Childhood obesity and the built environment

Family poverty, neighbourhood greenspace and perinatal outcomes

OBJECTIVE

The relationship between low income and adverse perinatal outcomes, such as low birth weight and developmental delays, is well established making the search for protective factors important. One such factor may be neighbourhood greenspace. This study elucidates the role of urban neighbourhood greenspace in the relationship between income and perinatal outcomes in a nationally representative birth cohort from the UK.

METHODS

Data on 14 050 infants participating in the initial wave at age 9 months of the Millennium Cohort Study were used (51% male, 20% non-white, 52% living in disadvantaged areas). We tested whether the association between income and perinatal outcomes is moderated by urban greenspace (measured in deciles) before and after adjustments for confounding. The perinatal outcomes included birth weight, gestational age (in days), communication and motor delays. The models were adjusted for the infant's sex and ethnicity, mother's age, education, substance use and mental health as well as area disadvantage and air pollution.

RESULTS

Neighbourhood greenspace moderated the association between income and gestational age, even after adjustment for all confounders, b=-0.11, 95% CI (-0.215, -0.004). For births in low-income households, in particular, it was associated with an increase in gestational age by an average of approximately 3 days. However, after adjustment, greenspace was not found to influence birth weight, communication or motor delays at age 9 months.

CONCLUSION

The biophilic design of urban environments is a modifiable factor for improving perinatal outcomes in the UK as urban greenspaces appear to be mitigating the risk of preterm birth associated with family poverty.

Infant and early childhood physical health assessments in the HEALthy Brain and Child Development (HBCD) Study

The HEALthy Brain and Child Development (HBCD) Study, a multi-site prospective longitudinal cohort study, will examine human brain, cognitive, behavioral, social and emotional development beginning prenatally and planned through early childhood. Many prenatal and early childhood exposures impact both later physical health and development. Moreover, early deficits in physical health, such as growth and vision, are associated with differences in brain development, language and cognitive functioning. For these reasons, the HBCD Study includes measures of early childhood physical health, many of which have clinical relevance, and are applicable for use as both predictors and outcomes. Study measures assess a broad range of physical health domains and include both objective measurement of child growth and health and subjective caregiver report of behaviors and attitudes about constructs known to influence growth and physical development. Lastly, we obtain caregiver report of the child's routine medical care as well as acute and chronic medical issues. We anticipate that these data will contextualize the impact of child physical growth and health on child brain development and function. In this report we present the rationale for each domain and an overview of the physical health measures included in the current HBCD Study protocol.

The Built Environment and Childhood Obesity

Counseling on physical activity (PA) to promote a child's overall growth, development, and wellness is a routine part of a well child visit. Given less than a quarter of children in the United States ages 6 to 17 years get 60 minutes of PA daily, there is increased focus on the built environment, that is, neighborhood level supports and barriers to PA and risk for obesity. Broad-based consideration of the built environment's contribution to childhood obesity can inform public health prevention strategies at the individual, family, community, and societal levels that promote children's health, especially in high-risk communities.

Built environment and childhood obesity

Childhood obesity, an escalating global health challenge, is intricately linked to the built environment in which children live, learn, and play. This review and perspective examined the multifaceted relationship between the built environment and childhood obesity, offering insights into potential interventions for prevention. Factors such as urbanization, access to unhealthy food options, sedentary behaviors, and socioeconomic disparities are critical contributors to this complex epidemic. Built environment encompasses the human-modified spaces such as homes, schools, workplaces, and urban areas. These settings can influence children's physical activity levels, dietary habits, and overall health. The built environment can be modified to prevent childhood obesity by enhancing active transportation through the development of safe walking and cycling routes, creating accessible and inviting green spaces and play areas, and promoting healthy food environments by regulating fast-food outlet density. School design is another area for intervention, with a focus on integrating outdoor spaces and facilities that promote physical activity and healthy eating. Community engagement and education in reinforcing healthy behaviors is necessary, alongside the potential of technology and innovation in encouraging physical activity among children. Policy and legislative support are crucial for sustaining these efforts. In conclusion, addressing the built environment in the fight against childhood obesity requires the need for a comprehensive, multipronged approach that leverages the built environment as a tool for promoting healthier lifestyles among children, ultimately paving the way for a healthier, more active future generation.

The Built Environment and Pediatric Health

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health professionals' care for patients and advocacy on their behalf. This technical report describes the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities. The accompanying policy statement outlines community design solutions that can improve pediatric health and health equity, including opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families.

The Built Environment and Pediatric Health

Buildings, parks, and roads are all elements of the "built environment," which can be described as the human-made structures that comprise the neighborhoods and communities where people live, work, learn, and recreate (https://www.epa.gov/smm/basic-information-about-built-environment). The design of communities where children and adolescents live, learn, and play has a profound impact on their health. Moreover, the policies and practices that determine community design and the built environment are a root cause of disparities in the social determinants of health that contribute to health inequity. An understanding of the links between the built environment and pediatric health will help to inform pediatricians' and other pediatric health care professionals' care for patients and advocacy on their behalf. This policy statement outlines community design solutions that can improve pediatric physical and mental health, and improve health equity. It describes opportunities for pediatricians and the health care sector to incorporate this knowledge in patient care, as well as to play a role in advancing a health-promoting built environment for all children and families. The accompanying technical report reviews the range of pediatric physical and mental health conditions influenced by the built environment, as well as historical and persistent effects of the built environment on health disparities.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS AND SETTINGS

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

MAIN OUTCOME MEASURES

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

STATISTICAL ANALYSIS

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

RESULTS

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

CONCLUSIONS

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

Heterogeneity in place effects on health: The case of time preferences and adolescent obesity

We leverage a natural experiment in combination with data on adolescents' time preferences to assess whether there is heterogeneity in place effects on adolescent obesity. We exploit the plausibly exogenous assignment of military servicemembers, and consequently their children, to different installations to identify place effects. Adolescents' time preferences are measured by a validated survey scale. Using the obesity rate in the assigned installation county as a summary measure of its obesity-related environments, we show that exposure to counties with higher obesity rates increases the likelihood of obesity among less patient adolescents but not among their more patient counterparts.

Neighborhood Walkability, Historical Redlining, and Childhood Obesity in Denver, Colorado

Childhood obesity is a precursor to future health complications. In adults, neighborhood walkability is inversely associated with obesity prevalence. Recently, it has been shown that current urban walkability has been influenced by historical discriminatory neighborhood disinvestment. However, the relationship between this systemic racism and obesity has not been extensively studied. The objective of this study was to evaluate the association of neighborhood walkability and redlining, a historical practice of denying home loans to communities of color, with childhood obesity. We evaluated neighborhood walkability and walkable destinations for 250 participants of the Healthy Start cohort, based in the Denver metropolitan region. Eligible participants attended an examination between ages 4 and 8. Walkable destinations and redlining geolocations were determined based on residential addresses, and a weighting system for destination types was developed. Sidewalks and trails in Denver were included in the network analyst tool in ArcMap to calculate the precise walkable environment for each child. We implemented linear regression models to estimate associations between neighborhood characteristics and child body mass index (BMI) z-scores and fat mass percent. There was a significant association between child BMI and redlining (β: 1.36, 95% CI: 0.106, 2.620). We did not find an association between walkability measures and childhood obesity outcomes. We propose that cities such as Denver pursue built environment policies, such as inclusionary zoning and direct investments in neighborhoods that have been historically neglected, to reduce the childhood health impacts of segregated poverty, and suggest further studies on the influences that redlining and urban built environment factors have on childhood obesity.

Associations of four indexes of social determinants of health and two community typologies with new onset type 2 diabetes across a diverse geography in Pennsylvania

Evaluation of geographic disparities in type 2 diabetes (T2D) onset requires multidimensional approaches at a relevant spatial scale to characterize community types and features that could influence this health outcome. Using Geisinger electronic health records (2008–2016), we conducted a nested case-control study of new onset T2D in a 37-county area of Pennsylvania. The study included 15,888 incident T2D cases and 79,435 controls without diabetes, frequency-matched 1:5 on age, sex, and year of diagnosis or encounter. We characterized patients’ residential census tracts by four dimensions of social determinants of health (SDOH) and into a 7-category SDOH census tract typology previously generated for the entire United States by dimension reduction techniques. Finally, because the SDOH census tract typology classified 83% of the study region’s census tracts into two heterogeneous categories, termed rural affordable-like and suburban affluent-like, to further delineate geographies relevant to T2D, we subdivided these two typology categories by administrative community types (U.S. Census Bureau minor civil divisions of township, borough, city). We used generalized estimating equations to examine associations of 1) four SDOH indexes, 2) SDOH census tract typology, and 3) modified typology, with odds of new onset T2D, controlling for individual-level confounding variables. Two SDOH dimensions, higher socioeconomic advantage and higher mobility (tracts with fewer seniors and disabled adults) were independently associated with lower odds of T2D. Compared to rural affordable-like as the reference group, residence in tracts categorized as extreme poverty (odds ratio [95% confidence interval] = 1.11 [1.02, 1.21]) or multilingual working (1.07 [1.03, 1.23]) were associated with higher odds of new onset T2D. Suburban affluent-like was associated with lower odds of T2D (0.92 [0.87, 0.97]). With the modified typology, the strongest association (1.37 [1.15, 1.63]) was observed in cities in the suburban affluent-like category (vs. rural affordable-like–township), followed by cities in the rural affordable-like category (1.20 [1.05, 1.36]). We conclude that in evaluating geographic disparities in T2D onset, it is beneficial to conduct simultaneous evaluation of SDOH in multiple dimensions. Associations with the modified typology showed the importance of incorporating governmentally, behaviorally, and experientially relevant community definitions when evaluating geographic health disparities.

Key Informants' Perspectives on Childhood Obesity in Vietnam: A Qualitative Study

Objectives

Vietnam’s post-war globalization, economic development, and urbanization have contributed to a nutrition transition from traditional diets to highly-processed diets, and increased prevalence of childhood overweight and obesity. Our study aims to explore the attitudes and behaviors driving this epidemic.

Methods

This qualitative study focused on the perspectives and practices of Vietnamese parents, schoolteachers and doctors. Semi-structured interviews were conducted with a convenience sample of 12 regarding the historical, social, and cultural influences contributing to childhood overweight and obesity. Audio-recorded interviews were translated and transcribed, then analyzed using modified ground theory to identify themes and representative quotes.

Results

Five themes were identified: (1) Change in diet between generations, (2) Preference for rounder children, (3) Unhealthy feeding practices, (4) Reduced physical activity, and (5) Increasing awareness of childhood obesity. A conceptual map detailed the shift from war-time to post-war economic environment and psycho-social context for raising children to be large, safe and academically-successful.

Conclusions for Practice

We found that globalization, urbanization and economic development—in the context of historical, social and cultural attitudes—may contribute to increasing child obesity in Vietnam. Obesity prevention through public health and educational institutions should involve policies and programs for healthy eating and exercise, tailored to address parental figures’ concerns.

Resource mobilization combined with motivational interviewing to promote healthy behaviors and healthy weight in low-income families: An intervention feasibility study

Objectives

This non-randomized pilot trial examined the feasibility and acceptability of an intervention for low-income families with one parent with obesity, glucose intolerance and/or diabetes.

Methods

The 12-month intervention combined health coaching using motivational interviewing to promote lifestyle behavior change and community resource mobilization to assist with basic needs plus diet quality and physical activity. Outcome measures included process measures, open-ended questions, and the Family Nutrition and Physical Activity scale.

Results

Forty-five families completed an average of 2.1 health coach in-person visits, including 15 families lost to follow-up. Parents who stayed in the intervention reported the intervention was helpful. Some families and the health coach had difficulties contacting one another, and some of these families reported they would have liked more sessions with the coach. The Family Nutrition and Physical Activity scores improved significantly for all children (6 months: 2.9; p < .01; 12 months: 3.2; p < .05) and at 6 months for index children (6 months: 3.5; p < .01; 12 months: 2.9; p = .09). There was variation in the FNPA and other outcome changes between families.

Conclusion

This intervention was feasible in terms of recruitment and delivery of family sessions and community referrals and acceptable to participants, but maintaining contact with participants was difficult. Findings warrant improvements to help retention and logistical aspects of communication between families and coaches and testing in a randomized, controlled trial.

Examining the state, quality and strength of the evidence in the research on built environments and physical activity among children and youth: An overview of reviews from high income countries

BACKGROUND

Built environments have shown to be associated with health, with physical activity (PA) considered one of the critical pathways for achieving benefits. Navigating available evidence on the built environment and PA is challenging given the number of reviews.

OBJECTIVE

Examine the current state and quality of research looking at associations between built environments and total PA and domains of PA (i.e., leisure/recreation, transportation, school) among children and youth (1-18 years).

METHODS

We systematically searched the grey literature and six bibliographic databases from January 2000 to May 2020. Review quality was assessed using the AMSTAR2. Results by age group were synthesized using narrative syntheses and harvest plots, and certainty of the evidence was assessed using a modified GRADE approach.

RESULTS

This overview included 65 reviews. Most reviews were of very low-to-low quality. High certainty was found for positive associations between transportation PA and walking/cycling/active transportation (AT) infrastructure. There was high certainty for positive associations between streets/play streets and total PA, alongside lower certainty for transportation and leisure PA. Very low-to-moderate certainty supports schoolyards designed to promote PA were positively associated with total PA, but mixed for school PA (except children). Less consistent positive associations were found for forests/trees, greenspace/open space, recreation facilities, street lighting, traffic safety, population/residential density, proximity/access to destinations, neighbourhood characteristics, and home environments. There is very low-to-moderate certainty for negative associations between greater distance to school and traffic volume and domains of PA. Generally, null or mixed associations were observed for aesthetics, parks, AT comfort infrastructure, land-use mix, street connectivity, urban/rural status, and public transit.

DISCUSSION

There remains a need for high quality systematic reviews and studies to evaluate the effects of environmental changes across the pediatric age spectrum and using a PA domain approach. Given the global physical inactivity crisis the built environment remains and important means to promote PA among children/youth.

Influence of Geographical Area and Living Setting on Children's Weight Status, Motor Coordination, and Physical Activity

This study was aimed (i) to examine the effect of living setting (rural vs. urban), geographical area (North vs. Center vs. South), and gender (boys vs. girls) on weight status, motor coordination, and physical activity (PA) level of Italian school-age children; (ii) to examine differences in the neighborhood walkability of different school areas from different geographical areas and living settings; and (iii) to examine whether motor coordination, PA level, geographical areas, living setting, neighborhood walkability, and gender could predict children's weight status. We assessed anthropometric parameters, gross motor coordination, and PA level in 1,549 children aged between 8 and 13 years. Results revealed that Central children had higher BMI than Northern and Southern children (η2 = 0.01). Moreover, Northern children showed the highest motor quotient (η2 = 0.148) and PA level (η2 = 0.02), followed by Southern and Central children, respectively. Children from the South of Italy attended schools located in neighborhoods with the highest Walk Score®. Urban children attended schools located in neighborhoods with a higher Walk Score® than rural children. Lower motor quotient (MQ), lower PA level, and living in a rural setting and in a car-dependent neighborhood were associated with a higher relative risk for obesity. Being a girl was associated with a lower relative risk for obesity. The alarming high percentage of overweight and obesity in children as well as motor coordination impairments revealed the urgent need of targeted PA interventions in pediatric population.

The Effect of Neighborhood-level Resources on Children's Physical Development: Trajectories of Body Mass Index and Pubertal Development and the Influence of Child Biological Sex

Growing research substantiates the role of neighborhood disadvantage in contributing to early pubertal maturation and higher body mass index; however, previous studies in this area have design limitations. Specifically, many studies have been cross-sectional, have used singular indicators of neighborhood disadvantage (e.g., poverty), and have provided mixed findings about the role of biological sex. The present study addresses these gaps by examining how neighborhood resources (spanning educational, health/environmental, and social/economic domains) predict trajectories of pubertal maturation and body mass index using longitudinal multi-wave data. Furthermore, multigroup analyses assessed how these associations may differ by child biological sex. Participants in this study (n = 505; 54% male) were assessed every 3 years at age 9 (M = 9.17, SD = 0.39), age 12 (M = 12.63, SD = 0.43), and age 15 (M = 15.23, SD = 0.37). Approximately 12% of the sample identified as Hispanic, and 11% as non-White. Using multigroup latent growth analyses, the study examined how neighborhood resources predicted trajectories of pubertal maturation and body mass index using multi-wave data across middle childhood through mid-adolescence. The findings suggested that greater neighborhood resources were cross-sectionally associated with lower pubertal development and predicted slower trajectories across time. Although all girls in the study eventually progressed through pubertal development, girls in lower resourced neighborhoods experienced a much earlier onset of puberty. Additionally, greater neighborhood resources predicted lower BMI both cross sectionally and longitudinally. Specifically, higher resourced neighborhoods were protective against obesity risk for both boys and girls across mid-childhood through mid-adolescence. In sum, the study highlights the role of broader neighborhood factors on early maturity risk for female children, and obesity risk for children regardless of biological sex.

The built environment as determinant of childhood obesity: A systematic literature review

We evaluated the epidemiological evidence on the built environment and its link to childhood obesity, focusing on environmental factors such as traffic noise and air pollution, as well as physical factors potentially driving obesity-related behaviors, such as neighborhood walkability and availability and accessibility of parks and playgrounds. Eligible studies were (i) conducted on human children below the age of 18 years, (ii) focused on body size measurements in childhood, (iii) examined at least one built environment characteristic, (iv) reported effect sizes and associated confidence intervals, and (v) were published in English language. A z test, as alternative to the meta-analysis, was used to quantify associations due to heterogeneity in exposure and outcome definition. We found strong evidence for an association of traffic-related air pollution (nitrogen dioxide and nitrogen oxides exposure, p < 0.001) and built environment characteristics supportive of walking (street intersection density, p < 0.01 and access to parks, p < 0.001) with childhood obesity. We identified a lack of studies that account for interactions between different built environment exposures or verify the role and mechanism of important effect modifiers such as age.

The effects of the built environment on the general health, physical activity and obesity of adults in Queensland, Australia

The built environment has been identified as a key factor for health intervention and obesity prevention. However, it is still unclear to what extent the built environment is associated with obesity and general health and to what extent such an association is mediated through variation in physical activity. This study aims to examine the associations between individual characteristics, the built environment, physical activity, general health and body mass index to reveal the pathways through which the built environment is associated with the prevalence of obesity. Using data from 1,788 adults aged 18 to 65 in Queensland from Wave 16 of the Household, Income, and Labour Dynamics in Australia survey, we use geographic information system-based methods to quantify built environment factors in 5D dimensions: Density, Diversity, Design, Distance and Destination accessibility. We then employ multi-level mixed-effect models to test the hypothesised relationships between individual characteristics, the built environment, physical activity, general health and body mass index. The results indicate that physical activity is positively associated with general health and negatively associated with the prevalence of obesity. Adjusting for individual characteristics, we find that built-environment factors have direct effects on physical activity but indirect effects on general health and obesity. Among these factors, greater green space exposure plays a key role in enhancing general health and reducing obesity. Low-density and car-dependent neighbourhoods can be activity-friendly and mitigate obesity if these neighbourhoods are also equipped with easy access to green space.

The Neighborhood Food Environment and the Onset of Child-Hood Obesity: A Retrospective Time-Trend Study in a Mid-sized City in China

Nowadays, obesity and its associated chronic diseases have become a steadily growing public health problem, spreading from the older to younger age groups. Studies have contended that the built environment, particularly the food environment and walkability, may contribute to the prevalence of childhood obesity. In Asian countries which are characterized by rapid urbanization, high population density and oriental diets, little is known about how such urban built environment affects the onset of childhood obesity. This study juxtaposes the effect of food environment, walkability, and outdoor activity spaces at the neighborhood level upon childhood body weight in a mid-sized city in China. This observational study utilizes a retrospective time-trend study design to examine the associations between neighborhood built environment and children's body weight in Zhanjiang City, a mid-sized city in Guangdong Province, China. Robust multiple linear and logistic regression models were used to estimate associations between the built environments and child BMI and weight status (i.e., overweight/obesity and obesity only). This study finds that: (1) Western-style fast food and Chinese-style fast food have divergent impacts on childhood body weight. At neighborhood level, while increased exposure to Western-style fast food may increase child BMI and the risk of overweight and obesity, increased exposure to Chinese-style fast food, on the contrary, may reduce child BMI and the risk of overweight and obesity, indicating a positive health impact of Chinese-style fast food. (2) However, the positive health impacts brought about by Chinese-style fast food, walkable environments and accessible traditional fruit/vegetable markets have gradually disappeared in recent years. This study is among the first to simultaneously consider the divergent and changing impact of food environment upon childhood body weight in urban China. The findings provide important implications for healthy city design and the management of food retail industry in addressing the obesity epidemic in younger generations living in Asian cities. As prominent differences exist in food culture between Asian and Western cities, more attention should be paid to healthy food environment in future studies and related urban planning strategies formulation.

Students Living in the Islands are Heavier and have Lower Fitness Levels Compared to their Mainland Counterparts; Results from the National Action for Children's Health (EYZHN) Program

Few studies have examined variations in obesity by geographic location in youth and its relation with fitness levels. The present study investigated the association between geographic status (islands versus mainland), excess of body weight and fitness levels among 335.810 schoolchildren (male: 51.3%, 6-18 y, during the school year 2014-2015). Students' anthropometric parameters and fitness levels - accessed via the Euro-fit test - were measured by trained physical education teachers and evaluated according to published norms. Prevalence of overweight (23.0 Vs 21.8%) and obese (10.1 Vs 8.0%) was significantly higher for students living in the islands contrary to their mainland counterparts. A significant difference was also observed for centrally obese children (33.5 Vs 28.2%). Except for speed test .408), in all other four fitness tests, the students from the islands presented significantly lower performance (≤25^th percentile of published age- and sex-specific normative values) versus their mainland counterparts. Boys and girls living in the islands had 48% and 37% increased odds of low physical fitness (as a total), respectively, compared to their mainland counterparts. Likewise, children living in islands presented increased odds of being overweight or obese by 19% and 15% in boys and girls, respectively, as compared to those living in the mainland. Increased general and abdominal adiposity have a direct negative impact on students' performance in Physical Fitness tests. Our data highlight the problem of excessive body weight that children living in rural areas, face.

Prevalence of severe childhood obesity in Wales UK

BACKGROUND

In Wales, approximately one in eight children is obese (aged 4-5 years). The aim of this prevalence study was to examine the trends in severe childhood obesity and investigate any relationship with socioeconomic deprivation.

METHODS

Data for all children included as part of the Wales Childhood Measurement Programme (2013/14-2017/18) were utilized. Data on the number who had a body mass index above the 99.6th centile indicating severe obesity were calculated over time by sex and in relation to deprivation.

RESULTS

Of the 162 208 children measured between 2013/14 and 2017/18 (mean age 5.06 years, standard deviation 0.35 years), the overall prevalence of severe obesity was 3.1% (95% confidence interval [CI] 3.0-3.2%). This varies from 1.9% (95% CI 1.7-2.1%) in the least deprived areas to 3.9% (95% CI 3.7-4.0%) in the most deprived areas. Boys have higher prevalence of severe obesity than girls: 3.6% (95% CI 3.4-3.9%) of boys (n = 598) and 3.0% (95% CI 2.7-3.2%) of girls (n = 467) were categorized as severely obese in reception year in Wales in 2017/18. Prevalence has increased over time but this is not statistically significant.

CONCLUSION

This study found significantly higher levels of severe obesity in areas of socioeconomic deprivation. Levels of severe obesity were significantly higher in boys than in girls.

Home and Neighborhood Physical Activity Location Availability among African American Adolescent Girls Living in Low-Income, Urban Communities: Associations with Objectively Measured Physical Activity

Based on the ecological model of active living, the neighborhood environment may relate to individual physical activity (PA) behaviors. The purposes of this study were to (1) generate a replicable neighborhood-level physical activity location availability score (PALAS) from data variables associated with physical activity among adolescents and adults, and apply this score to Baltimore City, Maryland, and (2) determine if relationships exist between PA and PA location availability. Geographic information systems (GISs) were used to create the PALAS. Using linear regression models, we examined relations between objectively measured PA among low-income, urban, predominantly African American adolescent girls (n = 555, 2009-2012 data collection), and the PALAS rating of their neighborhood environment (neighborhood PALAS) and their home neighborhood area (PALAS variables/subcomponents within 0.25 miles of the home). A PALAS map of the study area was created, illustrating neighborhoods varying in availability and variety of PA locations. After adjusting for confounders, a higher neighborhood PALAS (β = 0.10, p = 0.041) and the presence of a recreation center in the home neighborhood area (β = 0.46, p = 0.011) were associated with more minutes per day spent in moderate to vigorous PA. Policy makers and stakeholders should consider increasing access to PA locations as a strategy to promote PA among adolescent girls.

Associations between the built environment and dietary intake, physical activity, and obesity: A scoping review of reviews

There exists a large body of literature examining the association between built environment factors and dietary intake, physical activity, and weight status; however, synthesis of this literature has been limited. To address this gap, we conducted a scoping review of reviews and identified 74 reviews and meta-analyses that investigated the association between built environment factors and dietary intake, physical activity, and/or weight status. Results across reviews were mixed, with heterogeneous effects demonstrated in terms of strength and statistical significance; however, preliminary support was identified for several built environment factors. For example, quality of dietary intake appeared to be associated with the availability of grocery stores, higher levels of physical activity appeared to be most consistently associated with greater walkability, and lower weight status was associated with greater diversity in land-use mix. Overall, reviews reported substantial concern regarding methodological limitations and poor quality of existing studies. Future research should focus on improving study quality (e.g., using longitudinal methods, including natural experiments, and newer mobile sensing technologies) and consensus should be drawn regarding how to define and measure both built environment factors and weight-related outcomes.

Early childhood factors associated with obesity at age 8 in Vietnamese children: The Young Lives Cohort Study

Background

Over recent decades, Vietnam has experienced rapid economic growth, a nutrition transition from the traditional diet to highly-processed and calorie-dense foods and beverages, and an increasing prevalence of childhood overweight/obesity (ow/ob). The goal of this study is to describe the patterns of ow/ob in a longitudinal sample of Vietnamese children from ages 1 to 8, and the sociodemographic and behavioral factors associated with ow/ob at age 8.

Methods

This study is a secondary data analysis of a geographically-representative, longitudinal cohort of 1961 Vietnamese children from the Young Lives Cohort Study from 2002 to 2009. Thirty-one communities were selected with oversampling in rural communities, and children age 1 were recruited from each community using simple random sampling. Surveys of families and measurements of children were collected at child ages 1, 5, and 8. Our specified outcome measure was childhood ow/ob at age 8, defined by the World Health Organization’s thresholds for body-mass-index (BMI) for age Z-scores. Associations between early and concurrent socio-behavioral factors, childhood nutrition and physical activity variables were analyzed using STATA 15. Bivariate and multivariable analyses were completed utilizing logistic regression models.

Results

The prevalence of ow/ob increased from 1.1% in both sexes at age 1 to 7% in females and 13% in males at age 8. Bivariate analyses show greater likelihood of ow/ob at age 8 was significantly associated with early life sociodemographic factors (at age 1), male sex (OR = 2.2, 1.6–3.1), higher wealth (OR = 1.1–1.4), and urban residence (OR = 4.3, 3–6). In adjusted analyses, ow/ob at age 8 was associated with early nutrition practices at age 5, including frequent consumption of powdered milk (OR = 2.8, 1.6–4.6), honey/sugar (OR = 2.7, 1.8–4.1), prepared restaurant/fast foods (OR = 4.6, 2.6–8.2), and packaged sweets (OR = 3.4, 2.3–4.9). In addition, breastfeeding for 6 months or longer was protective against obesity at age 8 (OR = 0.3, 0.1–0.9).

Conclusions

We found that increased consumption of powdered milk, honey/sugar, packaged sweets, and prepared restaurants/fast foods are associated with childhood ow/ob. In contrast, breastfeeding for 6 months or longer was protective against childhood ow/ob. These findings suggest that public health programs and campaigns aimed to prevent childhood ow/ob in Vietnam should target early feeding practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10292-z.

Neighborhood sidewalk access and childhood obesity

The lack of access to sidewalks is a barrier for physical activity (PA) and may be a risk factor for childhood obesity. However, previous studies reported mixed findings and the association between sidewalk accessibility and childhood obesity remains unclear. This study systematically examined the evidence on the association between sidewalk accessibility and childhood obesity. PubMed, Cochrane Library, and Web of Science were searched for relevant articles (published before 1 January 2019) that reported on the association between neighborhood sidewalk access and weight-related behaviors and outcomes in children. Seventeen studies conducted in five countries were included. Ten studies used objective measure of access to sidewalks, seven studies measured children's height and weight, and seven studies objectively measured the PA or sedentary behaviors. Ten studies reported on the association of better access to sidewalks with increased PA (β ranging from 0.032 to 2.159; p < 0.05), reduced sedentary behaviors (β ranging from -0.19 to -0.14; p < 0.05), lower body mass index (BMI) (β ranging from -0.261 to -0.144; p < 0.001), or obesity risks (OR ranging from 1.02 to 1.32; p < 0.05); while the remaining seven studies did not report a desirable obesity-sidewalk association. Our findings support the hypothesis that higher sidewalk accessibility is associated with higher PA levels, lower BMI, and obesity risks. Efforts in building healthy environments, including health-promoting city planning, can help minimize the growing obesity epidemic and promote public health.

Prediction model study of overweight and obesity in preschool children with allergic diseases from an ecological perspective

Background

Allergic diseases have a high incidence in childhood and a high chance to be carried over into adulthood unless appropriately treated during childhood, it is important that healthcare providers actively manage these diseases. This study was to identify multidimensional factors that affect weight gain in preschool children with allergic diseases.

Methods

The overweight and obesity prediction model for children with allergic diseases was analyzed using multiple logistic regression analysis and a decision tree model and the present study was a secondary data analysis study that used data from the Panel Study on Korean Children conducted by the Korea Institute of Child Care and Education.

Results

The significance of this study is identify multidimensional factors that affect weight gain in preschool children with allergic diseases, which found that children (gender, sitting time during weekdays, sleeping hours during weekends,), parent (education level, mother’s job, quality of the home environment), local community (convenience of local community facilities, satisfaction level with local community facilities, quality of childcare in the local community) characteristics affected overweight and obesity at multidimensional levels as risk factors.

Conclusions

The significance of this study is identify multidimensional factors that affect weight gain in preschool children with allergic diseases using the data of the Panel Study on Korean Children, which found that children, parent, local community characteristics affected overweight and obesity at multidimensional levels as risk factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02515-4.

Changes in the Recreational Built Environment and Youth Body Mass Index

OBJECTIVE

Many cities have implemented programs to improve the recreational built environment. We evaluated whether neighborhood recreational built environmental changes are associated with change in body mass index (BMI).

METHODS

We performed a longitudinal assessment of association between the recreational built environment and BMI percent of 95th percentile (BMIp95). Patient data from 2012 to 2017 were collected from electronic medical records including height, weight, sex, race/ethnicity, insurance type, and address. BMIp95 was calculated. Environmental data including sidewalks, trails, Healthy Mile Trails, and parks were collected. Patients' neighborhood environments were characterized using proximity of features from home address. Multilevel linear regressions with multiple encounters per patient estimated effects of recreational features on BMIp95 and stratified models estimated effect differences.

RESULTS

Of 8282 total patients, 27.7% were non-Hispanic White, half were insured by Medicaid, and 29.5% changed residence. Median BMIp95 was 86.3%. A decrease in BMIp95 was associated with park proximity in the full cohort (-2.85; 95% CI [confidence interval]: -5.47, -0.24; P = .032), children with obesity at baseline (-6.50; 95% CI: -12.36, -0.64; P = .030) and privately insured children (-4.77; 95% CI: -9.14, -0.40; P = .032). Healthy Mile Trails were associated with an increase in BMIp95 among children without obesity (1.00; 95% CI 0.11, 1.89; P = .027) and children living in higher income areas (6.43; 95% CI: 0.23, 12.64; P = .042).

CONCLUSIONS

Differences in effect indicate that built environment changes may improve or exacerbate disparities. Improving obesity disparities may require addressing family-level barriers to the use of recreational features in addition to proximity.

Early life exposure to air pollution, green spaces and built environment, and body mass index growth trajectories during the first 5 years of life: A large longitudinal study

Urban environments are characterized by multiple exposures that may influence body mass index (BMI) growth in early life. Previous studies are few, with inconsistent results and no evaluation of simultaneous exposures. Thus, this study aimed to assess the associations between exposure to air pollution, green spaces and built environment characteristics, and BMI growth trajectories from 0 to 5 years. This longitudinal study used data from an electronic primary care health record database in Catalonia (Spain), including 79,992 children born between January 01, 2011 and December 31, 2012 in urban areas and followed until 5 years of age. Height and weight were measured frequently during childhood and BMI (kg/m²) was calculated. Urban exposures were estimated at census tract level and included: air pollution (nitrogen dioxide (NO₂), particulate matter <10 μm (PM₁₀) and <2.5 μm (PM_2.5)), green spaces (Normalized Difference Vegetation Index (NDVI) and % green space) and built environment (population density, street connectivity, land use mix, walkability index). Individual BMI trajectories were estimated using linear spline multilevel models with several knot points. In single exposure models, NO_2, PM_10, PM_2.5, and population density were associated with small increases in BMI growth (e.g. β per IQR PM₁₀ increase = 0.023 kg/m², 95%CI: 0.013, 0.033), and NDVI, % of green spaces and land use mix with small reductions in BMI growth (e.g. β per IQR % green spaces increase = -0.015 kg/m^2, 95%CI: -0.026, -0.005). These associations were strongest during the first two months of life. In multiple exposure models, most associations were attenuated, with only those for PM₁₀ and land use mix remaining statistically significant. This large longitudinal study suggests that early life exposure to air pollution, green space and built environment characteristics may be associated with small changes in BMI growth trajectories during the first years of life, and that it is important to account for multiple exposures in urban settings.

Identification of Effective Programs to Improve Access to and Use of Trails among Youth from Under-Resourced Communities: A Review

The primary purpose of this paper is to identify and review studies evaluating the effectiveness of programs to increase access to trails and trails use (physical activity) among youth from under-resourced communities. Three additional goals include identifying: (1) Correlates of physical activity/trail use and features of transportation systems and/or built environment and land use destinations, that may inform and support the planning and implementation of programs to promote trail use among youth, (2) benefits associated with trail use, and (3) barriers to trail use. Under-resourced communities are defined as those lacking sufficient resources (i.e., under-funded).

METHODS

A review of the literature was conducted to identify, abstract, and evaluate studies related to programs to promote trail use among youth and youth from under-resourced communities. In anticipation of very few studies being published about this topic, studies were also reviewed to identify correlates of transportation systems and built environment and land use destinations related to increases in physical activity, and benefits of, and barriers to trail use. PUBMED, MEDLINE, PsycINFO, Sportdiscus, Annual Reviews, American Trails, and Google Scholar databases were searched using terms including trails, built environment, physical activity, exercise, walking, children, adolescents, and youth to identify studies that potentially related to the purposes for conducting this review. Review methods identified, 5278 studies based on our search terms. A review of study titles, abstracts, and select full article screens determined that 5049 studies did not meet the study inclusion criteria, leaving 221 studies included in this review.

RESULTS

No studies were located that evaluated programs designed to promote and increase trail use among youth, including youth from under-resourced communities. Eight studies used longitudinal or quasi-experimental designs to evaluate physical activity and neighborhood characteristics prospectively among adolescent girls (n = 1), the effects of the path or trail development on physical activity behaviors of children, youth, and adults (n = 4), marketing or media campaigns (n = 2), and wayfinding and incremental distance signage (n = 1) to promote increased trail use. Correlates of transportation systems (e.g., trail access, road traffic congestion related to safe active travel, lack of sidewalks, closer proximity to trails, access to transportation), destinations (e.g., park availability and access, park improvements, greenspaces), or both routes and destinations (e.g., perceptions of safety, lighting), were identified. These correlates may support the planning and implementation of programs to increase trail use among youth, or may facilitate the connection of trails or routes to destinations in communities. Barriers to trail use included costs, crime, lack of transportation, lack of role models using trails, and institutional discrimination.

CONCLUSIONS

Scientific evidence in support of addressing the underrepresentation of trail use by youth from under-resourced communities is lacking. However, there is a related body of evidence that may inform how to develop programs that support trail use by youth from under-resourced areas. Dedicated, deliberate, and systematic efforts will be required to address research and knowledge gaps, and to evaluate programs and practice related to trail use among youth from low income, often racially or ethnically diverse under-resourced neighborhoods or communities.

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 Association between Ground Floor Features and Public Open Space Face-To-Face Interactions: Evidence from Nantou Village, Shenzhen

With face-to-face interaction proving beneficial for mental health, there is still a paucity of research on the correlation between ground floor features (GFFs), defined here as the features of the ground floor of buildings overlooking a street, and public open space face-to-face interaction density (POSFTFID), defined as the density of human face-to-face interactions in the public open space (POS) adjacent to each building. Is there a correlation between GFFs and POSFTFID? This study aims to answer this question gaining empirical evidence from a Chinese village in the city (ViC). Behavioural mapping and statistical analysis were employed and the following GFFs were tested: Ground floor area, indoor visible space, presence of stairs, POS adjacent area, and land use. Results show an association between POSFTFID and: (1) The area of the POS adjacent to each building, (2) the degree of visibility (ratio of indoor visible space to total internal space) of the ground floor, (3) the presence of stairs. Moreover, food appears to be an important attribute fostering social interaction. Results can provide insights on future implications in urban design strategies and planning policies aiming at enhancing mental health conditions in contemporary cities.

Design and methods of the Healthy Kids & Families study: a parent-focused community health worker-delivered childhood obesity prevention intervention

Background

One third of U.S. children and two thirds of adults are overweight or obese. Interventions to prevent obesity and thus avert threats to public health are needed. This paper describes the design and methods of the Healthy Kids & Families study, which tested the effect of a parent-focused community health worker (CHW)-delivered lifestyle intervention to prevent childhood obesity.

Methods

Participants were English or Spanish-speaking parent-child dyads (n = 247) from nine elementary schools (grades K-6) located in racial/ethnically diverse low-income communities in Worcester, Massachusetts. Using a quasi-experimental design with the school as the level of allocation, the study compared the lifestyle intervention vs. an attention-control comparison condition. The lifestyle intervention was guided by social cognitive theory and social ecological principles. It targeted the child’s social and physical home environment by intervening with parental weight-related knowledge, beliefs, and skills for managing child obesogenic behaviors; and addressed families’ needs for community resources supportive of a healthy lifestyle. The two-year CHW-delivered intervention was structured based on the 5As model (Agenda, Assess, Advise, Assist, Arrange follow up) and included two in person sessions and two telephone follow-ups per year with the parent, with a personalized letter and print materials sent after each contact. Parents also received quarterly newsletters, Facebook messages, and invitations to community events. The attention-control comparison condition used the same format and contact time as the intervention condition, but targeted positive parenting skills. Measurements occurred at baseline, and at 6-, 12-, 18- and 24-month follow-up. Assessments included anthropometrics, accelerometry, global positioning system (GPS), and self-report surveys. The primary outcome was child body mass index (BMI) z score. Secondary outcomes were parent BMI; and parent and child diet, physical activity, sedentariness, and utilization of community resources supportive of a healthy lifestyle.

Discussion

A CHW-delivered parent-focused lifestyle intervention may provide a translatable model for targeting the high priority public health problem of childhood obesity among low-income diverse communities. If demonstrated effective, this intervention has potential for high impact.

Trial registration

ClinicalTrials NCT03028233. Registered January 23,2017. The trial was retrospectively registered.

Built Environment and Health Behaviors: Deconstructing the Black Box of Interactions-A Review of Reviews

A review of reviews following a scoping review study design was conducted in order to deconstruct the black box of interactions between the built environment and human behaviors pertaining to physical activity and/or diet. In the qualitative analysis 107 records were included, 45 of which were also coded. Most review papers confirmed the influence of the built environment on the behaviors of interest with some noting that a same built environment feature could have different behavioral outcomes. The conceptual model developed sheds light on these mixed results and brings out the role of several personal and behavioral factors in the shift from the measured to the perceived built environment. This shift was found to shape individuals' behaviors critically and to have the power of redefining the strength of every interaction. Apart from its theoretical relevance, this model has high practical relevance especially for the design and implementation of interventions with a behavioral component. Intervention researchers can use the model developed to identify and label the built environment and individual factors that can be measured objectively or perceived as facilitators, concurrent options and barriers, in order to develop comprehensive and multi-component intervention strategies.

Childhood obesity and the associated roles of neighborhood and biologic stress

Exposure to violence and obesity continues to be growing epidemics, particularly among children. Our objective was to increase our understanding of the association between neighborhood violence exposure and children's weight and how biologic stress may mediate this relation. A matched, community-recruited cross-sectional study of 90 children, ages 5–16 years, from 52 neighborhoods took place in the greater New Orleans, LA area between 2012 and 2013. Children were matched on their propensity for living in a high violence neighborhood and previous exposure to Hurricane Katrina. Primary neighborhood exposure included violent crime, operationalized as crime rates within specific radii of children's home. Rates of exposure within 500, 1000 and 2000 meter radii from the child's home were calculated. Primary outcomes were body mass index (BMI) and waist circumference, and the primary mediator was telomere length (TL), a marker of cellular aging. Significant variation in obesity and TL was observed at the neighborhood level and violent crime was significantly associated with weight status, with an increase of 1.24 units in BMI for each additional violent crime in the child's neighborhood and a significant mediated or indirect effect of TL in the crime-BMI relation (0.32, 95% bootstrapped CI = 0.05, 0.81; 32% total mediated effect). Findings strengthen existing evidence linking neighborhood violence to childhood health and identify biologic stress, indexed by TL, as one mechanistic pathway by which neighborhood violence may influence childhood obesity. Neighborhood violence may be an important target for interventions focused on reducing obesity and other stress related health outcomes in children.

The role of urban design in childhood obesity: A case study in Lisbon, Portugal

OBJECTIVE

We hypothesize that physical features of the urban environment might enhance or prevent childhood obesity. Thus, this study's main goal was to verify if there is an association between the neighborhood urban design and childhood obesity-independent of well-known childhood obesity determinants, such as, father's level of schooling (as a proxy for socioeconomic status), and parent's weight status.

METHODS

This study classifies neighborhoods according to land use and building features using hierarchical clusters analysis and examines their association with childhood obesity through logistic regression models.

RESULTS

Four clusters resulted from the analysis: Cluster 1 represents areas with older buildings and mixed land use, cluster 2 is an area with small rented buildings and urban areas, cluster 3 comprises newer buildings with parking and urban green space, and cluster 4 is a forest area. Living in cluster 3 protects from childhood obesity, even when adjusting for father's level of schooling or parent's weight status.

CONCLUSIONS

There are distinct urban configurations in Lisbon's municipality and children who live in Cluster 3 (more recent and greener neighborhoods) seem to be protected from obesity. Therefore, public policy should focus on healthy urban planning at the neighborhood level, to promote positive impacts on peoples' health.

Social Environment and Epigenetics

Our social environment, from the microscopic to the macro-social, affects us for the entirety of our lives. One integral line of research to examine how interpersonal and societal environments can get "under the skin" is through the lens of epigenetics. Epigenetic mechanisms are adaptations made to our genome in response to our environment which include tags placed on and removed from the DNA itself to how our DNA is packaged, affecting how our genes are read, transcribed, and interact. These tags are affected by social environments and can persist over time; this may aid us in responding to experiences and exposures, both the enriched and the disadvantageous. From memory formation to immune function, the experience-dependent plasticity of epigenetic modifications to micro- and macro-social environments may contribute to the process of learning from comfort, pain, and stress to better survive in whatever circumstances life has in store.

Evaluation of a Mobile Farmer's Market Aimed at Increasing Fruit and Vegetable Consumption in Food Deserts: A Pilot Study to Determine Evaluation Feasibility

Purpose: In November 2015, Greater Pittsburgh Community Food Bank implemented a pilot phase of the Green Grocer mobile market, a program aimed at improving access to locally sourced fresh foods in low-resource neighborhoods. We conducted an evaluation of this pilot phase. Methods: We conducted baseline surveys of residents in six neighborhoods that received Green Grocer in the pilot phase to understand the food environment, including perceptions of fresh food availability, and another survey of Green Grocer consumers to evaluate their experiences and satisfaction. We measured respondent intake of fruit and vegetable in the terms of days per week and servings per day. We used Poisson regression with cluster-robust standard errors to model the average change in produce consumption pre-post intervention. Results: Residents of select communities observed meaningful improvements in intake. After covariate adjustment, Homewood residents observed an average 13% increase in vegetable intake (days/week) rates post-Green Grocer (p=0.04). Clairton residents also showed marked increases, with an average 20% increase in vegetable intake (servings/day) (p=0.049). After 6 months, declines in produce purchase from discount stores and supercenters were observed alongside increases in procurement from Green Grocer, farmer's markets, gardens, and other sources. Conclusion: Our preliminary work provides support that this mobile market serving under-resourced areas was valued by consumers and showed increases in vegetable consumption in several neighborhoods. When scaled-up, this program had the potential to reduce geographically-based food and health disparities.

Promotion of physical activity in rural, remote and northern settings: a Canadian call to action

INTRODUCTION

The lack of policy, practice and research action on physical activity and features of the physical (built and natural) environments in rural, remote and northern settings is a significant threat to population health equity in Canada. This paper presents a synthesis of current evidence on the promotion of physical activity in non-urban settings, outcomes from a national priority-setting meeting, and a preliminary call to action to support the implementation and success of population-level initiatives targeting physical activity in non-urban settings.

METHODS

We conducted a "synopses of syntheses" scoping review to explore current evidence on physical activity promotion in rural, remote, northern and natural settings. Next, we facilitated a collaborative priority-setting conference with 28 Canadian experts from policy, research and practice arenas to develop a set of priorities on physical activity in rural, remote and northern communities. These priorities informed the development of a preliminary Canadian call to action.

RESULTS

We identified a limited number of reviews that focused on physical activity and the built environment in rural, remote and northern communities. At the prioritysetting conference, participants representing rural, remote and northern settings identified top priorities for policy, practice and research action to begin to address the gaps and issues noted in the literature. These priorities include self-identifying priorities at the community level; compiling experiences; establishing consistency in research definitions and methods; and developing mentorship opportunities.

CONCLUSION

Coordinated action across policy, practice and research domains will be essential to the success of the recommendations presented in this call to action.

Neighbourhoods and obesity: A prospective study of characteristics of the built environment and their association with adiposity outcomes in children in Montreal, Canada

This paper examined prospective associations between built environment features assessed at baseline using direct audits and adiposity outcomes two years later in Montreal, Canada. Data stem from the Quebec Adipose and Lifestyle Investigation in Youth study of 630 children aged 8-10 years with a parental history of obesity. Baseline measurements took place between 2005 and 2008. Follow-up took place between 2008 and 2011. Built environment features were assessed at baseline in up to 10 contiguous street segments around participants' residential addresses using on-site audits. Analyses were restricted to participants who reported the same address both at baseline and follow-up. Prospective associations between adiposity outcomes at follow-up (BMI z-score and waist-height ratio) and built environment features at baseline (traffic-calming features, pedestrian aids, disorder, physical activity facilities, convenience stores, and fast-food restaurants) were examined using multivariable regression models. 391 children were included in the analyses. In fully-adjusted models, children living in residential areas with presence of pedestrian aids had lower BMI z-score, and lower waist-height ratio. Also, children residing in residential areas with at least one convenience store had lower BMI z-score, and lower waist-height ratio at follow-up. Findings provide evidence of the potential role of street-level urban design features in shaping childhood adiposity. To better inform policy and intervention, future research should explore the possibility of reducing obesogenic neighbourhoods by enhancing street-level design features.

School environment assessment tools to address behavioural risk factors of non-communicable diseases: A scoping review

We aimed to identify, describe and analyse school environment assessment (SEA) tools that address behavioural risk factors (unhealthy diet, physical inactivity, tobacco and alcohol consumption) for non-communicable diseases (NCD). We searched in MEDLINE and Web of Science, hand-searched reference lists and contacted experts. Basic characteristics, measures assessed and measurement properties (validity, reliability, usability) of identified tools were extracted. We narratively synthesized the data and used content analysis to develop a list of measures used in the SEA tools. Twenty-four SEA tools were identified, mostly from developed countries. Out of these, 15 were questionnaire based, 8 were checklists or observation based tools and one tool used a combined checklist/observation based and telephonic questionnaire approach. Only 1 SEA tool had components related to all the four NCD risk factors, 2 SEA tools has assessed three NCD risk factors (diet/nutrition, physical activity, tobacco), 10 SEA tools has assessed two NCD risk factors (diet/nutrition and physical activity) and 11 SEA tools has assessed only one of the NCD risk factor. Several measures were used in the tools to assess the four NCD risk factors, but tobacco and alcohol was sparingly included. Measurement properties were reported for 14 tools. The review provides a comprehensive list of measures used in SEA tools which could be a valuable resource to guide future development of such tools. A valid and reliable SEA tool which could simultaneously evaluate all NCD risk factors, that has been tested in different settings with varying resource availability is needed.

Policies to Promote Active Travel: Evidence from Reviews of the Literature

PURPOSE OF REVIEW

While many levels of government recognize that walking and cycling (active travel) are critical to healthy cities, a continued challenge is to identify and prioritize strategies that will increase walking and cycling for transportation. We review evidence on policies that can increase active travel.

RECENT FINDINGS

The reviews included here conclude that policies related to active travel may operate at various levels of the socio-ecological framework, including society, cities, routes or individuals. The provision of convenient, safe and connected walking and cycling infrastructure is at the core of promoting active travel, but policies may work best when implemented in comprehensive packages. There is strong evidence that active travel can result in substantial health benefits. However, there remains considerable uncertainty about the exact effects of specific policies on walking or cycling rates or safety. Further research is needed to quantify the impact of specific policies or packages of policies, especially across different settings or for different population segments.

Modeling Pediatric Body Mass Index and Neighborhood Environment at Different Spatial Scales

In public health research, it has been well established that geographic location plays an important role in influencing health outcomes. In recent years, there has been an increased emphasis on the impact of neighborhood or contextual factors as potential risk factors for childhood obesity. Some neighborhood factors relevant to childhood obesity include access to food sources, access to recreational facilities, neighborhood safety, and socioeconomic status (SES) variables. It is common for neighborhood or area-level variables to be available at multiple spatial scales (SS) or geographic units, such as the census block group and census tract, and selection of the spatial scale for area-level variables can be considered as a model selection problem. In this paper, we model the variation in body mass index (BMI) in a study of pediatric patients of the Virginia Commonwealth University (VCU) Medical Center, while considering the selection of spatial scale for a set of neighborhood-level variables available at multiple spatial scales using four recently proposed spatial scale selection algorithms: SS forward stepwise regression, SS incremental forward stagewise regression, SS least angle regression (LARS), and SS lasso. For pediatric BMI, we found evidence of significant positive associations with visit age and black race at the individual level, percent Hispanic white at the census block group level, percent Hispanic black at the census tract level, and percent vacant housing at the census tract level. We also found significant negative associations with population density at the census tract level, median household income at the census tract level, percent renter at the census tract level, and exercise equipment expenditures at the census block group level. The SS algorithms selected covariates at different spatial scales, producing better goodness-of-fit in comparison to traditional models, where all area-level covariates were modeled at the same scale. These findings underscore the importance of considering spatial scale when performing model selection.

Evaluating the Contribution of the Built Environment on Obesity Among New York State Students

OBJECTIVES

One third of school-aged children in New York State (NYS) are overweight or obese, with large geographic disparities across local regions. We used NYS student obesity surveillance data to assess whether these geographical variations are attributable to the built environment.

METHOD

We combined NYS Student Weight Status Category Reporting System 2010-2012 data with other government publicly available data. Ordinary least squares regression models identified key determinants of school district-level student obesity rates for elementary and middle/high schools. Geographical weighted regression models explored spatial variations in local coefficients of the built environment predictors.

RESULTS

From ordinary least squares models, higher farmers' market density was only significantly associated with lower obesity rates among elementary school students (b = -0.116; p < .01). Higher fast-food restaurant density was significantly associated with higher obesity rates (b = 0.014; p < .05), and higher land use mix was only significantly associated with lower obesity rates (b = -0.054; p < .01) among middle/high school students. In geographical weighted regression analyses, the inverse association between market density and obesity rates among elementary school students was more pronounced in the eastern portion of the state. The relationship between higher fast-food restaurant density and higher obesity rates among middle/high school students was found in the southeastern portion of the state.

CONCLUSIONS

Different patterns of food consumption may explain varying determinants of obesity between younger and older students. Regional variations in local associations between the built environment variables and obesity may suggest differences in how healthy food sources are accessed locally.

Neighborhood built environment and socio-economic status in relation to multiple health outcomes in adolescents

The study aim was to examine associations of neighborhood built environment and neighborhood socio-economic status (SES) with multiple physical activity (PA) behaviors, sedentary time, and obesity indicators among adolescents. Cross-sectional study of 325 adolescents aged 14-18years recruited from schools in Valencia, Spain. Participants' home neighborhoods were classified according to walkability and SES levels. Walkability was defined as an index of three built environment characteristics (i.e., residential density, land use mix, and street connectivity) based on geographic information system data. Moderate-vigorous PA (MVPA) and sedentary time were assessed using accelerometers. Active commuting to school, leisure-time PA, and time in specific sedentary activities were evaluated by questionnaire. Objectively measured weight and height were used to calculate body mass index, and percent body fat was analyzed by bioelectrical impedance. Data were collected in 2013-15. Mixed model regression analyses were performed. Analyses showed an SES-by-walkability interaction for MVPA on weekends. MVPA was highest in high-SES/high-walkable neighborhoods. Another SES-by-walkability interaction was found for sedentary minutes per weekend day. The lowest average sedentary minutes were found in high-SES/high-walkable areas. Neighborhood SES was positively related to participation in sports teams/PA classes and, negatively to time spent in sedentary behaviors. Adolescents living in lower-SES neighborhoods spent more time watching TV and had more obesity and body fat. Present findings strengthen the rationale for targeting neighborhood built and SES environments as health promotion interventions for adolescents.

Influence of neighbourhood safety on childhood obesity: a systematic review and meta-analysis of longitudinal studies

Unsafe residential neighbourhoods are thought to be a risk factor for childhood obesity by discouraging physical activity while encouraging sedentary behaviours, but findings from cross-sectional studies are susceptible to selection bias (e.g. children who are obese disproportionately reside in unsafe neighbourhoods). A literature search was conducted in the Cochrane Library, PubMed, Web of Science and Google Scholar for articles published until January 2017 that used baseline neighbourhood safety levels to predict future weight-related behaviours and body-weight status among children aged 17 years and younger. Twenty-two prospective cohort studies conducted in seven countries were identified. The median sample size was 1,104, and the median follow-up was 3.5 years. Sixteen studies used parent-reported and/or child-reported neighbourhood safety measures, and six adopted some objective measures (e.g. county crime rate and interviewers' block observations). The meta-analysis found that living in unsafe neighbourhoods was associated with a reduction in children's physical activity by 0.13 h week-1 . Living in unsafe neighbourhoods predicted a trivial (but statistically significant) gain in body mass index but no change in childhood overweight/obesity risk. Current research indicates a limited influence of neighbourhood safety on childhood obesity; this finding could be partially due to measurement problems. Future longitudinal studies should adopt validated neighbourhood safety measures.

Differences in perceived causes of childhood obesity between migrant and local communities in China: A qualitative study

In developing countries, obesity traditionally affectsmore affluent children, butis spreading to a wider social group. Understanding the perceivedcontributors can provide valuable insights to plan preventive interventions. We exploreddifferences in the perceived causes of childhood obesity between local and migrant communities in a major Chinese city. We conducted 20 focus groups (137 parents, grandparents, school teachers) and 11semi-structured interviews with school Principals from migrant and local communities in Guangzhou. Data were transcribed and analysed using a thematic approach. We found that Lack of influence from grandparents, who were perceived to promote obesogenic behaviorin local children, fewer opportunities for unhealthy snacking and less pressure for academic attainment leading to moreactive play were interpreted as potential "protective" factors among migrant children. Nevertheless, two perceived causes of obesity were more pronounced in migrant than local children: lack of parental monitoring after-school andunsafe neighborhoods limiting physical-activity. Two barriers that restricted child physical activity were only found in the migrant community: limited home space, and cultural differences, inhabitinginteractive play with local children. Future interventions should consider uniquedeterminants of obesity in children from different social backgrounds, with tailored strategies to prevent further rise of the epidemic.

[What are the determinants of childhood obesity? : A literature review as part of the project "Nationwide Monitoring of Childhood Obesity Determinants"]

BACKGROUND

Obesity can impair health even in childhood and unfold negative health consequences through an individual's lifespan. In Germany, to date, a systematic and periodically updated synopsis of the multifaceted determinants of childhood obesity is lacking. In this paper, we present the results of a systematic literature review on childhood obesity determinants, which was conducted over the course of the implementation of nationwide monitoring.

METHODS

The review was carried out in three steps. Initially, a search for etiological models of childhood obesity was conducted. Based on these results, a systematic review of reviews on childhood obesity determinants was carried out. Finally, the results were verified by taking international guidelines on childhood obesity into account.

RESULTS

In total, 21 etiological models, 75 reviews and 7 guidelines were identified. Over 60 determinants were extracted from these publications and were summarized into the following categories: nutritional behavior, physical activity behavior, sleeping pattern, biological determinants and diseases, prenatal and early childhood determinants, psycho-social determinants, food environment, moveability/walkability, setting and social environment, health promotion and prevention, socioeconomic, demographic, and sociocultural determinants.

CONCLUSION

This review demonstrates the complex patterns of childhood obesity determinants in correspondence with a socio-ecological approach. The review will form the basis for the monitoring-system "Nationwide Monitoring of Childhood Obesity Determinants", which will be implemented at the Robert Koch Institute by the end of 2017.

Relationship between Recreational Resources in the School Neighborhood and Changes in Fitness in New York City Public School Students

Physical fitness in children has many beneficial effects, including the maintenance of a healthy weight. The built environment may influence youths' physical fitness by encouraging physical activity. This paper assessed whether higher density of parks, playgrounds, and sports facilities around a school is related to improvements in fitness in middle school boys and girls. Fitness scores and other student covariates collected as part of NYC FITNESSGRAM between the 2006-2007 and 2010-2011 school years were linked with school neighborhood data on characteristics of the built environment for NYC public school students in grades 6-8. Data were analyzed in 2015. Medium, but not high, density of recreational resources in the area surrounding a school was associated with greater annual improvements in fitness for both boys and girls. This association appeared to be driven mainly by the presence of parks. Findings for sports facilities and playgrounds were inconsistent. Overall, few associations were observed between recreational resources near a school and changes in student fitness. Future studies of school influences on student fitness should consider the influence of school resources and the home neighborhood.

[Settings-based prevention of overweight in childhood and adolescents : Theoretical foundation, determinants and intervention planning]

BACKGROUND

Childhood and adolescent overweight can still be seen as a global public health problem. Based on our socioeconomic understanding, overweight is the result of a complex interplay of a diverse array of factors acting on different levels. Hence, in addition to individual level determinants overweight prevention should also address environmental related factors as part of a holistic and integrated setting approach.

OBJECTIVE

This paper aims to discuss the setting approach with regard to overweight prevention in childhood and adolescence. In addition to a summary of environmental factors and their empirical influence on the determinants of overweight, theoretical approaches and planning models of settings-based overweight prevention are discussed.

RESULTS

While settings can be characterized as specific social-spatial subsystems (e. g. kindergarten, schools), living environments relate to complex subject-oriented environments that may include various subsystems. Direct social contexts, educational contexts and community contexts as relevant systems for young people contain different evidence-based influences that need to be taken into account in settings based overweight prevention. To support a theory-driven intervention, numerous planning models exist, which are presented here.

DISCUSSION

Given the strengthening of environments for health within the prevention law, the underlying settings approach also needs further development with regard to overweigth prevention. This includes the improvement of the theoretical foundation by aligning intervention practice of planning models, which also has a positive influence on the ability to measure its success.

Built and socioeconomic neighbourhood environments and overweight in preschool aged children. A multilevel study to disentangle individual and contextual relationships

BACKGROUND

Structural factors of neighbourhood environments in which children live have attracted increasing attention in epidemiological research. This study investigated whether neighbourhood socioeconomic position (SEP), public playground and park space, and perceived environmental exposures were independently associated with overweight in preschool aged children while simultaneously considering individual child and family factors.

METHODS

Body-Mass-Index (BMI) data from 3499 children (53% boys and 47% girls) from three surveys between 2004 and 2007 from 18 school enrolment zones in the city of Munich, Germany, were analysed with hierarchical logistic regression models. An index of neighbourhood SEP was calculated with principal component analysis. Individual socioeconomic data, parental BMI, birth weight, housing characteristics, and perceived annoyance due to exposures to noise, air pollution, lack of greenspace, and traffic were collected with parental questionnaires. Measures of age-specific playground space and availability of park space derived from Geographic Information System were additionally weighted with age-specific population data.

RESULTS

In bivariate analysis perceived annoyance due to exposures to noise or lack of greenspace, high frequency of lorries, traffic jam, living in a multiple dwelling or next to a main road, low neighbourhood SEP, and low playground space were significantly associated with overweight. However, in multivariate analysis only living in a multiple dwelling was independently associated with overweight. From the considered individual child and family factors low parental education, parental overweight or obesity, and a high birthweight showed an independent relation to overweight.

CONCLUSIONS

Our study identified individual child and parental factors, and living in a multiple dwelling as the strongest predictors for overweight in preschool aged children. However, perceived annoyance to built environmental exposures additionally explained overweight variance between neighbourhoods. Based on our findings interventions and policies addressing overweight prevention in young children should focus on parental behaviours and the immediate home environment.

Food swamps and food deserts in Baltimore City, MD, USA: associations with dietary behaviours among urban adolescent girls

OBJECTIVE

To determine whether living in a food swamp (≥4 corner stores within 0·40 km (0·25 miles) of home) or a food desert (generally, no supermarket or access to healthy foods) is associated with consumption of snacks/desserts or fruits/vegetables, and if neighbourhood-level socio-economic status (SES) confounds relationships.

DESIGN

Cross-sectional. Assessments included diet (Youth/Adolescent FFQ, skewed dietary variables normalized) and measured height/weight (BMI-for-age percentiles/Z-scores calculated). A geographic information system geocoded home addresses and mapped food deserts/food swamps. Associations examined using multiple linear regression (MLR) models adjusting for age and BMI-for-age Z-score.

SETTING

Baltimore City, MD, USA.

SUBJECTS

Early adolescent girls (6th/7th grade, n 634; mean age 12·1 years; 90·7 % African American; 52·4 % overweight/obese), recruited from twenty-two urban, low-income schools.

RESULTS

Girls' consumption of fruit, vegetables and snacks/desserts: 1·2, 1·7 and 3·4 servings/d, respectively. Girls' food environment: 10·4 % food desert only, 19·1 % food swamp only, 16·1 % both food desert/swamp and 54·4 % neither food desert/swamp. Average median neighbourhood-level household income: $US 35 298. In MLR models, girls living in both food deserts/swamps consumed additional servings of snacks/desserts v. girls living in neither (β=0·13, P=0·029; 3·8 v. 3·2 servings/d). Specifically, girls living in food swamps consumed more snacks/desserts than girls who did not (β=0·16, P=0·003; 3·7 v. 3·1 servings/d), with no confounding effect of neighbourhood-level SES. No associations were identified with food deserts or consumption of fruits/vegetables.

CONCLUSIONS

Early adolescent girls living in food swamps consumed more snacks/desserts than girls not living in food swamps. Dietary interventions should consider the built environment/food access when addressing adolescent dietary behaviours.