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

Geographic Comparison of Dietary Intake and Quality in Manitoba Adolescents

Purpose: The Food and Nutrition for Manitoba Youth (FANS) study examined dietary intakes, food behaviours, food security status, health indicators, and body mass index of a cohort of grade 9 students. This paper describes regional differences and similarities in dietary intake (food and nutrients) and quality of youth participants in the FANS study.Methods: Grade 9 students completed a web-based survey on dietary intakes (24-hour recall), food behaviours, self-reported health indicators, and sociodemographic variables. Nutrient intakes were compared with national guidelines and diet quality was assessed using a modified Healthy Eating Index.Results: A total of 1587 students participated from northern, rural, and urban regions in Manitoba. Northern and rural students had higher intakes of sugar, sodium, and saturated fat compared with urban. Northern students consumed fewer grain products compared to urban, and more servings of "other" foods compared with rural and urban. While most participants were classified into the "needs improvement" or "poor" Healthy Eating Index categories, significantly more northern participants were in the "poor" category.Conclusions: Most adolescents in the study are at nutritional risk; however, there are additional vulnerabilities for those in rural and northern communities. Dietitians can use results to advocate for and plan interventions to improve adolescent nutrition.

Food environment research in Canada: a rapid review of methodologies and measures deployed between 2010 and 2021

Numerous research methodologies have been used to examine food environments. Existing reviews synthesizing food environment measures have examined a limited number of domains or settings and none have specifically targeted Canada. This rapid review aimed to 1) map research methodologies and measures that have been used to assess food environments; 2) examine what food environment dimensions and equity related-factors have been assessed; and 3) identify research gaps and priorities to guide future research. A systematic search of primary articles evaluating the Canadian food environment in a real-world setting was conducted. Publications in English or French published in peer-reviewed journals between January 1 2010 and June 17 2021 and indexed in Web of Science, CAB Abstracts and Ovid MEDLINE were considered. The search strategy adapted an internationally-adopted food environment monitoring framework covering 7 domains (Food Marketing; Labelling; Prices; Provision; Composition; Retail; and Trade and Investment). The final sample included 220 articles. Overall, Trade and Investment (1%, n = 2), Labelling (7%, n = 15) and, to a lesser extent, Prices (14%, n = 30) were the least studied domains in Canada. Among Provision articles, healthcare (2%, n = 1) settings were underrepresented compared to school (67%, n = 28) and recreation and sport (24%, n = 10) settings, as was the food service industry (14%, n = 6) compared to grocery stores (86%, n = 36) in the Composition domain. The study identified a vast selection of measures employed in Canada overall and within single domains. Equity-related factors were only examined in half of articles (n = 108), mostly related to Retail (n = 81). A number of gaps remain that prevent a holistic and systems-level analysis of food environments in Canada. As Canada continues to implement policies to improve the quality of food environments in order to improve dietary patterns, targeted research to address identified gaps and harmonize methods across studies will help evaluate policy impact over time.

Changes of Grocery Shopping Frequencies and Associations with Food Deserts during the COVID-19 Pandemic in the United States

The COVID-19 pandemic has dramatically altered people's lives in multiple aspects, including grocery shopping behaviors. Yet, the changing trend of grocery shopping frequencies during the COVID-19 and its associations with food deserts remain unclear. We aimed to (1) examine variations of grocery shopping frequencies at county level in the USA during the COVID-19 pandemic from March 2020 to December 2021; (2) investigate associations between grocery shopping frequencies and food deserts during the COVID-19 pandemic; and (3) explore heterogeneity in grocery shopping frequencies-food desert associations across urban and rural areas. The county-level grocery shopping frequencies were derived from a grocery pattern dataset obtained from SafeGraph. We divided the 22-month period into 5 stages and employed the growth curve modeling to estimate the trajectories of grocery shopping frequencies and the associations between grocery shopping frequencies and food deserts in each stage, separately. Results revealed that grocery shopping frequencies experienced a "W-shaped" pattern from March 2020 to December 2021. Counties with the least percent of food deserts had slower decrease in grocery shopping frequencies at the initial stage and recovered more rapidly at later stages. Counties with the highest percent of food deserts were subject to deprivation amplification as a result of the pandemic. We also found differences existed in the grocery shopping frequencies-food desert associations between metropolitan counties and rural counties. Our findings suggest the impacts of COVID-19 on grocery shopping frequencies varied across different time periods, shedding light on designing different strategies to reduce the risk of contagion while shopping inside of grocery stores. Further, our findings highlight an urgent need to help people living in food deserts (especially in rural counties) to procure healthy foods safely during health emergencies like COVID-19 pandemic which disrupt mobility and social behaviors.

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.

Advertising expenditures on child-targeted food and beverage products in two policy environments in Canada in 2016 and 2019

BACKGROUND

The food industry advertises unhealthy foods intended for children which in turn fosters poor diets. This study characterized advertising expenditures on child-targeted products in Canada and compared these expenditures between Quebec, where commercial advertising to children under 13 is restricted, and the rest of Canada, where food advertising to children is self-regulated.

METHODS

Advertising expenditures data for 2016 and 2019 for 57 select food categories and five media channels were licensed from Numerator. Products and brands targeted to children were identified based on their nature and the advertising techniques used to promote them. Advertising expenditures were classified as healthy/unhealthy using Health Canada's nutrient profile model. Expenditures per child capita aged 2-12 years were calculated and expenditures from 2016 were adjusted for inflation. Advertising expenditures were described by media, food category, year, and geographic region.

RESULTS

Overall, $57.2 million CAD was spent advertising child-targeted products in Canada in 2019. Television accounted for 77% of expenditures followed by digital media (18%), and the food categories with the highest expenditures were candy/chocolate (30%) and restaurants (16%). The totality of expenditures (99.9%-100%) in both Quebec and the rest of Canada in 2016 and 2019 were considered 'unhealthy'. Across all media channels (excluding digital), advertising expenditures were 9% lower in 2019 versus 2016. Advertising expenditures per capita were 32% lower in Quebec ($9.40/capita) compared to the rest of the country ($13.91/capita).

CONCLUSION

In Canada, millions are spent promoting child-targeted products considered inappropriate for advertising to children. While per capita advertising expenditures for these products are lower in Quebec compared to the rest of Canada, they remain high, suggesting that Quebec's commercial advertising restrictions directed to children are likely not sufficiently protecting them from unhealthy food advertising.

Identifying barriers to emergency department-initiated buprenorphine: A spatial analysis of treatment facility access in Michigan

STUDY OBJECTIVES

Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access.

METHODS

Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers.

RESULTS

Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress.

CONCLUSION

Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.

Free Sugars Consumption in Canada

Free sugars (FS) are associated with a higher risk of dental decay in children and an increased risk of weight gain, overweight and obesity and type 2 diabetes. For this reason, Canada’s Food Guide recommends limiting foods and beverages that contribute to excess free sugars consumption. Estimating FS intakes is needed to inform policies and interventions aimed at reducing Canadians’ consumption of FS. The objective of this study was to estimate FS intake of Canadians using a new method that estimated the free sugars content of foods in the Canadian Nutrient File, the database used in national nutrition surveys. We define FS as sugars present in food products in which the structure has been broken down. We found that 12% of total energy (about 56 g) comes from FS in the diet of Canadians 1 year of age and older (≥1 year). The top four sources were: (1) sugars, syrups, preserves, confectionary, desserts; (2) soft drinks; (3) baked products and (4) juice (without added sugars), and accounted for 60% of total free sugars intake. The results show that efforts need to be sustained to help Canadians, particularly children and adolescents, to reduce their FS intake.

Baseline Assessment of Children's Meals and Healthy Beverage Options Prior to a State-Level Healthy Default Beverage (HDB) Law

In January 2020, Hawai'i became the second state with a healthy default beverage (HDB) law, requiring restaurants to offer HDBs with their children's meals. This observational study presents baseline characteristics of restaurants with a children's menu and meal. The study describes pre-law beverage options to inform future HDB policy language, implementation, and evaluation. Between November and December 2019, data were collected from a statewide sample of unique restaurants (N = 383) with health inspection permits. Restaurants were assessed separately for a children's menu and meal using website reviews, telephone calls, and in-person visits. Meals were evaluated for pre-law beverage type and compliance. Logistic regression was used to estimate the likelihood of having a children's menu and meal. Most of the restaurants were full-service (70.2%) and non-chains (67.9%). While 49.3% of restaurants had a children's menu, only 16.7% had a children's meal. Significant predictors of having a children's menu were being full-service, national/international or local chains, neighbor island (non-Honolulu) locations, and hotel locations. Only being a national/international chain significantly predicted having a children's meal. Although 35.9% of children's meals offered a non-sugar-sweetened beverage (SSB) option, only 3.1% offered law-compliant beverages. Inclusion of an SSB default option (60.9%) and not specifying the type of default beverage were the predominant factors for pre-law non-compliance. Results support the need for HDB regulations, especially for national/international chains, which were most likely to have children's meals, and provide data to inform policies in other jurisdictions.

Are closed campus policies associated with adolescent eating behaviours?

INTRODUCTION

The effectiveness of school nutrition regulations may be undermined by food environments surrounding schools. Given challenges in regulating external retail, some have recommended policies that ensure students are unable to leave school property during the day (closed campus policies; CCP). We aimed to examine whether CCP are associated with student eating behaviours.

METHODS

We used student and school-administrator survey data from the 60 610 Grades 9 to 12 students and 134 Canadian secondary schools that participated in Year 7 (2018/19) of the COMPASS study. Multiple ordinal regression models tested school CCP as a predictor of weekday dietary behaviours (0-5 days), controlling for student-level (grade, sex, spending money, ethnicity) and school-level (urbanicity, province, area median household income, vending machines) covariates.

RESULTS

CCP were reported by 16 schools. Students who attended CCP schools reported eating lunch purchased from fast food outlets or other restaurants and drinking sugar-sweetened beverages (SSBs; soft drinks and sports drinks; sweetened coffee or tea drinks) on fewer weekdays, but consumed snacks from school vending machines on more weekdays, relative to students at open campus schools. No significant differences were observed in student reports of eating home-packed or school cafeteria lunches or snacks purchased off-campus.

CONCLUSION

CCP may help improve adolescent diets by reducing SSB and lunchtime fast food consumption on weekdays; however, students already purchasing food may shift from off-campus to within-school options, highlighting the importance of ensuring healthy school food environments and encouraging students to bring home-prepared lunches. Future studies using experimental longitudinal designs are needed to determine the effect of CCP on various health behaviours and outcomes.

Desert on the menu? What children are served in German full-service restaurants

OBJECTIVES

Prevalence of obesity and overweight among children is rising worldwide. Thus, the importance of restaurants as food environments is also growing. Considering these developments, the present study describes and evaluates menus and meals offered to children in German full-service restaurants.

METHODS

Using quota sampling procedure, a representative sample of German full-service restaurants was identified. The individual meals were then assessed, using the Children's Menu Assessment tool (CMA). A total of 500 restaurants and 1,877 individual meals were analyzed.

RESULTS

On average, every menu included 3.76 ± 1.31 meals for children. The arithmetic mean of the CMA score was 0.73 ± 0.85. Around 80% of all offered meals were limited to eight typical dishes and over 50% included French fries or another form of fried potatoes. Not one of the meals included any nutritional information. Healthy entrees were never marked (e.g. by an optional qualitative information such as healthy food symbol or a healthier choice tag). Eighty-one percent of all the main components in the meals were rated as unhealthy and none of the meals used wholegrain products. The automatic inclusion of a drink and free refill options are both rather unusual in Germany, as well as the use of cartoon characters and product logos or giving away promotional toys. A positive correlation was found between the price of the food and its quality. The majority of dishes feature a high energy density while simultaneously having a low nutrient density.

CONCLUSIONS

Overall, the range of food on offer for children in German restaurants is unhealthy and lacking in variety. There is an urgent need for improvement of both the menus themselves as well as the offered meals. Our study is not only by far the most comprehensive study, but also the study with the worst CMA score values worldwide.

Testing the efficacy of and parents' preferences for nutrition labels on children's menus from a full-service chain restaurant: results of an online experiment

OBJECTIVE

Test the efficacy and perceived effectiveness of nutrition labels on children's menus from a full-service chain restaurant in an online study.

DESIGN

Using a between-groups experiment, parents were randomised to view children's menus displaying one of five children's nutrition labelling conditions: (i) No Nutrition Information (control); (ii) Calories Only; (iii) Calories + Contextual Statement (CS); (iv) Calories, Sodium + CS; or (v) Calories and Sodium in Traffic Lights + CS. Parents hypothetically ordered up to one entrée, side, beverage and dessert for their child, then rated and ranked all five labelling conditions on the level of perceived effectiveness.

SETTING

Online survey.

PARTICIPANTS

998 parents with a 3-12 year old child.

RESULTS

Parents exposed to menus displaying 'Calories, Sodium + CS' selected significantly fewer calories 'overall' (entrées + side + dessert + beverage) compared to parents exposed to the control condition (-53·1 calories, P < 0·05). Parents selected 'entrees' with significantly fewer calories and lower sodium when exposed to menus with 'Calories + CS' (-24·3 calories, P < 0·05); 'Calories, Sodium + CS' (-25·4 calories, -56·1 mg sodium, P < 0·05 for both); and 'Calories and Sodium in Traffic Lights + CS' (-29·1 calories, -58·6 mg sodium, P < 0·05 for both). Parents exposed to menus with 'Calories, Sodium + CS' and 'Calories and Sodium in Traffic Lights + CS' were more likely to notice and understand nutrition information compared to other nuntrition labelling conditions. Parents perceived the menu with 'Calories and Sodium in Traffic Lights + CS' as most effective (P < 0·05).

CONCLUSIONS

Menus disclosing calories, sodium and a contextual statement increased the proportion of parents who noticed and understood nutrition information, and resulted in parents selecting lower calorie and sodium entrées for their children in the hypothetical purchase task.

Knowledge Visualizations to Inform Decision Making for Improving Food Accessibility and Reducing Obesity Rates in the United States

The aim of this article is to promote the use of knowledge visualization frameworks in the creation and transfer of complex public health knowledge. The accessibility to healthy food items is an example of complex public health knowledge. The United States Department of Agriculture Food Access Research Atlas (FARA) dataset contains 147 variables for 72,864 census tracts and includes 16 food accessibility variables with binary values (0 or 1). Using four-digit and 16-digit binary patterns, we have developed data analytical procedures to group the 72,684 U.S. census tracts into eight and forty groups respectively. This value-added FARA dataset facilitated the design and production of interactive knowledge visualizations that have a collective purpose of knowledge transfer and specific functions including new insights on food accessibility and obesity rates in the United States. The knowledge visualizations of the binary patterns could serve as an integrated explanation and prediction system to help answer why and what-if questions on food accessibility, nutritional inequality and nutrition therapy for diabetic care at varying geographic units. In conclusion, the approach of knowledge visualizations could inform coordinated multi-level decision making for improving food accessibility and reducing chronic diseases in locations defined by patterns of food access measures.

Development of a Teen-Informed Coding Tool to Measure the Power of Food Advertisements

The food-related information environment, comprised of food and beverage advertising within one’s surroundings, is a growing concern for adolescent health given that food marketing disproportionately targets adolescents. Despite strong public interest concerning the effects of food marketing on child health, there is limited evidence focused on outdoor food advertising in relation to teenage diets, food purchasing, and perceptions. Further, limited research has considered both the exposure to and influence of such advertisements. This study used a novel multi-method approach to identify and quantify the features of outdoor food and beverage advertisements that are most effective at drawing teenagers into retail food establishments. An environmental audit of outdoor advertisements and consultations with youth were used to: (1) identify teen-directed food marketing techniques; (2) validate and weigh the power of individual advertising elements; and, (3) develop a teen-informed coding tool to measure the power of food-related advertisements. Results indicate that marketing power is a function of the presence and size of teen-directed advertisement features, and the relative nature of each feature is an important consideration. This study offers a quantitative measurement tool for food environment research and urges policymakers to consider teen-directed marketing when creating healthy communities.

Measuring Rural Food Environments for Local Action in Australia: A Systematic Critical Synthesis Review

Poor diet is a significant contributor to obesity and chronic disease. With all being more prevalent in rural than urban Australia, modifying the food environment is a potential intervention point to improve the health of rural populations. This review examined the applicability of measurement tools used in rural food environment research for rural Australia. Six electronic databases were searched for peer-reviewed literature, published in English between 2006 and 2018, including at least one objective measure of the Community or Consumer Food Environment in a rural or mixed rural/urban context. One-hundred and seventy-seven papers were returned after removal of duplicates, with a final review of 25. Most studies were cross-sectional, with one intervention study of quasi-experimental design. Nine studies employed a conceptual model; there was considerable variability in tools used; and few described psychometric testing. The most common attribute measured was price, followed by available healthy options. The findings of this review do not offer a suite of ‘gold standard’ measurement tools known to be reliable, valid and sensitive to change to assess the community or consumer food environments in rural Australian towns. However, recommendations are proposed to progress this important area of research within a rural context.

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

OBJECTIVE

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

DESIGN

Cross-sectional observational study.

SETTING

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

RESULTS

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

CONCLUSIONS

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

Conceptualizing Youth Participation in Children's Health Research: Insights from a Youth-Driven Process for Developing a Youth Advisory Council

Given the power asymmetries between adults and young people, youth involvement in research is often at risk of tokenism. While many disciplines have seen a shift from conducting research on youth to conducting research with and for youth, engaging children and teens in research remains fraught with conceptual, methodological, and practical challenges. Arnstein's foundational Ladder of Participation has been adapted in novel ways in youth research, but in this paper, we present a new rendering: a 'rope ladder.' This concept came out of our youth-driven planning process to develop a Youth Advisory Council for the Human Environments Analysis Laboratory, an interdisciplinary research laboratory focused on developing healthy communities for young people. As opposed to a traditional ladder, composed of rigid material and maintaining a static position, the key innovation of our concept is that it integrates a greater degree of flexibility and mobility by allowing dynamic movement beyond a 2D vertical plane. At the same time, the pliable nature of the rope makes it both responsive and susceptible to exogenous forces. We argue that involving youth in the design of their own participatory framework reveals dimensions of participation that are important to youth, which may not be captured by the existing participatory models.