Understanding neighbourhood retail food environmental mechanisms influencing BMI in the Caribbean: a multilevel analysis from the Jamaica Health and Lifestyle Survey: a cross-sectional study

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).

A systems thinking framework for understanding rising childhood obesity in the Caribbean

OBJECTIVE

The aim of this study is to develop a systems thinking framework to describe the common complexities of childhood obesity in the Caribbean region and identify potential areas of intervention.

METHODS

Group model building (GMB) is a form of systems science. Trained GMB facilitators in Puerto Rico, the US Virgin Islands, Barbados, and Trinidad and Tobago convened a group of multi-disciplinary stakeholders in a series of virtual meetings in 2021 to elaborate a hypothesis of the system driving childhood obesity represented by causal loop diagrams (CLD). Commonalities and differences between the CLDs from each island were identified and reconciled to create a synthesized CLD.

RESULTS

A single explanatory CLD across the islands was developed and includes nine reinforcing loops. These loops addressed the interconnected role of schools, policy, commercial determinants, community and the personal experience of the child in rising childhood obesity rates.

CONCLUSIONS

Despite differences across settings, there is a core system driving childhood obesity in the Caribbean, as described by stakeholders in GMB workshops. Policy solutions to the problem must be multi-faceted and multi-level to address the interlinked reinforcing loops of the complex system and reduce rates of childhood obesity.

Social support and ideal cardiovascular health in urban Jamaica: A cross-sectional study

Recent studies have suggested that high levels of social support can encourage better health behaviours and result in improved cardiovascular health. In this study we evaluated the association between social support and ideal cardiovascular health among urban Jamaicans. We conducted a cross-sectional study among urban residents in Jamaica's south-east health region. Socio-demographic data and information on cigarette smoking, physical activity, dietary practices, blood pressure, body size, cholesterol, and glucose, were collected by trained personnel. The outcome variable, ideal cardiovascular health, was defined as having optimal levels of ≥5 of these characteristics (ICH-5) according to the American Heart Association definitions. Social support exposure variables included number of friends (network size), number of friends willing to provide loans (instrumental support) and number of friends providing advice (informational support). Principal component analysis was used to create a social support score using these three variables. Survey-weighted logistic regression models were used to evaluate the association between ICH-5 and social support score. Analyses included 841 participants (279 males, 562 females) with mean age of 47.6 ± 18.42 years. ICH-5 prevalence was 26.6% (95%CI 22.3, 31.0) with no significant sex difference (male 27.5%, female 25.7%). In sex-specific, multivariable logistic regression models, social support score, was inversely associated with ICH-5 among males (OR 0.67 [95%CI 0.51, 0.89], p = 0.006) but directly associated among females (OR 1.26 [95%CI 1.04, 1.53], p = 0.020) after adjusting for age and community SES. Living in poorer communities was also significantly associated with higher odds of ICH-5 among males, while living communities with high property value was associated with higher odds of ICH among females. In this study, higher level of social support was associated with better cardiovascular health among women, but poorer cardiovascular health among men in urban Jamaica. Further research should explore these associations and identify appropriate interventions to promote cardiovascular health.

Identifying obesogenic environment through spatial clustering of body mass index among adults

BACKGROUND

The escalating trend of obesity in Malaysia is surmounting, and the lack of evidence on the environmental influence on obesity is untenable. Obesogenic environmental factors often emerge as a result of shared environmental, demographic, or cultural effects among neighbouring regions that impact lifestyle. Employing spatial clustering can effectively elucidate the geographical distribution of obesity and pinpoint regions with potential obesogenic environments, thereby informing public health interventions and further exploration on the local environments. This study aimed to determine the spatial clustering of body mass index (BMI) among adults in Malaysia.

METHOD

This study utilized information of respondents aged 18 to 59 years old from the National Health and Morbidity Survey (NHMS) 2014 and 2015 at Peninsular Malaysia and East Malaysia. Fast food restaurant proximity, district population density, and district median household income were determined from other sources. The analysis was conducted for total respondents and stratified by sex. Multilevel regression was used to produce the BMI estimates on a set of variables, adjusted for data clustering at enumeration blocks. Global Moran's I and Local Indicator of Spatial Association statistics were applied to assess the general clustering and location of spatial clusters of BMI, respectively using point locations of respondents and spatial weights of 8 km Euclidean radius or 5 nearest neighbours.

RESULTS

Spatial clustering of BMI independent of individual sociodemographic was significant (p < 0.001) in Peninsular and East Malaysia with Global Moran's index of 0.12 and 0.15, respectively. High-BMI clusters (hotspots) were in suburban districts, whilst the urban districts were low-BMI clusters (cold spots). Spatial clustering was greater among males with hotspots located closer to urban areas, whereas hotspots for females were in less urbanized areas.

CONCLUSION

Obesogenic environment was identified in suburban districts, where spatial clusters differ between males and females in certain districts. Future studies and interventions on creating a healthier environment should be geographically targeted and consider gender differences.

Availability and Accessibility of Healthy and Unhealthy Foods in Neighborhood and their Association with Noncommunicable Diseases: A Scoping Review

ABSTRACT

Worldwide, 7 million mortalities and 187.7 million morbidities have been associated with dietary risks. Poor diets emerge because of an obesogenic environment. However, clear evidence indicating an association between food environment and noncommunicable diseases (NCDs) is inconclusive. The present review was conducted to study the associations between the availability/accessibility of healthy/unhealthy foods and the risk of NCDs among adults of the age group above 18. Studies published between 2012 and 2022 were reterived using three databases - PubMed, Google Scholar, and Science Direct. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), (2018) guidelines and based on the selection criteria, 3034 studies were retrieved, of which 64 were included in this review. Maximum studies were conducted in high-income countries and adopted a cross-sectional study design. Overall, the results of the review illustrate mixed findings. Compared to healthy food, direct associations between obesity and the availability/accessibility of unhealthy foods were reported (n = 12). In case of diabetes, supermarket availability was more likely to be protective (4 positive) compared to negative association with unhealthy food stores (3 associations in 11 studies). For cardiovascular diseases, an increased number of cases with fast-food outlets (n = 6) outnumbered positive associations with healthy food (n = 3). Studies concerning multiple NCDs reported direct association with unhealthy food outlets (n = 5) while inconclusive associations with healthy food. Despite a large number of studies, a weak, inconclusive relationship between food environment and NCDs was found. The use of standardized tools and longitudinal and interventional studies are warranted to rationalize the execution of the policies related to the food environment.

Comparison of spatial approaches to assess the effect of residing in a 20-minute neighbourhood on body mass index

Beliefs that neighbourhood environments influence body mass index (BMI) assume people residing proximally have similar outcomes. However, spatial relationships are rarely examined. We considered spatial autocorrelation when estimating associations between neighbourhood environments and BMI in two Australian cities. Using cross-sectional data from 1329 participants (Melbourne = 637, Adelaide = 692), spatial autocorrelation in BMI was examined for different spatial weights definitions. Spatial and ordinary least squares regression were compared to assess how accounting for spatial autocorrelation influenced model findings. Geocoded household addresses were used to generate matrices based on distances between addresses. We found low positive spatial autocorrelation in BMI; magnitudes differed by matrix choice, highlighting the need for careful consideration of appropriate spatial weighting. Results indicated statistical evidence of spatial autocorrelation in Adelaide but not Melbourne. Model findings were comparable, with no residual spatial autocorrelation after adjustment for confounders. Future neighbourhoods and BMI research should examine spatial autocorrelation, accounting for this where necessary.

Perceptions of the local food environment and fruit and vegetable intake in the Eastern Caribbean Health Outcomes research Network (ECHORN) Cohort study

INTRODUCTION

Studies conducted in the US and other high-income countries show that the local food environment influences dietary intakes that are protective for cardiovascular health.However, few studies have examined this relationship in the Caribbean. This study aimed to determine whether perceptions of the local food environment were associated with fruit and vegetable (FV) intake in the Eastern Caribbean, where daily FV intake remains below recommended levels.

METHODS

Cross-sectional analysis of Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS) baseline data (2013-2016) from Barbados, Puerto Rico, Trinidad and Tobago, and US Virgin Islands was conducted in 2020. The National Cancer Institute Dietary Screener Questionnaire was adapted to measure daily servings of FV. Existing scales were used to assess participant perceptions of the food environment (availability, affordability, and quality). Chi-square tests and Poisson regression were used for analyses.

RESULTS

Participants reported eating one mean daily serving of FV. Mean daily intake was higher among those who perceived FV as usually/always affordable, available, and high quality. Multivariate results showed statistically significant associations between FV and affordability. Persons who perceived FV as affordable had 0.10 more daily servings of FV compared to those who reported FV as not always affordable (p = 0.02). Food insecurity modified the association between affordability and FV intake.

CONCLUSIONS

This study highlights the importance of affordability in consumption of FV in the Eastern Caribbean, and how this relationship may be modified by food insecurity.

The association between fast-food outlet proximity and density and Body Mass Index: Findings from 147,027 Lifelines Cohort Study participants

Unhealthy food environments may contribute to an elevated Body Mass Index (BMI), which is a chronic disease risk factor. We examined the association between residential fast-food outlet exposure, in terms of proximity and density, and BMI in the Dutch adult general population. Additionally, we investigated to what extent this association was modified by urbanisation level. In this cross-sectional study, we linked residential addresses of baseline adult Lifelines Cohort participants (n = 147,027) to fast-food outlet locations using geo-coding. We computed residential fast-food outlet proximity, and density within 500 m, 1, 3, and 5 km. We used stratified (urban versus rural areas) multilevel linear regression models, adjusting for age, sex, partner status, education, employment, neighbourhood deprivation, and address density. The mean BMI of participants was 26.1 (SD 4.3) kg/m². Participants had a mean (SD) age of 44.9 (13.0), 57.3% was female, and 67.0% lived in a rural area. Having two or more (urban areas) or five or more (rural areas) fast-food outlets within 1 km was associated with a higher BMI (B = 0.32, 95% confidence interval (CI): 0.03, 0.62; B = 0.23, 95% CI: 0.10, 0.36, respectively). Participants in urban and rural areas with a fast-food outlet within <250 m had a higher BMI (B = 0.30, 95% CI: 0.03, 0.57; B = 0.20, 95% CI: 0.09, 0.31, respectively). In rural areas, participants also had a higher BMI when having at least one fast-food outlet within 500 m (B = 0.10, 95% CI: 0.02, 0.18). In conclusion, fast-food outlet exposure within 1 km from the residential address was associated with BMI in urban and rural areas. Also, fast-food outlet exposure within 500 m was associated with BMI in rural areas, but not in urban areas. In the future, natural experiments should investigate changes in the fast-food environment over time.

The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: a systematic review

INTRODUCTION

Diet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and health outcomes in low-income and middle-income countries (LMICs), relevant to urban settings, to support development and implementation of appropriate interventions.

METHODS

We conducted a comprehensive search of 9 databases from 1 January 2000 to 16 September 2020 with no language restrictions. We included original peer-reviewed observational studies, intervention studies or natural experiments conducted in at least one urban LMIC setting and reporting a quantitative association between a characteristic of the food environment and a diet, nutrition or health outcome. Study selection was done independently in duplicate. Data extraction and quality appraisal using the National Heart Lung and Blood Institute checklists were completed based on published reports using a prepiloted form on Covidence. Data were synthesised narratively.

RESULTS

74 studies met eligibility criteria. Consistent evidence reported an association between availability characteristics in the neighbourhood food environment and dietary behaviour (14 studies, 10 rated as good quality), while the balance of evidence suggested an association with health or nutrition outcomes (17 of 24 relevant studies). We also found a balance of evidence that accessibility to food in the neighbourhood environment was associated with diet (10 of 11 studies) although evidence of an association with health outcomes was contradictory. Evidence on other neighbourhood food environment characteristics was sparse and mixed. Availability in the school food environment was also found to be associated with relevant outcomes. Studies investigating our other primary outcomes in observational studies of the school food environment were sparse, but most interventional studies were situated in schools. We found very little evidence on how workplace and home food environments are associated with relevant outcomes. This is a substantial evidence gap.

CONCLUSION

'Zoning' or 'healthy food cart' interventions to alter food availability may be appropriate in urban LMIC.

PROSPERO REGISTRATION NUMBER

CRD42020207475.