE

To evaluate the evidence on longitudinal associations between objectively measured retail food outlets and metabolic syndrome components in children, adolescents, and adults.

DATA EXTRACTION

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality and risk of bias were assessed with the Newcastle-Ottawa Scale.

DATA SOURCES

The Scopus, Embase, Web of Science, Scielo, PubMed, MEDLINE, and Lilacs databases were searched without any restriction on publication dates.

DATA ANALYSIS

Of the 18 longitudinal studies included, significant associations were reported in 9 between retail food outlets and metabolic syndrome components in adults (6 positive associations, 2 negative, and 1 both positive and negative), and in 3 studies of children and adolescents (2 negative associations and 1 both positive and negative). Six studies with adults found no association.

CONCLUSION

Limited evidence was found for longitudinal associations between retail food outlets and metabolic syndrome components. In future studies, researchers should consider the use of standardized retail food outlet measurements and accurate analysis to better understand the influence of the community food environment on metabolic syndrome.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no: CRD42020177137.

Early nutritional influences of cardiovascular health

INTRODUCTION

Increasing evidence shows that nutritional choices during children's formative years, including prenatally, impacts the development of adult onset cardiovascular diseases (CVDs), such as hypertension, myocardial infarction, or stroke.

AREAS COVERED

This literature review aims to synthesize the current body of evidence on nutritional factors, from conception through adolescence, which may influence a person's risk factors for future development of CVD.

EXPERT OPINION

Given the escalating healthcare costs associated with CVD, it is imperative that medical professionals and scientists remain steadfast in prioritizing and promoting early CVD prevention, even within the first few years of life. Though not the only contributing risk factor, diet is a modifiable risk factor and has been shown to have a profound impact on the reduction of cardiovascular morbidity and mortality in adult literature. Nutritional choices should be targeted on multiple levels: prenatally with the mother, individually with the patient, in conjunction with their family unit, and also within the broader community wherein they reside. Healthcare providers can play a key advocacy role for local and national food environment policy changes.

Bittersweet: How prices of sugar-rich foods contribute to the diet-related disease epidemic in Mexico

I provide new evidence on how price changes of nutritionally similar foods, such as those rich in sugar or fats, change obesity and diet-related diseases in the context of Mexico between 1996-2010. I merge a bar-code level price dataset with product-specific nutritional composition to two datasets with health outcomes: state-level administrative and nationally representative individual-level panel data. Exploiting within-city variation in prices using fixed effects models, I show that decreased prices of sugar-rich foods increase obesity, type 2 diabetes, and hypertension prevalence; yet the prices of foods rich in other nutrients do not. Health responses to price changes are the largest for those abdominally obese or at the highest risk for chronic disease. The association between prices of sugary foods and chronic disease is meaningful: I estimate that in Mexico, price reductions of sugary foods explain roughly 15 percent of the rise in obesity and diabetes during the 15-year study period.

Geospatial Analysis of Food Deserts and Their Impact on Health Outcomes in Children with Cystic Fibrosis

Food insecurity (FI) is defined as "the limited or uncertain access to adequate food." One root cause of FI is living in a food desert. FI rates among people with cystic fibrosis (CF) are higher than the general United States (US) population. There is limited data on the association between food deserts and CF health outcomes. We conducted a retrospective review of people with CF under 18 years of age at a single pediatric CF center from January to December 2019 using demographic information and CF health parameters. Using a Geographic Information System, we conducted a spatial overlay analysis at the census tract level using the 2015 Food Access Research Atlas to assess the association between food deserts and CF health outcomes. We used multivariate logistic regression analysis and adjusted for clinical covariates and demographic covariates, using the Child Opportunity Index (COI) to calculate odds ratios (OR) with confidence intervals (CI) for each health outcome. People with CF living in food deserts and the surrounding regions had lower body mass index/weight-for-length (OR 3.18, 95% CI: 1.01, 9.40, p ≤ 0.05 (food desert); OR 4.41, 95% CI: 1.60, 12.14, p ≤ 0.05 (600 ft buffer zone); OR 2.83, 95% CI: 1.18, 6.76, p ≤ 0.05 (1200 ft buffer zone)). Food deserts and their surrounding regions impact pediatric CF outcomes independent of COI. Providers should routinely screen for FI and proximity to food deserts. Interventions are essential to increase access to healthy and affordable food.

Parental experiences of adopting healthy lifestyles for children with disabilities living with overweight and obesity

BACKGROUND

Children with disabilities present with high obesity rates.

OBJECTIVE

This study explored the parental experience of adopting healthy lifestyle choices, for children with disabilities, who received dietetic weight management advice.

METHODS

Semi-structured qualitative interviews were carried out with eight parents/carers in their own homes or healthcare setting in an inner London locality, or by telephone. Data was analyzed using an interpretative phenomenological analysis (IPA) approach.

RESULTS

Five superordinate themes emerged: 1. Strategies to promote healthy lifestyles: encouraging physical activity, limiting access to food and taking a gradual approach to making lifestyle changes. 2. Challenges to adopting healthy lifestyles: selective eating patterns, the high cost of healthy foods and parental/carer lack of time. 3. The role of healthcare professionals (HCPs): revealed that not all parents/carers received advice or support, prior to dietetic referral, when managing their child's weight. Feeling reassured by HCPs was valued. Parents/carers reported a positive experience of seeing the dietitian, as they appreciated receiving practical and individualized advice. 4. Support needs: family support and support from families with children with disabilities was explored. 5. Parent/carer wellbeing: such as stress was found to have a detrimental impact on parents making healthy lifestyle changes.

CONCLUSIONS

Adopting a healthy lifestyle involved a variety of strategies and challenges, some of which are specific to this population group and should be considered by HCPs, when having weight-related discussions and offering advice. Parental/carer support needs and wellbeing should also be taken into consideration when planning weight management services for this population group.

Prioritizing Built Environmental Factors to Tackle Chronic and Infectious Diseases in Remote Northern Territory (NT) Communities of Australia: A Concept Mapping Study

High prevalence of chronic and infectious diseases in Indigenous populations is a major public health concern both in global and Australian contexts. Limited research has examined the role of built environments in relation to Indigenous health in remote Australia. This study engaged stakeholders to understand their perceptions of the influence of built environmental factors on chronic and infectious diseases in remote Northern Territory (NT) communities. A preliminary set of 1120 built environmental indicators were systematically identified and classified using an Indigenous Indicator Classification System. The public and environmental health workforce was engaged to consolidate the classified indicators (n = 84), and then sort and rate the consolidated indicators based on their experience with living and working in remote NT communities. Sorting of the indicators resulted in a concept map with nine built environmental domains. Essential services and Facilities for health/safety were the highest ranked domains for both chronic and infectious diseases. Within these domains, adequate housing infrastructure, water supply, drainage system, reliable sewerage and power infrastructure, and access to health services were identified as the most important contributors to the development of these diseases. The findings highlight the features of community environments amenable to public health and social policy actions that could be targeted to help reduce prevalence of chronic and infectious diseases.

Food insecurity (hunger) and fast-food consumption among 180 164 adolescents aged 12-15 years from sixty-eight countries

Food insecurity has been shown to be associated with fast-food consumption. However, to date, studies on this specific topic are scarce. Therefore, the aim of the present study was to investigate the association between food insecurity and fast-food consumption in adolescents aged 12-15 years from sixty-eight countries (seven low-income, twenty-seven lower middle-income, twenty upper middle-income, fourteen high-income countries). Cross-sectional, school-based data from the Global School-based Student Health Survey were analysed. Data on past 30-d food insecurity (hunger) and fast-food consumption in the past 7 d were collected. Multivariable logistic regression and meta-analysis were conducted to assess associations. Models were adjusted for age, sex and BMI. There were 180 164 adolescents aged 12-15 years (mean age 13·8 (sd 1·0) years; 50·8 % boys) included in the analysis. Overall, severe food insecurity (i.e. hungry because there was not enough food in home most of the time or always) was associated with 1·17 (95 % CI 1·08, 1·26) times higher odds for fast-food consumption. The estimates pooled by country-income levels were significant in low-income countries (adjusted OR (aOR) = 1·30; 95 % CI 1·05, 1·60), lower middle-income countries (aOR = 1·15; 95 % CI 1·02, 1·29) and upper middle-income countries (aOR = 1·26; 95 % CI 1·07, 1·49), but not in high-income countries (aOR = 1·04; 95 % CI 0·88, 1·23). The mere co-occurrence of food insecurity and fast-food consumption is of public health importance. To tackle this issue, a strong governmental and societal approach is required to utilise effective methods as demonstrated in some high-income countries such as the implementation of food banks and the adoption of free school meals.

Heterogeneities in Consumer Diet Quality and Health Outcomes of Consumers by Store Choice and Income

Obesity and other diet-related health conditions have received much attention in the public health literature over the past two decades. This study investigates the relationship between household food budget shares at different food outlets with diet quality and weight-related health outcomes in the United States. Our analysis used event-level food purchase data from the national household food acquisition and purchases survey (FoodAPS). We find that, after controlling for observables, food purchase location is significantly associated with diet quality and body mass index (BMI). Our findings indicate that larger food budget shares at convenience stores and restaurants are linked with poor diet quality based on the healthy eating index-2015 (HEI-2015) scores and higher BMI. We further explored potential heterogeneity on outcomes of interest across income groups. Results suggest heterogeneous effects may exist across income groups: low-income households, who spent a larger share of their food budget at convenience stores and fast-food restaurants are related to poor diet quality and more likely to be obese. Our findings will help improve understanding of the causes of diet-related health problems and may illuminate potential avenues of intervention to address obesity.

State-of-the-art of measures of the obesogenic environment for children

Various measures of the obesogenic environment have been proposed and used in childhood obesity research. The variety of measures poses methodological challenges to designing new research because methodological characteristics integral to developing the measures vary across studies. A systematic review has been conducted to examine the associations between different levels of obesogenic environmental measures (objective or perceived) and childhood obesity. The review includes all articles published in the Cochrane Library, PubMed, Web of Science and Scopus by 31 December 2018. A total of 339 associations in 101 studies have been identified from 18 countries, of which 78 are cross-sectional. Overall, null associations are predominant. Among studies with non-null associations, negative relationships between healthy food outlets in residential neighbourhoods and childhood obesity is found in seven studies; positive associations between unhealthy food outlets and childhood obesity are found in eight studies, whereas negative associations are found in three studies. Measures of recreational or physical activity facilities around the participants' home are also negatively correlated to childhood obesity in nine out of 15 studies. Results differ by the types of measurement, environmental indicators and geographic units used to characterize obesogenic environments in residential and school neighbourhoods. To improve the study quality and compare reported findings, a reporting standard for spatial epidemiological research should be adopted.

Fast-food restaurant, unhealthy eating, and childhood obesity: A systematic review and meta-analysis

Excessive access to fast-food restaurants (FFRs) in the neighbourhood is thought to be a risk factor for childhood obesity by discouraging healthful dietary behaviours while encouraging the exposure to unhealthful food venues and hence the compensatory intake of unhealthy food option. A literature search was conducted in the PubMed, Web of Science, and Embase for articles published until 1 January 2019 that analysed the association between access to FFRs and weight-related behaviours and outcomes among children aged younger than 18. Sixteen cohort studies and 71 cross-sectional studies conducted in 14 countries were identified. While higher FFR access was not associated with weight-related behaviours (eg, dietary quality score and frequency of food consumption) in most studies, it was commonly associated with more fast-food consumption. Despite that, insignificant results were observed for all meta-analyses conducted by different measures of FFR access in the neighbourhood and weight-related outcomes, although 17 of 39 studies reported positive associations when using overweight/obesity as the outcome. This systematic review and meta-analysis revealed a rather mixed relationship between FFR access and weight-related behaviours/outcomes among children and adolescents.

Grocery store access and childhood obesity: A systematic review and meta-analysis

Grocery store is usually considered to be a healthy food outlet as it provides access to a variety of healthy food, such as fruits and vegetables, which may potentially improve overall dietary quality and protect against obesity. However, findings of the association between grocery store and childhood obesity are controversial. This study aimed to systematically review the evidence on the association between access to grocery stores and childhood obesity. A literature search was conducted in the PubMed, Embase, and Web of Science for articles published before January 1, 2019, using the combinations of three groups of keywords separately for grocery store, children and adolescents, and weight-related behaviours and outcomes. A total of 27 cross-sectional and eight longitudinal studies were identified. Controversial results existed among 24 studies, which examined the association between the access to grocery stores and weight-related outcomes. A null association was observed in almost all meta-analyses conducted by different measures of grocery stores and weight status, except the analysis between presence of grocery stores and overweight, which reached borderline significance. For weight-related behaviours, mixed findings were reported between grocery stores and dietary behaviours, and no significant associations were found for physical activity. This systematic review and meta-analysis suggested that access to grocery stores may have a rather small influence on child weight.

Association between access to full-service restaurants and childhood obesity

The lack of access to full-service restaurants (FSRs) is generally thought to be a risk factor for childhood obesity, as it could discourage healthful eating-out behaviours while increasing the exposure to unhealthful food venues as "compensatory" options. However, the association between FSR access and childhood obesity has not been comprehensively reviewed previously. A literature search was conducted on PubMed and Web of Science for articles published before 1 January 2019 that examined the association between FSR access and weight-related behaviours and outcomes among children and adolescents. Eighteen studies conducted in three countries were identified, published from 2006 to 2018 with a median sample size of 2352 (ranging from 323 to 529 367). Findings were mixed among these 18 studies that reported on the association between access to FSRs and weight-related outcomes. Our meta-analyses showed that there were no significant associations of FSR access with the level of body mass index (BMI) and the BMI z-score among children. Also, there was no apparent evidence on the association between FSR access and the risk of overweight/obesity. Our results need to be interpreted with caution, considering the menu quality of FSRs and heterogeneity of eligible studies in this meta-analysis. Well-designed epidemiologic studies are warranted to further elaborate on the potential association between FSR access and children's weight status.

A longitudinal analysis of fast-food exposure on child weight outcomes: Identifying causality through school transitions

This article investigates the effect of fast-food availability on childhood weight outcomes by gender, race, and location. We use a novel identification strategy based on changes in fast-food exposure along the route between the home and school that occur as students progress through the public school system and transition to different types of schools, e.g. from elementary school to intermediate school or from intermediate school to high school. Using a longitudinal census of height and weight for public school students in Arkansas, we find no evidence that changes in fast-food exposure are associated with changes in body mass index z-score for any student subpopulation.

Racial Differences in Perceived Food Swamp and Food Desert Exposure and Disparities in Self-Reported Dietary Habits

Both food swamps and food deserts have been associated with racial, ethnic, and socioeconomic disparities in obesity rates. Little is known about how the distribution of food deserts and food swamps relate to disparities in self-reported dietary habits, and health status, particularly for historically marginalized groups. In a national U.S. sample of 4305 online survey participants (age 18+), multinomial logistic regression analyses were used to assess by race and ethnicity the likelihood of living in a food swamp or food desert area. Predicted probabilities of self-reported dietary habits, health status, and weight status were calculated using the fitted values from ordinal or multinomial logistic regression models adjusted for relevant covariates. Results showed that non-Hispanic, Black participants (N = 954) were most likely to report living in a food swamp. In the full and White subsamples (N = 2912), the perception of residing in a food swamp/desert was associated with less-healthful self-reported dietary habits overall. For non-Hispanic Blacks, regression results also showed that residents of perceived food swamp areas (OR = 0.66, p < 0.01, 95% CI (0.51, 0.86)) had a lower diet quality than those not living in a food swamp/food desert area. Black communities in particular may be at risk for environment-linked diet-related health inequities. These findings suggest that an individual's perceptions of food swamp and food desert exposure may be related to diet habits among adults.

A cross-sectional study using the Childhood Measurement Programme for Wales to examine population-level risk factors associated with childhood obesity

OBJECTIVE

The aim of this cross-sectional study was to examine the association between childhood obesity and modifiable population-level risk factors, after accounting for deprivation.

DESIGN

A review of the literature identified population-level risk factors including a healthy childcare setting, the local food environment, accessible open space, community safety and crime. Data for these risk factors were then identified and matched by each of the twenty-two local government areas in Wales to each child that had data on height and weight in the Wales Childhood Measurement Programme (CMP) (2012-2017). Multivariable logistic regression was used to identify associations with childhood obesity.

SETTING

The current study was undertaken in Wales, UK, where approximately one in eight 4-5-year-olds are classified as obese.

PARTICIPANTS

All participants were children aged 4 or 5 years who attend school, measured as part of the CMP, between 2012 and 2017 (n 129 893, mean age 5·0 (sd 0·4) years).

RESULTS

After adjusting for deprivation, small but statistically significant associations were found between childhood obesity and percentage of land available as accessible open space OR 0·981 (95 % CI: 0·973, 0·989) P < 0·001) and density of fast food outlets OR 1·002 (95 % CI 1·001, 1·004, P = 0·001). No other population-level risk factors were associated with childhood obesity.

CONCLUSIONS

The current study indicates that, even after accounting for deprivation, risk factors such as the density of fast food outlets and access to green space should be considered when tackling childhood obesity as a public health issue.

The differential effect of maternal dietary patterns on quantiles of Birthweight

BACKGROUND

Maternal dietary habits during pregnancy are considered essential for development and growth of the fetus as well as maternal health. It has an effect on the birthweight of infants. However, little is known about the effect of dietary patterns on birthweight in urban South Africa. This study aimed to investigate differential effect of dietary patterns of pregnant women on quantiles of birthweight.

METHODS

Data for the study were obtained from a Mother and Child in the Environment birth cohort study in Durban South Africa. Quantile regression was used to investigate the effect of maternal dietary patterns on quantiles of birthweight. Data collection was conducted during the period of 2013 to 2017 in Durban South Africa. Using factor analysis, eight dietary groups were identified from 687 pregnant women in the cohort. Quantile regression analysis was employed to identify the differential effects of the seven dietary groups and demographic factors on the birthweight.

RESULTS

The quantile regression estimates at the 50^th quantile and the ordinary regression estimates painted the same picture about the conditional mean effect of covariates on the birthweight. But unlike the quantile regression the ordinary regression fails to give insights about the covariates effect disparities at the low and/or upper birthweight quantiles. All the dietary groups show a significant differential effect at different birthweight quantiles. For instance, increased frequency of protein rich foods intake was associated with reduction in birthweight at lower and upper quantiles; increased frequency of junk foods intake has a slight increase in birthweight at the lower quantiles but significantly higher increase at the 95^th quantile (p < 0.001); increase in consuming vegetable rich foods, reduced birthweight at 95^th quantile (p < 0.001). The results further showed that employment (p = 0.006) and family size (p = 0.002) had differential effects across different birthweight quantiles.

CONCLUSIONS

Both maternal undernutrition and overnutrition of protein rich foods, junk foods, snack and energy foods and vegetable rich foods have shown a substantial varying effects on those infants with birthweights in the lower and upper birthweight quantiles.

The relative price of healthy and less healthy foods available in Australian school canteens

School canteens have an important role in modelling a healthy food environment. Price is a strong predictor of food and beverage choice. This study compared the relative price of healthy and less healthy lunch and snack items sold within Australian school canteens. A convenience sample of online canteen menus from five Australian states were selected (100 primary and 100 secondary schools). State-specific canteen guidelines were used to classify menu items into 'green' (eat most), 'amber' (select carefully) and 'red' (not recommended in schools). The price of the cheapest 'healthy' lunch (vegetable-based 'green') and snack ('green' fruit) item was compared to the cheapest 'less healthy' ('amber/red') lunch and snack item, respectively, using an un-paired t-test. The relative price of the 'healthy' items and the 'less healthy' items was calculated to determine the proportion of schools that sold the 'less healthy' item cheaper. The mean cost of the 'healthy' lunch items was greater than the 'less healthy' lunch items for both primary (AUD $0.70 greater) and secondary schools ($0.50 greater; p < 0.01). For 75% of primary and 57% of secondary schools, the selected 'less healthy' lunch item was cheaper than the 'healthy' lunch item. For 41% of primary and 48% of secondary schools, the selected 'less healthy' snack was cheaper than the 'healthy' snack. These proportions were greatest for primary schools located in more, compared to less, disadvantaged areas. The relative price of foods sold within Australian school canteens appears to favour less healthy foods. School canteen healthy food policies should consider the price of foods sold.

Childhood Obesity and the Food Environment: A Population-Based Sample of Public School Children in New York City

OBJECTIVE

This study aimed to examine the relationship between proximity to healthy and unhealthy food outlets around children's homes and their weight outcomes.

METHODS

A total of 3,507,542 student-year observations of height and weight data from the 2009-2013 annual FitnessGram assessment of New York City public school students were used. BMI z scores were calculated, student obesity or obesity/overweight was determined using Centers for Disease Control and Prevention growth charts, and these data were combined with the locations of four food outlet types (fast-food restaurants, wait-service restaurants, corner stores, and supermarkets) to calculate distance to the nearest outlet. Associations between weight status outcomes and distance to these food outlet types were examined using neighborhood (census tract) fixed effects.

RESULTS

Living farther than 0.025 mile (about half of a city block) from the nearest fast-food restaurant was associated with lower obesity and obesity/overweight risk and lower BMI z scores. Results ranged from 2.5% to 4.4% decreased obesity. Beyond this distance, there were generally no impacts of the food environment and little to no impact of other food outlet types.

CONCLUSIONS

Proximity to fast-food restaurants was inversely related to childhood obesity, but no relationships beyond that were seen. These findings can help better inform policies focused on food access, which could, in turn, reduce childhood obesity.

Weight gain in mid-childhood and its relationship with the fast food environment

Background

Childhood obesity is a serious public health issue. Understanding environmental factors and their contribution to weight gain is important if interventions are to be effective.

Aims

The purpose of this research was to assess the relationship between weight gain in children and accessibility of fast-food outlets.

Methods

A longitudinal sample of 1577 children was created using two time points from the National Child Measurement Programme in South Gloucestershire (2006/7 and 2012/13). A spatial analysis was conducted using a weighted accessibility score on the number of fast-food outlets within a 1-km network radius of each child's residence to quantify access to fast food.

Results

The mean accessibility score for all children was 0.73 (standard deviation: 1.14). Fast-food outlets were more prevalent in areas of deprivation. A moderate association was found between deprivation score and accessibilty score (r = 0.4, P < 0.01). Children who had greater access to fast-food outlets were more likely (odds ratio = 1.89, P = 0.04) to gain significant weight (>50 percentile points) compared to children who had no access to fast-food outlets.

Conclusions

This paper supports previous research that fast-food outlets are more prevalent in areas of deprivation and presents new evidence on fast-food outlets as a potential contributor towards weight gain in mid-childhood.

Improvement in food environments may help prevent childhood obesity: Evidence from a 9-year cohort study

BACKGROUND

Effects of food environments (FEs) on childhood obesity are mixed.

OBJECTIVES

To examine the association of residential FEs with childhood obesity and variation of the association across gender and urbanicity.

METHODS

We used the US Early Childhood Longitudinal Study-Kindergarten Cohort data, with 9440 kindergarteners followed up from 1998 to 2007. The Dun and Bradstreet commercial datasets in 1998 and 2007 were used to construct 12 FE measures of children, ie, changes in the food outlet mix and density of supermarkets, convenience stores, full-service restaurants, fast-food restaurants, retail bakery, dairy-product stores, health/dietetic food stores, confectionery stores, fruit/vegetable markets, meat/fish markets, and beverage stores. Two-level mixed-effect and cluster robust logistic regression models were fitted to examine associations.

RESULTS

Decreased exposures to full-service restaurants, retail bakeries, fruit/vegetable markets, and beverage stores were generally obesogenic, while decreased exposure to dairy-product stores was generally obesoprotective; the magnitude and statistical significance of these associations varied by gender and urbanicity of residence. Higher obesity risk was associated with increased exposure to full-service restaurants among girls, and with decreased exposures to fruit/vegetable markets in urban children, to beverage stores in suburban children, and to health/dietetic food stores in rural children. Mixed findings existed between genders on the associations of fruit/vegetable markets with child weight status.

CONCLUSION

In the United States, exposure to different FEs seemed to lead to different childhood obesity risks during 1998 to 2007; the association varied across gender and urbanicity. This study has important implications for future urban design and community-based interventions in fighting the obesity epidemic.

Intervention effects of a kindergarten-based health promotion programme on obesity related behavioural outcomes and BMI percentiles

In recent decades, prevalence of childhood overweight has increased worldwide and became a public health concern. One reason is children's insufficient engagement in physical activity (PA) which may lead to deficient motor skills, which are interdependent. Therefore, early health promotion such as the kindergarten-based health promotion programme "Join the Healthy Boat" is necessary. In order to evaluate the programme's effectiveness on children's BMI percentiles (BMIPCT), PA and endurance capacity, a randomised controlled trial including intervention (IG) and control group (CG) was conducted. 973 kindergarten children (3.6 ± 0.6 years; 47.1% male) in 57 kindergartens were assessed at baseline and 558 of them at follow-up. Anthropometrics and endurance capability (3-minute-run) were assessed on site. PA behaviour and socio-economic data were assessed using parental report. Linear regression models were used to determine intervention effects for all health outcomes, adjusting for baseline values, age, gender, BMIPCT and socio-economic variables. After one year, a significant positive intervention effect on children's BMIPCT was found (p ≤ 0.04). Children in the IG spent significantly more days in sufficient PA than children in the CG (3.1 ± 2.1 days vs. 2.5 ± 1.9 days; p ≤ 0.005). Children in the IG performed significantly better in the three minute endurance run than their counterparts in the CG (305.8 ± 46.2 m vs. 286.9 ± 43.2 m; p ≤ 0.001). This teacher-centred health promotion using a low-dose bottom-up approach with action alternatives achieved significant positive effects in the reduction of BMIPCT and significant increases in endurance capacity and daily PA. The programme is therefore ideal for integrating health promotion more intensively into the everyday life of children.

Impact of multiple food environments on body mass index

Background

Although the relationship between residential food environments and health outcomes have been extensively studied, the relationship between body mass index (BMI) and multiple food environments have not been fully explored. We examined the relationship between characteristics of three distinct food environments and BMI among elementary school employees in the metropolitan area of New Orleans, LA. We assessed the food environments around the residential and worksite neighborhoods and the commuting corridors.

Research methodology/principal findings

This study combined data from three different sources: individual and worksite data (ACTION), food retailer database (Dunn and Bradstreet), and the U.S. Census TIGER/Line Files. Spatial and hierarchical analyses were performed to explore the impact of predictors at the individual and environmental levels on BMI. When the three food environments were combined, the number of supermarkets and the number of grocery stores at residential food environment had a significant association with BMI (β = 0.56 and β = 0.24, p < 0.01), whereas the number of full-service restaurants showed an inverse relationship with BMI (β = -0.15, p < 0.001). For the commute corridor food environment, it was found that each additional fast-food restaurant in a vicinity of one kilometer traveled contributed to a higher BMI (β = 0.80, p <0.05), while adjusting for other factors. No statistical associations were found between BMI and worksite food environment.

Conclusions

The current study was the first to examine the relationship between BMI and food environments around residential neighborhoods, work neighborhoods, and the commuting corridor. Significant results were found between BMI and the availability of food stores around residential neighborhoods and the commuting corridor, adjusted for individual-level factors. This study expands the analysis beyond residential neighborhoods, illustrating the importance of multiple environmental factors in relation to BMI.

Effects of Contextual Economic Factors on Childhood Obesity

OBJECTIVES

To examine the association between changes in contextual economic factors on childhood obesity in the US.

METHODS

We combined data from 2003, 2007, and 2011/2012 National Surveys of Children's Health for 129,781 children aged 10-17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income.

RESULTS

Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households.

CONCLUSIONS FOR PRACTICE

Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity.

Use of Deep Learning to Examine the Association of the Built Environment With Prevalence of Neighborhood Adult Obesity

IMPORTANCE

More than one-third of the adult population in the United States is obese. Obesity has been linked to factors such as genetics, diet, physical activity, and the environment. However, evidence indicating associations between the built environment and obesity has varied across studies and geographical contexts.

OBJECTIVE

To propose an approach for consistent measurement of the features of the built environment (ie, both natural and modified elements of the physical environment) and its association with obesity prevalence to allow for comparison across studies.

DESIGN

The cross-sectional study was conducted from February 14 through October 31, 2017. A convolutional neural network, a deep learning approach, was applied to approximately 150 000 high-resolution satellite images from Google Static Maps API (application programing interface) to extract features of the built environment in Los Angeles, California; Memphis, Tennessee; San Antonio, Texas; and Seattle (representing Seattle, Tacoma, and Bellevue), Washington. Data on adult obesity prevalence were obtained from the Centers for Disease Control and Prevention's 500 Cities project. Regression models were used to quantify the association between the features and obesity prevalence across census tracts.

MAIN OUTCOMES AND MEASURES

Model-estimated obesity prevalence (obesity defined as body mass index ≥30, calculated as weight in kilograms divided by height in meters squared) based on built environment information.

RESULTS

The study included 1695 census tracts in 6 cities. The age-adjusted obesity prevalence was 18.8% (95% CI, 18.6%-18.9%) for Bellevue, 22.4% (95% CI, 22.3%-22.5%) for Seattle, 30.8% (95% CI, 30.6%-31.0%) for Tacoma, 26.7% (95% CI, 26.7%-26.8%) for Los Angeles, 36.3% (95% CI, 36.2%-36.5%) for Memphis, and 32.9% (95% CI, 32.8%-32.9%) for San Antonio. Features of the built environment explained 64.8% (root mean square error [RMSE], 4.3) of the variation in obesity prevalence across all census tracts. Individually, the variation explained was 55.8% (RMSE, 3.2) for Seattle (213 census tracts), 56.1% (RMSE, 4.2) for Los Angeles (993 census tracts), 73.3% (RMSE, 4.5) for Memphis (178 census tracts), and 61.5% (RMSE, 3.5) for San Antonio (311 census tracts).

CONCLUSIONS AND RELEVANCE

This study illustrates that convolutional neural networks can be used to automate the extraction of features of the built environment from satellite images for studying health indicators. Understanding the association between specific features of the built environment and obesity prevalence can lead to structural changes that could encourage physical activity and decreases in obesity prevalence.

Tracking and Variability in Childhood Levels of BMI: The Bogalusa Heart Study

OBJECTIVE

Although the tracking of BMI levels from childhood to adulthood has been examined, there is little information on the within-person variability of BMI.

METHODS

Longitudinal data from 11,591 schoolchildren, 3,096 of whom were reexamined as adults, were used to explore the tracking and variability of BMI levels. This article focuses on changes in age-adjusted levels of BMI.

RESULTS

There was strong tracking of BMI levels. The correlation of adjusted BMI levels was r = 0.88, and 78% of children with severe obesity at one examination had severe obesity at the next examination (mean interval, 2.7 years). Further, an increase in adjusted BMI from +5 kg/m² (above the median) to + 10 increased the risk for adult BMI ≥ 40 by 2.7-fold. However, BMI levels among children and adolescents were variable. Over a 9- to 15-month interval, the SD of adjusted BMI change was 0.9 kg/m² , and 0.7% of children had an absolute change ≥ 3.5. This variability was associated with the interval between examinations and with the initial BMI.

CONCLUSIONS

Despite the high degree of tracking of BMI, annual changes of 3.5 kg/m² or more are plausible. Knowledge of this variability is important when following a child over time.

Medical Marijuana Availability, Price, and Product Variety, and Adolescents' Marijuana Use

PURPOSE

We aimed to examine the availability of medical marijuana dispensaries, price of medical marijuana products, and variety of medical marijuana products in school neighborhoods and their associations with adolescents' use of marijuana and susceptibility to use marijuana in the future.

METHODS

A representative sample of 8th, 10th, and 12th graders (N = 46,646) from 117 randomly selected schools in California participated in the cross-sectional 2015-2016 California Student Tobacco Survey (CSTS). Characteristics of medical marijuana dispensaries in California were collected and combined with school locations to compute availability, price, and product variety of medical marijuana in school neighborhoods. Multilevel logistic regressions with random intercepts at school level were conducted to test the associations, accounting for individual and school socioeconomic characteristics.

RESULTS

The distance from school to the nearest medical marijuana dispensary (within 0- to 1-mi and 1- to 3-mi bands) was not associated with adolescents' use of marijuana in the past month or susceptibility to use marijuana in the future, nor was the weighted count of medical marijuana dispensaries within the 3-mi band of school. Neither the product price nor the product variety in the dispensary nearest to school was associated with marijuana use or susceptibility to use. The results were robust to different specifications of medical marijuana measures.

CONCLUSIONS

There was no evidence supporting the associations of medical marijuana availability, price, or product variety around school with adolescents' marijuana use and susceptibility to use.

How Do African-American Caregivers Navigate a Food Desert to Feed Their Children? A Photovoice Narrative

OBJECTIVES

To determine how African-American caregivers living in a food desert navigate neighborhood resources to procure foods for their children and to identify actions to improve those resources.

DESIGN

Using the Photovoice approach, we conducted two sets of individual in-depth interviews with 16 African-American primary caregivers of children (total of 32 interviews) and one culminating workshop (n=10 participants). Data were systematically analyzed according to the Social Ecological Framework to evaluate the role of different environments in shaping individual decisions.

SETTING

Urban, low-income and geographically marginalized neighborhoods.

RESULTS

Despite the challenges of living in a food desert, caregivers perceived that they were providing the foods that they wanted for their children. These perceptions were based on their own health concerns, food customs, time and convenience, and responses to their children's food preferences. Caregivers were resourceful in how they procured these foods, searching for quality and better-priced foods. They relied on their friends, family, and local/national programs to mitigate the challenges of the food desert. Caregivers were interested in taking action to improve the underlying determinants of food access and choice (eg, affordable housing, job training, nutrition knowledge, food shopping experience).

CONCLUSION

These African-American caregivers procured foods they thought were best for their children by relying on their strong social relationships and national and local food programs to navigate the food desert. Public health nutrition interventions that aim to reduce diet-related disparities should look beyond the presence or absence of supermarkets in food deserts to address multisectoral determinants of access while shaping food choices.

Resident Perceptions of Neighborhood Conditions, Food Access, Transportation Usage, and Obesity in a Rapidly Changing Central City

There is a lack of research on obesity that uses primary data and fine-grained information on neighborhoods. I use primary data for 367 participants in Detroit to examine neighborhood predictors of obesity. These data were supplemented with public data. I considered multilevel and spatial modeling, but the data lent itself best to ordinary least squares (OLS) regressions. I find that socioeconomic factors, the built environment, transportation usage, and perceptions of neighborhoods are important predictors of obesity. Importantly, litter is associated with higher levels of obesity. Planners can take measures to reduce litter and collaborate with other policy-makers to encourage less driving, though drawing direct lines of causality is complicated.

Neighborhood Built and Social Environments and Change in Weight Status over the Summer in Low-Income Elementary School Children

Neighborhoods can provide opportunities for children to maintain a healthy weight or encourage unhealthy weight gain. Which neighborhood characteristics matter most remains poorly understood. We investigated links between neighborhood characteristics and weight change over the summer in children from 12 elementary schools with a high proportion of children from low-income families, in a mid-sized city in the US South. Mixed models and objective measures of height and weight were used. Study participants were 2770 children (average age 8.3, range 5.6–12.6 years). Older and female children and those who were already overweight were more likely to gain weight over the summer compared to younger, male, and normal weight children. Overweight children who lived near 2 or more small grocery stores gained less weight than overweight children who lived near 0 (weight change, p = 0.0468; body mass index (BMI) change, p = 0.0209) or 1 store (weight change, p = 0.0136; BMI change, p = 0.0033). Normal weight children living in neighborhoods with more large multifamily buildings gained more weight over the summer, although this association only approached significance. Additional efforts to understand which neighborhood factors have greater significance for overweight compared to normal weight children are warranted.

Is adolescent body mass index and waist circumference associated with the food environments surrounding schools and homes? A longitudinal analysis

BACKGROUND

There has been considerable interest in the role of access to unhealthy food options as a determinant of weight status. There is conflict across the literature as to the existence of such an association, partly due to the dominance of cross-sectional study designs and inconsistent definitions of the food environment. The aim of our study is to use longitudinal data to examine if features of the food environment are associated to measures of adolescent weight status.

METHODS

Data were collected from secondary schools in Leeds (UK) and included measurements at school years 7 (ages 11/12), 9 (13/14), and 11 (15/16). Outcome variables, for weight status, were standardised body mass index and standardised waist circumference. Explanatory variables included the number of fast food outlets, supermarkets and 'other retail outlets' located within a 1 km radius of an individual's home or school, and estimated travel route between these locations (with a 500 m buffer). Multi-level models were fit to analyse the association (adjusted for confounders) between the explanatory and outcome variables. We also examined changes in our outcome variables between each time period.

RESULTS

We found few associations between the food environment and measures of adolescent weight status. Where significant associations were detected, they mainly demonstrated a positive association between the number of amenities and weight status (although effect sizes were small). Examining changes in weight status between time periods produced mainly non-significant or inconsistent associations.

CONCLUSIONS

Our study found little consistent evidence of an association between features of the food environment and adolescent weight status. It suggests that policy efforts focusing on the food environment may have a limited effect at tackling the high prevalence of obesity if not supported by additional strategies.

Automated identification of implausible values in growth data from pediatric electronic health records

Objective

Large electronic health record (EHR) datasets are increasingly used to facilitate research on growth, but measurement and recording errors can lead to biased results. We developed and tested an automated method for identifying implausible values in pediatric EHR growth data.

Materials and Methods

Using deidentified data from 46 primary care sites, we developed an algorithm to identify weight and height values that should be excluded from analysis, including implausible values and values that were recorded repeatedly without remeasurement. The foundation of the algorithm is a comparison of each measurement, expressed as a standard deviation score, with a weighted moving average of a child's other measurements. We evaluated the performance of the algorithm by (1) comparing its results with the judgment of physician reviewers for a stratified random selection of 400 measurements and (2) evaluating its accuracy in a dataset with simulated errors.

Results

Of 2 000 595 growth measurements from 280 610 patients 1 to 21 years old, 3.8% of weight and 4.5% of height values were identified as implausible or excluded for other reasons. The proportion excluded varied widely by primary care site. The automated method had a sensitivity of 97% (95% confidence interval [CI], 94-99%) and a specificity of 90% (95% CI, 85-94%) for identifying implausible values compared to physician judgment, and identified 95% (weight) and 98% (height) of simulated errors.

Discussion and Conclusion

This automated, flexible, and validated method for preparing large datasets will facilitate the use of pediatric EHR growth datasets for research.

Modest ratios of fast food outlets to supermarkets and green grocers are associated with higher body mass index: Longitudinal analysis of a sample of 15,229 Australians aged 45 years and older in the Australian National Liveability Study

Food purchasing decisions are made within the context of the range of options available, yet most epidemiological studies focus upon single outlet types. Ratios of fast food outlets to supermarkets and green grocers were linked to addresses of 15,229 adults in the 45 and Up Study at baseline (2006-2008) and follow-up (2009-2010). Compared to having no fast food outlet but having healthy food outlets within 3.2km from home, multilevel growth curves revealed that relative exposure>25% fast food outlets were associated with 0.36-1.19kg/m² higher BMI (p<0.05). These associations were consistent as people aged. No associations were observed for food outlets<0.8km.

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

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

How Latina mothers navigate a 'food swamp' to feed their children: a photovoice approach

OBJECTIVE

To understand how mothers who recently migrated from Central America to the USA feed their children in a neighbourhood saturated with unhealthful food choices ('food swamp') and to formulate a mother-driven plan of action to facilitate their acquisition of foods. Design/Setting/Subjects We purposively sampled mothers with children (<10 years old) who were recent immigrants/refugees from Central America and lived in a 'food swamp' neighbourhood. We used the photovoice approach to elicit textual data from thirty in-depth interviews, a participatory workshop, and visual data from photographs. Analyses were guided by the Social Ecological Framework and Social Cognitive Theory to identify barriers, facilitators and strategies that support parents in feeding their children.

RESULTS

Mothers valued foods that they considered to be 'traditional' and 'healthful'. They navigated their food retail environment looking for these foods (of good quality and well-priced). Food values were reinforced by pre-migration food customs and culture, health professionals' advice and, in some cases, by the desire to avoid conflict with their children. The neighbourhood food environment could directly influence children's food preferences and often created conflict between what the child wanted to eat and the foods that mothers valued. Mothers in this 'food swamp' wanted to be engaged in addressing the selection of foods offered in schools and in neighbourhood food venues to reflect their own food values.

CONCLUSIONS

These mothers' feeding choices were influenced directly by their food values, and indirectly by the neighbourhood and school food environments via their children's preferences.

Food Environment and Weight Change: Does Residential Mobility Matter?: The Diabetes Study of Northern California (DISTANCE)

Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in food environment from 2006 to 2011 and change in BMI among adults with type 2 diabetes using clinical data from the Kaiser Permanente Diabetes Registry collected from 2007 to 2011. Healthy food environment was measured using the kernel density of healthful food venues. Fixed-effects models with a 1-year-lagged BMI were estimated. Separate models were fitted for persons who moved and those who did not. Sensitivity analysis using different lag times and kernel density bandwidths were tested to establish the consistency of findings. On average, patients lost 1 pound (0.45 kg) for each standard-deviation improvement in their food environment. This relationship held for persons who remained in the same location throughout the 5-year study period but not among persons who moved. Proximity to food venues that promote nutritious foods alone may not translate into clinically meaningful diet-related health changes. Community-level policies for improving the food environment need multifaceted strategies to invoke clinically meaningful change in BMI among adult patients with diabetes.

Policy, Research and Residents' Perspectives on Built Environments Implicated in Heart Disease: A Concept Mapping Approach

An underrepresentation of stakeholder perspectives within urban health research arguably limits our understanding of what is a multi-dimensional and complex relationship between the built environment and health. By engaging a wide range of stakeholders using a participatory concept mapping approach, this study aimed to achieve a more holistic and nuanced understanding of the built environments shaping disease risk, specifically cardiometabolic risk (CMR). Moreover, this study aimed to ascertain the importance and changeability of identified environments through government action. Through the concept mapping process, community members, researchers, government and non-government stakeholders collectively identified eleven clusters encompassing 102 built environmental domains related to CMR, a number of which are underrepresented within the literature. Among the identified built environments, open space, public transportation and pedestrian environments were highlighted as key targets for policy intervention. Whilst there was substantive convergence in stakeholder groups' perspectives concerning the built environment and CMR, there were disparities in the level of importance government stakeholders and community members respectively assigned to pedestrian environments and street connectivity. These findings support the role of participatory methods in strengthening how urban health issues are understood and in affording novel insights into points of action for public health and policy intervention.

Association between Childhood Obesity and Neighbourhood Accessibility to Fast-Food Outlets: A Nationwide 6-Year Follow-Up Study of 944,487 Children

OBJECTIVES

The aim of this 6-year follow-up study was to examine whether neighbourhood accessibility to fast-food outlets was associated with diagnosed childhood obesity, after adjustment for neighbourhood- and individual-level socio-demographic factors.

METHODS

This 6-year follow-up study comprised 484,677 boys and 459,810 girls aged 0-14 years in Sweden. The follow-up period ran from January 1, 2005, until hospitalisation/out-patient treatment for obesity, death, emigration or the end of the study period on December 31, 2010. Multilevel logistic regression models (individual-level factors at the first level and neighbourhood-level factors at the second level) were used to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

We identified 6,968 obesity cases (3,878 boys and 3,090 girls) during the follow-up period. Higher odds of childhood obesity for those living in neighbourhoods with accessibility to fast-food outlets was observed (OR = 1.14, 95% CI = 1.07-1.22) that remained significant after adjustments (OR = 1.06, 95% CI = 1.00-1.13).

CONCLUSIONS

This prospective nationwide study showed that the neighbourhood accessibility to fast-food outlets was independently associated with increased odds of diagnosed childhood obesity. This finding implicates that residential environments should be considered when developing health promotion programmes.

Do GIS-derived measures of fast food retailers convey perceived fast food opportunities? Implications for food environment assessment

PURPOSE

Geographic information systems (GISs) have been used to define fast food availability, with higher availability perhaps promoting poorer quality diets. Alternative measures involve perceptions; however, few studies have examined associations between GIS-derived and perceived measures of the food environment.

METHODS

Telephone surveys of 705 participants within an eight-county region in South Carolina were analyzed using logistic regression to examine relationships between geographic presence of and distance to various types of food retailers and perceived fast food availability.

RESULTS

The mean distance to the nearest fast food restaurant was 6.1 miles, with 16% of participants having a fast food restaurant within 1 mile of home. The geographic presence of and distance to all food retailer types were significantly associated with perceived availability of fast food in unadjusted models. After adjustment, only the presence of a fast food restaurant or pharmacy was significantly associated with greater odds of higher perceived availability of fast food. Greater odds of lower perceived availability of fast food were observed with the presence of a dollar store and increasing distance to the nearest supermarket or pharmacy.

CONCLUSIONS

Measures of fast food availability, whether objective or perceived, may not be interchangeable. Researchers should carefully decide on the appropriate measurement tool-GIS-derived or perceived-in food environment studies.

How can GPS technology help us better understand exposure to the food environment? A systematic review

Purpose

Global Positioning Systems (GPS) are increasingly being used to objectively assess movement patterns of people related to health behaviours. However research detailing their application to the food environment is scarce. This systematic review examines the application of GPS in studies of exposure to food environments and their potential influences on health.

Methods

Based on an initial scoping exercise, published articles to be included in the systematic review were identified from four electronic databases and reference lists and were appraised and analysed, the final cut-off date for inclusion being January 2015. Included studies used GPS to identify location of individuals in relation to food outlets and link that to health or diet outcomes. They were appraised against a set of quality criteria.

Results

Six studies met the inclusion criteria, which were appraised to be of moderate quality. Newer studies had a higher quality score. Associations between observed mobility patterns in the food environment and diet related outcomes were equivocal. Findings agreed that traditional food exposure measures overestimate the importance of the home food environment.

Conclusions

The use of GPS to measure exposure to the food environment is still in its infancy yet holds much potential. There are considerable variations and challenges in developing and standardising the methods used to assess exposure.

•

Since 2011 just 6 studies have been published employing GPS to quantify exposure to food environments.

•

The studies were generally only of moderate quality.

•

There were significant variations and challenges in the methods and techniques used.

•

GIS neighbourhoods may not well represent food environment exposures based on GPS data.

The context of context: Examining the associations between healthy and unhealthy measures of neighborhood food, physical activity, and social environments

Multilevel health research often focuses on a singular dimension of the neighborhood environment in relation to individual-level health behaviors (e.g., diet, physical activity) and outcomes (e.g., obesity). This study examined associations between healthy and unhealthy neighborhood features across food, physical activity, and social environments. We used neighborhood-level (i.e., census block group) access (0/1) measures of the 1) food (grocery store, convenience store, fast food restaurant), 2) physical activity (fitness/recreation facility, park), and 3) social (crime, renter occupancy) environments to capture both healthy and unhealthy neighborhood features for a sample of neighborhoods (n=126) in East Baton Rouge Parish, Louisiana, United States. We employed a) bivariate correlations, or spatial regression where necessary, to identify significant associations between neighborhood access measures; and b) two-step cluster analysis to identify neighborhood typologies based upon neighborhood access measures. Results demonstrated multiple significant associations between healthy and unhealthy access measures across the three neighborhood environments. Cluster analysis further confirmed that neighborhoods are not completely healthy or unhealthy, but rather can be characterized by neighborhood features that are both health-promoting and health-constraining. This study elucidates a 'context of context' whereby no singular aspect of a neighborhood completely explains health in individuals. Rather, in order to effectively model the association between neighborhood and individual-level health, it may be necessary to account for the inter-related nature of neighborhood features.

Urban Latino Families' Food Built Environment and Young Children's Produce Consumption

This study explored the association between objective and subjective ratings of the food environment and child produce consumption for Latino preschoolers at-risk for obesity. Parental surveys (N = 115) assessed perceptions of food availability, affordability, and acceptability. Comparable factors were objectively rated by a trained observer, using the Nutrition Environment Measures Survey for Stores (NEMS-S), in commonly frequented grocery stores cited by participants. There were no significant correlations between objective and subjective measures of food availability, affordability, and acceptability. Greater household income was associated with higher participant perceptions of food acceptability (r = .33, p = .003) and affordability (r = .22, p = .04). Participant-perceived affordability of food was correlated with more frequent child fruit and vegetable consumption (r = .21, p = .03). These findings support that parental subjective ratings of the food environment affects their child's eating behaviors more than objective ratings.

Household, psychosocial, and individual-level factors associated with fruit, vegetable, and fiber intake among low-income urban African American youth

BACKGROUND

Childhood obesity, one of the greatest challenges to public health, disproportionately affects low-income urban minority populations. Fruits and vegetables (FV) are nutrient dense foods that may be inversely associated with excessive weight gain. We aimed to identify the individual characteristic, psychosocial, and household factors influencing FV and fiber consumption in low-income African-American (AA) youth in Baltimore, MD.

METHODS

Cross-sectional analysis of data collected from 285 low-income AA caregiver-youth (age range: 10-14 y) dyads participating in the baseline evaluation of the B'More Healthy Communities for Kids obesity prevention trial. The Kid's Block FFQ was used to estimate daily intakes of FV (including 100 % fruit juice) and dietary fiber. Questionnaires were used to assess household socio-demographics, caregiver and youth food purchasing and preparation behavior, and youth psychosocial information. Ordered logit regression analyses were conducted to examine psychosocial and food-related behavior associated with FV and dietary fiber intake (quartile of intake) controlling for youth age, sex, BMI percentile, total calorie intake and household income.

RESULTS

On average, youth consumed 1.5 ± 1.1 (M ± SD) servings of fruit, 1.8 ± 1.7 serving of vegetables, and 15.3 ± 10.9 g of fiber/day. There were no differences by gender, age or household income. Greater youth's healthy eating intentions and self-efficacy scores were associated with greater odds ratio for higher intake of FV and fiber (Intention: ORfruit 1.22; 95 % CI: 1.06-1.41, ORvegetable 1.31; 1.15-1.51 and ORfiber 1.46; 1.23-1.74, Self-efficacy: ORfruit 1.07; 1.03-1.12, ORvegetable 1.04; 1.01-1.09, ORfiber 1.10; 1.04-1.16). Youth receiving free/low-cost breakfast were more than twice as likely to have higher fiber intake than those who did not receive free breakfast (OR 2.7; 1.10; 6.9). In addition, youth shopping more frequently at supermarkets were more likely to have greater vegetable and fiber intake (OR 1.26; 1.06-1.50; OR 1.28; 1.03-1.58, respectively). Also, youth with parents who shopped more frequently at fast-food stores had 7 % lower odds for higher vegetable intake (95 % CI: 0.88-0.99).

CONCLUSION

In this study, both, youth and household factors were associated with youth FV and fiber intake, underscoring the need for a multi-level approach to increasing youths' diet quality. These results will inform and shape an effective intervention program for improving youth dietary intakes.

Walkable home neighbourhood food environment and children's overweight and obesity: Proximity, density or price?

OBJECTIVES

To identify characteristics of the food environment associated with child overweight/obesity that could, if subjected to intervention, mitigate the risk of childhood overweight/obesity. We examined whether the proximity to or density of grocery and convenience stores or fast food restaurants, or the prices of healthy food options were more strongly associated with overweight/obesity risk in children.

METHODS

We collected geocoded data by residential addresses for 1,469 children aged 10-14 years and conducted a census of all food outlets in Saskatoon. The Nutrition Environment Measures Survey (NEMS)-Stores and the NEMS-Restaurants were used to measure availability, quality and relative price of healthy food items in stores and restaurants. Children's weight status was calculated on the basis of measured height and weight. Logistic regression was used to test the associations between overweight/obesity and food environment variables.

RESULTS

Within an 800 m walking distance from home, 76% of children did not have access to a grocery store; 58% and 32% had access to at least one convenience store or one fast-food restaurant respectively. A significantly lower odds of overweight/obesity was associated with lower price of healthy food items/options in grocery stores (odds ratio [OR] = 0.87, 95% confidence interval [CI] 0.77-0.99) and fast-food restaurants (OR = 0.97, 95% CI 0.95-0.99) within walking distance of home. Neither the distance to the closest food outlet nor the density of food outlets around children's homes was associated with odds of overweight/obesity.

CONCLUSIONS

Improving economic access to healthy food in food outlets or fast-food restaurants is one strategy to counter childhood overweight/ obesity.

Neighborhood and home food environment and children's diet and obesity: Evidence from military personnel's installation assignment

Research and policy initiatives are increasingly focused on the role of neighborhood food environment in children's diet and obesity. However, existing evidence relies on observational data that is limited by neighborhood selection bias. The Military Teenagers' Environments, Exercise, and Nutrition Study (M-TEENS) leverages the quasi-random variation in neighborhood environment generated by military personnel's assignment to installations to examine whether neighborhood food environments are associated with children's dietary behaviors and BMI. Our results suggest that neither the actual nor the perceived availability of particular food outlets in the neighborhood is associated with children's diet or BMI. The availability of supermarkets and convenience stores in the neighborhood was not associated with where families shop for food or children's dietary behaviors. Further, the type of store that families shop at was not associated with the healthiness of food available at home. Similarly, availability of fast food and restaurants was unrelated to children's dietary behaviors or how often children eat fast food or restaurant meals. However, the healthiness of food available at home was associated with healthy dietary behaviors while eating at fast food outlets and restaurants were associated with unhealthy dietary behaviors in children. Further, parental supervision, including limits on snack foods and meals eaten as a family, was associated with dietary behaviors. These findings suggest that focusing only on the neighborhood food environment may ignore important factors that influence children's outcomes. Future research should also consider how families make decisions about what foods to purchase, where to shop for foods and eating out, how closely to monitor their children's food intake, and, ultimately how these decisions collectively impact children's outcomes.

Association Between Age and Obesity Over Time

BACKGROUND AND OBJECTIVES

A decline in the prevalence of obesity among 2- to 5-year-olds in the United States was recently reported. This decline may be due to changes in the population composition of children over time or may be a consequence of changes in how strongly individual- or family-level factors are linked to childhood obesity. We applied regression decomposition techniques to identify the sources of the decline.

METHODS

We used data from the 2003-2004 and 2011-2012 NHANES restricted to 2- to 5-year-old children and Blinder-Oaxaca regression decomposition techniques to partition the decline in early childhood obesity into 2 components: changes resulting from (1) how demographic, economic, and health characteristics of children have changed over this period (ie, changes in population composition) and (2) changes in how these demographic, economic, and health factors are associated with obesity (ie, changes in associations).

RESULTS

The obesity rate was lower in 2011-2012 than it was in 2003-2004 mainly because obesity was strongly and positively associated with age in 2003-2004 (ie, older children were more likely to be obese than younger children) but not in 2011-2012 (ie, older children were not more likely to be obese than younger children).

CONCLUSIONS

If the weaker association between age and obesity we observed for this cohort of 2- to 5-year-old children in 2011-2012 persists for subsequent cohorts of young children, the obesity rate for young children will remain at or near the lower rate seen in 2011-2012.