Using photography to explore people with diabetes' perspectives on food environments in urban and rural South Africa

The rural food environment and its association with diet, nutrition status, and health outcomes in low-income and middle-income countries (LMICs): a systematic review

BACKGROUND

The food environment consists of external and personal domains that shape food purchasing decisions. While research on food environments has grown rapidly within high-income countries (HICs) in response to increasing rates of overweight, obesity, and non-communicable diseases (NCDs), critical research gaps remain. The role of food environment on diet, health and nutrition has been understudied in LMICs. To date, there has not been a systematic review specifically focusing on rural LMICs. This systematic review aims to synthesize findings from studies examining the association between rural food environment domains and diet, nutrition and health in LMICs or effects of food environment interventions on these outcomes.

METHODS

Searches were conducted from 9 databases: Medline (PubMed), Embase (Ovid), Global Health (Ovid), PsycINFO (Ovid), EconLit (EBSCOhost), Web of Science (Social Science Citation Index), Scopus, CINAHL (EBSCOhost), and Applied Social Sciences Index and Abstracts (ProQuest) to identify studies published between 2000 and 2023 that reported associations between this/these dimensions with diets, nutrition or health outcomes. Both quantitative and qualitative studies that were published in English were included. Data extraction and quality appraisal was conducted independently by two authors, before the study findings were collated and summarized through a narrative data synthesis.

RESULTS

Nineteen eligible studies were identified from 9 databases covering 11 LMICs. The included studies employed quantitative (n = 12), mixed method (n = 6) and qualitative (n = 1) designs in the neighbourhood food environment. In this review, availability dimension of the external food environment featured most prominently, followed by accessibility, affordability, desirability, and convenience dimensions of the personal food environment. Food availability was positively associated with diet (n = 10), nutrition (n = 7) and health (n = 1). There was good evidence regarding associations between food accessibility, diet (n = 7) and nutrition (n = 3). We identified some evidence that food price and affordability (n = 8) were considered key barriers to achieving healthy diets. Desirability (n = 4) and convenience (n = 2) dimensions were also associated with dietary outcomes, although we found only a few studies. Only one South African qualitative study was identified which highlighted limited availability and accessibility to local supermarkets and surrounding informal fruit and vegetable vendors to be a barrier to expensive, healthy foods consumption. Finally, evidence regarding health outcomes, sustainability dimension, impacts of food environment interventions on relevant outcomes and interactions between food environment dimensions was missing. Overall, seven out of nineteen studies were rated as good quality, six were rated as fair and six were rated as poor.

CONCLUSIONS

Future interventions should consider improving availability and accessibility of nutritious foods to improve public health nutrition in rural LMICs. Evidence from studies assessing the workplace, home, and school food environments, food environment interventions, sustainability dimension and other key dimensions of the external food environment such as prices, vendor and product properties and marketing and regulation is needed to identify effective interventions to address malnutrition in all its forms characterized by the coexistence of undernutrition, overnutrition, undernutrition and diet-related non-communicable diseases (NCDs).

Measuring characteristics of wild and cultivated food environments: a scoping review

BACKGROUND

Global food systems are essential to sustain life; however, unhealthy diets are the leading cause of poor health and death worldwide. Natural food environments are a critical source of healthful food such as fresh fruit and vegetables, lean meat and aquatic foods, particularly in low- and middle-income countries (LMICs) and Indigenous food systems. Understanding and monitoring natural food environments is critical to protecting the supply of healthy food, and the land and water it comes from, for current and future generations.

METHODS

A scoping review was applied to classify and summarise empirical methods and measures used for characterising natural food environments. The ways in which food environment characteristics are conceptualised and measured for natural (wild and cultivated) food environments were explored. Data were extracted from the included studies using the following fields: study country, aim/objective(s), type of natural food environment (wild vs. cultivated), method or measure used to measure the food environment, key food environment characteristic/s (up to four) measured and key findings in relation to the food environment measurement.

RESULTS

One hundred forty seven studies were found to be relevant in this review. Most studies investigated food environments in LMICs, with almost two-thirds of all studies focussing on middle-income countries (n = 89, 61%). There was a strong focus on food security and home-based agriculture from studies that measured the cultivated food environment in LMICs, while the majority of studies on the cultivated food environment from high-income countries focussed on urban and community gardening. In addition to the most common survey-based methodological approaches, our review yielded a broad range of both qualitative and quantitative methods for measuring natural food environments, such as geospatial analysis; biochemical analysis of food, soil and water; citizen science; photovoice and food availability calendars.

CONCLUSIONS

Our review demonstrated that the concept and characteristics of the food environment are a promising conceptualization for measuring natural food environments, particularly in relation to food availability, healthiness and food security. Mapping the currently used methods and measures to assess natural food environments is important to help identify critical leverage points for strengthening policy interventions, and monitoring and evaluation of progress.

Perspective: Food Environment Research Priorities for Africa-Lessons from the Africa Food Environment Research Network

Over the last 2 decades, many African countries have undergone dietary and nutrition transitions fueled by globalization, rapid urbanization, and development. These changes have altered African food environments and, subsequently, dietary behaviors, including food acquisition and consumption. Dietary patterns associated with the nutrition transition have contributed to Africa's complex burden of malnutrition-obesity and other diet-related noncommunicable diseases (DR-NCDs)-along with persistent food insecurity and undernutrition. Available evidence links unhealthy or obesogenic food environments (including those that market and offer energy-dense, nutrient-poor foods and beverages) with suboptimal diets and associated adverse health outcomes. Elsewhere, governments have responded with policies to improve food environments. However, in Africa, the necessary research and policy action have received insufficient attention. Contextual evidence to motivate, enable, and create supportive food environments in Africa for better population health is urgently needed. In November 2020, the Measurement, Evaluation, Accountability, and Leadership Support for Noncommunicable Diseases Prevention Project (MEALS4NCDs) convened the first Africa Food Environment Research Network Meeting (FERN2020). This 3-d virtual meeting brought researchers from around the world to deliberate on future directions and research priorities related to improving food environments and nutrition across the African continent. The stakeholders shared experiences, best practices, challenges, and opportunities for improving the healthfulness of food environments and related policies in low- and middle-income countries. In this article, we summarize the proceedings and research priorities identified in the meeting to advance the food environment research agenda in Africa, and thus contribute to the promotion of healthier food environments to prevent DR-NCDs, and other forms of malnutrition.

Can you picture it? Photo elicitation in qualitative cardiovascular health research

Photo elicitation offers novel opportunities to augment the qualitative research toolbox. The use of photographs can enrich connections with participants, and empower them to be creative and engaged to communicate their insights, priorities, and perspectives. There is growing evidence of the effective use of photo elicitation in health research, with emerging interest in the cardiovascular community. Careful study planning, including attention to equipment, participant training, photograph selection, data collection, and ethical consideration, is essential. Detailed reporting of the study design and rationale for use of photographs, conceptual thinking underpinnings, elicitation process, and analytical plan contribute to strengthening the methodological approach.