Barriers to buying healthy foods for people with diabetes: evidence of environmental disparities

Perceived neighborhood disadvantage and poor chronic health in Israel

BACKGROUND

Social disparities in health persist in Israel despite universal health care. Few studies have focused on the impact of neighborhood disadvantage on health in a representative sample of the Israeli population while accounting for multiple socioeconomic factors. The objective of this study was to assess the independent association between perceived neighborhood disadvantage and self-reported poor chronic health.

METHODS

Self-reported poor chronic health was defined as (1) reported not very good/poor health, and (2) having a chronic health/physical problem for > = 6 months disrupting daily life activities. Neighborhood disadvantage was based on self-reported measures of residential environment (scale of dissatisfaction with transportation, parks, cleanliness, waste removal, noise, pollution, safety, and walkability) and social problems (dissatisfaction related to neighbors, and neighbors interacting to improve the environment). High levels of neighborhood problems were defined as top 25th percentile of dissatisfaction scales. Logistic regression models included incremental adjustment for sex, age, ethnicity/religion, immigration status, peripheral region and then income, education and employment status.

RESULTS

A total of n = 7,020 participants with non-missing data were included. High levels of neighborhood environmental and social problems were independently associated with poor chronic health even after adjustment for sex, age, ethnicity/religion, immigration status, and peripheral region, and remained statistically significant after additionally adjusting for income, education, employment and lifestyle factors (odds ratio (OR) 1.5, 95% confidence interval (CI) 1.2-1.9 for environmental problems; OR 1.3, 95% CI 1.1-1.6 for social problems).

CONCLUSIONS

Living in areas of perceived disadvantage conferred health risks beyond those related to ethnicity or socioeconomic status. These findings suggest that neighborhood-level factors contribute significantly to health disparities in Israel and should be included in national efforts to evaluate and minimize these health disparities. Future research is needed to also consider objective measures of neighborhood disadvantage, in order to determine the more salient neighborhood measures with respect to health outcomes and to effectively develop targeted interventions to reduce area-level health disparities.

Integrating Social Determinants of Health in Machine Learning-Driven Decision Support for Diabetes Case Management: Protocol for a Sequential Mixed Methods Study

BACKGROUND

The use of both clinical factors and social determinants of health (SDoH) in referral decision-making for case management may improve optimal use of resources and reduce outcome disparities among patients with diabetes.

OBJECTIVE

This study proposes the development of a data-driven decision-support system incorporating interactions between clinical factors and SDoH into an algorithm for prioritizing who receives case management services. The paper presents a design for prediction validation and preimplementation assessment that uses a mixed methods approach to guide the implementation of the system.

METHODS

Our study setting is a large, tertiary care academic medical center in the Deep South of the United States, where SDoH contribute to disparities in diabetes-specific hospitalizations and emergency department (ED) visits. This project will develop an interpretable artificial intelligence model for a population with diabetes using SDoH and clinical data to identify which posthospitalization cases have a higher likelihood of subsequent ED use. The electronic health record data collected for the study include demographics, SDoH, comorbidities, hospitalization-related factors, laboratory test results, and medication use to predict posthospitalization ED visits. Subsequently, a mixed methods approach will be used to validate prediction outcomes and develop an implementation strategy from insights into patient outcomes from case managers, clinicians, and quality and patient safety experts.

RESULTS

As of December 2023, we had abstracted data on 174,871 inpatient encounters between January 2018 and September 2023, involving 89,355 unique inpatients meeting inclusion criteria. Both clinical and SDoH data items were included for these patient encounters. In total, 85% of the inpatient visits (N=148,640) will be used for training (learning from the data) and the remaining 26,231 inpatient visits will be used for mixed-methods validation (testing).

CONCLUSIONS

By integrating a critical suite of SDoH with clinical data related to diabetes, the proposed data-driven risk stratification model can enable individualized risk estimation and inform health professionals (eg, case managers) about the risk of patients' upcoming ED use. The prediction outcome could potentially automate case management referrals, helping to better prioritize services. By taking a mixed methods approach, we aim to align the model with the hospital's specific quality and patient safety considerations for the quality of patient care and the optimization of case management resource allocation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56049.

Integrating human activity into food environments can better predict cardiometabolic diseases in the United States

The prevalence of cardiometabolic diseases in the United States is presumably linked to an obesogenic retail food environment that promotes unhealthy dietary habits. Past studies, however, have reported inconsistent findings about the relationship between the two. One underexplored area is how humans interact with food environments and how to integrate human activity into scalable measures. In this paper, we develop the retail food activity index (RFAI) at the census tract level by utilizing Global Positioning System tracking data covering over 94 million aggregated visit records to approximately 359,000 food retailers across the United States over two years. Here we show that the RFAI has significant associations with the prevalence of multiple cardiometabolic diseases. Our study indicates that the RFAI is a promising index with the potential for guiding the development of policies and health interventions aimed at curtailing the burden of cardiometabolic diseases, especially in communities characterized by obesogenic dietary behaviors.

Use of the Nutrition Environment Measures Survey: A Systematic Review

INTRODUCTION

The Nutrition Environment Measurement Survey (NEMS) measures were developed to assess the consumer food environment in stores and restaurants. NEMS tools have been widely used in research and adapted for diverse settings and populations in the 15 years since they were created. This systematic review examines the use and adaptations of these measures and what can be learned from published studies using NEMS tools.

METHODS

A comprehensive search of bibliographic databases was conducted from 2007 to September 2021, supplemented by backward searches and communications with authors, to identify research articles using NEMS tools. Data on purpose, key findings, sample characteristics, NEMS characteristics, and modifications were abstracted. Articles were categorized on the basis of study goals, NEMS tool(s) used, variables measured, and common themes.

RESULTS

A total of 190 articles from 18 countries were identified. Most studies (69.5%, n=123) used a modified version of NEMS tools. There were 23 intervention studies that used measures from NEMS tools or adaptations as outcomes, moderators, or process assessments. A total of 41% (n=78) of the articles evaluated inter-rater reliability, and 17% (n=33) evaluated test-retest reliability.

DISCUSSION

NEMS measures have played an important role in the growth of research on food environments and have helped researchers to explore the relationships among healthy food availability, demographic variables, eating behaviors, health outcomes, and intervention-driven changes in food environments. The food environment is constantly changing, so NEMS measures should continue to evolve. Researchers should document data quality of modifications and use in new settings.

Supermarket Proximity and Risk of Hypertension, Diabetes, and CKD: A Retrospective Cohort Study

RATIONALE & OBJECTIVE

Living in environments with low access to food may increase the risk of chronic diseases. We investigated the association of household distance to the nearest supermarket (as a measure of food access) with the incidence of hypertension, diabetes, and chronic kidney disease (CKD) in a metropolitan area of the United States.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

777,994 individuals without hypertension, diabetes, or CKD at baseline within the HealthLNK Data Repository, which contains electronic health records from 7 health care institutions in Chicago, Illinois.

EXPOSURE

Zip code-level average distance between households and nearest supermarket.

OUTCOME

Incidence of hypertension, diabetes, and CKD based on presence of ICD-9 code and/or blood pressure≥140/90mm Hg, hemoglobin A1c≥6.5%, and eGFR<60mL/min/1.73m², respectively.

ANALYTICAL APPROACH

Average distance to nearest supermarket was aggregated from street-level metrics for 56 Chicagoland zip codes. The cumulative incidence of hypertension, diabetes, and CKD from 2007-2012 was calculated for each zip code in patients free of these diseases in 2006. Spatial analysis of food access and disease incidence was performed using bivariate local indicator of spatial association (BiLISA) maps and bivariate local Moran I statistics. The relationship between supermarket access and outcomes was analyzed using logistic regression.

RESULTS

Of 777,994 participants, 408,608 developed hypertension, 51,380 developed diabetes, and 56,365 developed CKD. There was significant spatial overlap between average distance to supermarket and incidence of hypertension and diabetes but not CKD. Zip codes with large average supermarket distances and high incidence of hypertension and diabetes were clustered in southern and western neighborhoods. Models adjusted only for neighborhood factors (zip code-level racial composition, access to vehicles, median income) revealed significant associations between zip code-level average distance to supermarket and chronic disease incidence. Relative to tertile 1 (shortest distance), ORs in tertiles 2 and 3, respectively, were 1.27 (95% CI, 1.23-1.30) and 1.38 (95% CI, 1.33-1.43) for diabetes, 1.03 (95% CI, 1.02-1.05) and 1.04 (95% CI, 1.02-1.06) for hypertension, and 1.18 (95% CI, 1.15-1.21) and 1.33 (95% CI, 1.29-1.37) for CKD. Models adjusted for demographic factors and health insurance showed significant and positive association with greater odds of incident diabetes (tertile 2: 1.29 [95% CI, 1.26-1.33]; tertile 3: 1.35 [95% CI, 1.31-1.39]) but lesser odds of hypertension (tertile 2: 0.95 [95% CI, 0.94-0.97]; tertile 3: 0.91 [95% CI, 0.89-0.92]) and CKD (tertile 2: 0.80 [95% CI, 0.78-0.82]; tertile 3: 0.73 [95% CI, 0.72-0.76]). After adjusting for both neighborhood and individual covariates, supermarket distance remained significantly associated with greater odds of diabetes and lesser odds of hypertension, but there was no significant association with CKD.

LIMITATIONS

Unmeasured neighborhood and social confounding variables, zip code-level analysis, and limited individual-level information.

CONCLUSIONS

There are significant disparities in supermarket proximity and incidence of hypertension, diabetes, and CKD in Chicago, Illinois. The relationship between supermarket access and chronic disease is largely explained by individual- and neighborhood-level factors.

Perceived facilitators and barriers to healthy dietary behaviour in adults with type 2 diabetes mellitus in Kenya: A qualitative study

OBJECTIVE

This study aimed to explore the facilitators and barriers to healthy dietary behaviour in adults with type 2 diabetes mellitus (T2DM) in Kenya.

DESIGN

A qualitative descriptive design using telephone interviews was applied. An interview guide was developed through a modified theoretical framework.

SETTING

This study was conducted in selected hospitals in Nakuru County, located in west-central Kenya.

PARTICIPANTS

A two-step sampling strategy was used to select hospitals and study participants. Adult participants aged 30 to 85 years old, with T2DM from six hospitals were selected based on their ability to openly elaborate on the theme of dietary behaviour.

RESULTS

Thirty respondents were interviewed (mean age 62 years; 43.3% females). The average duration of the interviews was 32:02 minutes (SD 17.07). The highest-ranking internal facilitators of healthy dietary behaviour were knowledge of healthy food choices, gardening, self-efficacy, food preparation skills and eating at home. External facilitators included inaccurate beliefs and information on food and diet, education by healthcare workers, food availability, proximity to food selling points and family support. Internal barriers included tastes and preferences, health conditions barring intake of certain foods, and random eating of unhealthy foods. External barriers included socioeconomic factors, seasonal unavailability of fruits and food safety concerns.

CONCLUSIONS

Facilitators and barriers to healthy dietary behaviour among Kenyan adults with T2DM are related to food literacy and include selection, preparation and eating. Interventions to enhance healthy dietary behaviour should target context-specific knowledge, skills and self-efficacy.

Environmental and public health co-benefits of consumer switches to immunity-supporting food

During COVID-19, there has been a surge in public interest for information on immunity-boosting foods. There is little scientific support for immunity-supporting properties of specific foods, but strong evidence for food choice impacts on other health outcomes (e.g. risk of non-communicable disease) and environmental sustainability. Here, we relate online recommendations for "immunity-boosting" foods across five continents to their environmental and human health impacts. More frequently recommended food items and groups are plant based and have lower land use and greenhouse gas emission impacts plus more positive health outcomes (reducing relative risks of mortality or chronic diet-related diseases) per serving of food. We identify trade-offs between environmental outcomes of increasing consumption of recommended food items, with aquatic environment impacts increasing with food recommendation frequency. People's reliance on the Internet for health information creates an opportunity to consolidate behaviour change towards consuming foods with multiple co-benefits. Our study identifies win-win options for nudging online information-seeking behaviour towards more sustainable choices for terrestrial biodiversity conservation and human health.

Counting, Coping, and Navigating the Flux: A Focused Ethnographic Study of HIV and Diabetes Self-Management

Approximately 10-15% of people living with HIV are also diagnosed with diabetes. To manage their two chronic conditions, people must undertake certain activities and adopt behaviors. Due to overlapping symptoms, complex medication regimens, and heavy patient workloads, implementing these self-management practices can be difficult. In this focused ethnography, data were collected from semi-structured interviews and limited participant-observation with a selected subset of participants to gain insight into self-management challenges and facilitators. We conducted interviews and multiple observations with 22 participants with HIV+T2DM over the period of 9 months. Participants experienced numerous barriers to self-management in the areas of diet, medication adherence, and mental health. Social and familial support, as well as consistent access to care, were facilitators for optimal self-management. At the same time participants' lives were in a unique flux shaped by the dual diagnoses, and therefore, required constant mental and physical adjustments, thus illustrating challenges of managing chronicity.

Parental perceptions of the food environment and their influence on food decisions among low-income families: a rapid review of qualitative evidence

Background

The food environment within and surrounding homes influences family dietary habits with socio-economic areas at a nutritional disadvantage. Families’ perception of the food environment and how it influences their food decisions is less clear. This rapid review aimed to synthesise qualitative evidence of parental perspectives of the food environment and their influence on food decisions among disadvantaged families.

Method

Qualitative and mixed-methods peer-reviewed journal articles published after 2000, that explored the perspectives of low-income parents in relation to their food environment and how this impacted food decisions for families with children aged 2-17 years, were included in this review. Embase, Scopus and PsycINFO were the databases chosen for this review. Search strategies included seven concepts related to family, food, perceptions, influences, environment, socio-economic status and study type. Two independent reviewers screened sixty-four studies. Thematic synthesis was employed.

Results

Two thousand one hundred and forty five results were identified through database searching and 1,650 were screened. Fourteen articles that originated from the US, Australia and the UK were included in this review. No articles were excluded following quality appraisal. Child preferences, financial and time constraints, and location and access to food outlets were barriers to accessing healthy food. Parental nutrition education and feeding approaches varied but positive outcomes from interventions to address these behaviours will be short-lived if inequities in health caused by poverty and access to affordable and healthy food are not addressed. The reliance on social support from families or government sources played an important role for families but are likely to be short-term solutions to health and nutritional inequities.

Conclusions

This qualitative evidence synthesis provides an insight into the perceptions of low-income parents on the factors influencing food decisions. Findings have implications for public health and the development of effective strategies to improve the dietary habits of children of disadvantaged families. Sustainable changes to dietary habits for families on low-income requires policy responses to low income, food access and to the high cost of healthy foods.

Telehealth Interventions to Improve Diabetes Management Among Black and Hispanic Patients: a Systematic Review and Meta-Analysis

BACKGROUND

Previous systematic reviews have found that telehealth is an effective strategy for implementing interventions to improve glycemic control and other clinical outcomes for diabetes patients. However, these reviews have not meaningfully focused on Black and Hispanic patients-partly because of the lack of adequate representation of people from racial and ethnic minority groups in clinical trials. It is unclear whether telehealth interventions are effective at improving glycemic control among Black and Hispanic patients given the disproportionate number of barriers they face accessing health care.

OBJECTIVES

A systematic review and meta-analysis of randomized control trials that used telehealth interventions for improving glycemic control among Black and Hispanic diabetes patients.

METHODS

We reviewed PubMed, Embase, Web of Science, CINAHL, PsycINFO, and clinicalTrials.gov from inception to March 2021. We used a narrative summary approach to describe key study characteristics and graded the quality of studies using two reviewers. The pooled net change in HbA1c values was estimated across studies using a random-effects model.

RESULTS

We identified 10 studies that met our inclusion and exclusion criteria. Nine studies were included in the meta-analysis. Only one study was rated as having low bias. Telehealth interventions were primarily delivered by telephone calls, text messages, web-based portals, and virtual visits. Most interventions involved delivering diabetes self-management education. Telehealth intervention pooled across studies with a mix of Black and Hispanic participants (> 50% sample) was associated with a - 0.465 ([CI: - 0.648 to - 0.282], p = 0.000) reduction in HbA1c.

CONCLUSIONS

Our findings suggest telehealth interventions are effective at improving glycemic control among Black and Hispanic diabetes patients.

Practices and Barriers to Sustainable Urban Agriculture: A Case Study of Louisville, Kentucky

As urban populations increase, there is growing interest in developing innovative technologies, sustainable urban farming practices, policy measures, and other strategies to address key barriers in urban agriculture that impede improved food security and sustained urban livelihoods. We surveyed forty urban farmers and gardeners (growers) in Louisville, Kentucky, for base-level information to assess their agricultural practices and the various factors or key barriers that could influence such practices. Secondary objectives were identifying areas where practices could be improved, and identifying opportunities for research, outreach, and incentives for urban growers to transition to more sustainable and higher-yielding practices. The majority of these urban growers were white females, were more diverse than Kentucky farmers, and attained a higher degree of education than Kentucky residents as a whole. Most were engaged in urban agriculture for non-commercial reasons, and 11% were full-time urban growers operating farms for profit. Smaller farms were less likely to be operated for profit or have farm certifications than medium-sized or larger farms (Chi-squared = 14.459, p = 0.042). We found no significant differences among farm sizes in terms of whether growers rented or owned the land they were on (Chi-squared = 9.094, p = 0.168). The most common sustainable practices recorded were composting (60%), crop rotation (54%), polyculture (54%), organic farming (49%), and low or no-till (46%). The least common practices were alley cropping (5%), plasticulture (3%), and hydroponics (3%). Small farms were less likely to use crop rotation than medium-sized or large farms (Chi-squared = 13.548, p = 0.003), and farms responding to the survey in the latter part of the data collection were less likely to use compost than expected based on responses from the early part of data collection (Chi-shared = 5.972, p = 0.014). Challenges faced by these growers included limited space, accessibility to farm certification, presence of pests and diseases, and lack of record keeping and soil testing for fertility and contamination. Our study documents the need for more farm certification, education, outreach, training, research, investment, innovative ideas and solutions, collaboration among stakeholders, and better access to land through favorable urban policies and local support.

A Spatial Analysis of Obesity: Interaction of Urban Food Environments and Racial Segregation in Chicago

The obesity rate in Chicago has increased up to more than 30% in the last two decades. Obesity is a major problem in Chicago, where 36% of the city's high school students and 61% of adults in the metropolitan area are overweight or obese. Simultaneously, Chicago remains highly segregated by race-a phenomenon that begs for spatial analysis of health. Extant work exploring associations between the food retail environment and obesity has provided mixed findings, and virtually, none of this work has been done with the effects of the interaction between racial segregation and the food retail environment on obesity, where obesity rates are among the highest in the segregation area for the city defined by racial segregation. This study explores whether being overweight or obese is associated with urban food environments, such as access to different types of food retail outlets, and how its associations interact with racial factors, at the community level. This study uses the 2016-2018 data from the Healthy Chicago Survey to investigate the spatial variations in obesity and their association with food environments in Chicago. Also, this study examines the moderating effects of racial segregation on associations between obesity and access to food retail outlets. Using spatial statistics and regression models with interaction terms, this study assesses how the urban food environment can interact with racial segregation to explain the spatial distribution of obesity. The results indicate that the obesity population is highly concentrated in the African American community. In Chicago, each additional convenience store in a community is associated with a 0.42% increase in the obesity rate. Fast food restaurant access is predictive of a greater obesity rate, and grocery store access is predictive of less obesity rate in a community with a higher percentage of African American population. Findings can be used to promote equitable access to food retail outlets, which may help reduce broader health inequities in Chicago.

Linking the Flint Food Store Survey: Is Objective or Perceived Access to Healthy Foods Associated with Glycemic Control in Patients with Type 2 Diabetes?

Type 2 diabetes mellitus (DM-2) remains a significant public health concern, particularly in low-income neighborhoods where healthy foods may be scarcer. Despite the well-known relationship between diet and diabetes, little evidence exists on the connections among the objectively measured community and consumer food environment, perception of food access, and diabetes management or outcomes. This cross-sectional, ecological study represents the first example of combining a GIS-based, objectively measured food store audit considering quality, variety, and price of foods in stores with a clinical survey of patients with DM-2 (n = 126). In this way, we offer evidence on the relationship between healthy food access-measured more robustly than proximity to or density of certain store types-and diabetes management knowledge, medication adherence, and glycemic control. Better glycemic control was not correlated with better overall food store score, meaning that people in neighborhoods with better access to healthy foods are not necessarily more likely to manage their diabetes. While perceived healthy food access was not correlated with glycemic control, it was strongly correlated with objective healthy food access at shorter distances from home. These results have great importance both for clinical understanding of the persistence of poor diabetes management outcomes and for the understanding of the influence of the food environment on health behaviors.

Incongruency of youth food and physical activity environments in the United States: Variations by region, rurality, and income

Local environments are increasingly the focus of health behavior research and practice to reduce gaps between fruit/vegetable intake, physical activity (PA), and related guidelines. This study examined the congruency between youth food and PA environments and differences by region, rurality, and income across the United States. Food and PA environment data were obtained for all U.S. counties (N = 3142) using publicly available, secondary sources. Relationships between the food and PA environment tertiles was represented using five categories: 1) congruent-low (county falls in both the low food and PA tertiles), 2) congruent-high (county falls in both the high food and PA tertiles), 3) incongruent-food high/PA low (county falls in high food and low PA tertiles), 4) incongruent-food low/PA high (county falls in low food and high PA tertiles), and 5) intermediate food or PA (county falls in the intermediate tertile for food and/or PA). Results showed disparities in food and PA environment congruency according to region, rurality, and income (p < .0001 for each). Nearly 25% of counties had incongruent food and PA environments, with food high/PA low counties mostly in rural and low-income areas, and food low/PA high counties mostly in metropolitan and high-income areas. Approximately 8.7% of counties were considered congruent-high and were mostly located in the Northeast, metropolitan, and high-income areas. Congruent-low counties made up 10.0% of counties and were mostly in the South, rural, and low-income areas. National and regional disparities in environmental obesity determinants were identified that can inform targeted public health interventions.

Migration as a determinant of childhood obesity in the United States and Latin America

International migration has economic and health implications. The acculturation process to the host country may be linked to childhood obesity. We use the Community Energy Balance (CEB) framework to analyze the relationship between migration and childhood obesity in Mexican households with international migrants. Using longitudinal data from the Mexican Family Life Survey (MxFLS), we examine how migrant networks affect childhood obesity in origin communities. We also review binational health programs that could be effective at tackling childhood obesity in migrant households from Mexico. Children embedded in migrant networks are at greater risk of developing overweight or obesity, suggesting a significant relationship between childhood obesity and international migration in Mexican households. Based on our search criteria, our analysis of health outreach programs shows that Ventanillas de Salud (VDS)/Health Windows has great promise to prevent childhood obesity in a culturally sensitive and trustful environment. The CEB framework is useful to understand how migration contributes to the risk of childhood overweight and obesity in migrant households. VDS is a feasible and replicable strategy with great potential to address childhood obesity among migrant families accounting for the dynamic and binational determinants of childhood obesity.

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

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

Evaluating Consumer Nutrition Environment in Food Deserts and Food Swamps

This research examines the consumer nutrition environment in the selected neighborhoods identified as food deserts, food swamps, and food oases in Austin, Texas, by considering food availability, food price, food quality, and food labeling. A food auditing instrument M-TxNEA-S (He Jin, San Marcos, TX, USA) was developed to capture the unique dietary culture and food preferences in Texas. A total of 93 food items in 14 grocery stores and supermarkets (GS) and 32 convenience stores (CS) were surveyed. The GS in food swamps and food oases were found to offer significantly more healthy foods than the CS. The availability of healthy food in the GS in the food swamps and food oases is significantly higher than that of the GS from the food deserts; CS in the three neighborhoods did not exhibit a significant difference in healthy food availability. There was no significant difference between the price for the healthy items (lower fat, lower calorie, and whole grain) and that for the regular food options. No significant difference was found for food quality or food labeling between the stores from the different types of neighborhoods. The GS in food deserts are small grocery stores carrying limited ranges of foods. The establishment of larger food stores in the food deserts might not be very rewarding, but opening more small grocery stores with healthier options may alleviate food issues.

Defining and Developing Measures of Checklist for Measuring Food Store Environment: A Systematic Review

Background:

Food store measurement is important for planners and policy makers to improve unhealthy stores towards healthy stores. This review aimed to outline the concepts and measures development of checklists that assess food store environment in urban communities.

Methods:

The search was carried out in PubMed, Embase, Web of Science and Scopus as well as reference lists of included studies for obtaining published articles between 1990 up to the date of search (30 June 2017). Eligibility criteria attempted to capture peer-reviewed articles aimed at development and validation of checklists for assessing food stores.

Results:

From 3,862 records, 24 studies were included in this review. Findings showed constructs included in the instruments were availability (n=22); price (n=22); quality of fresh foods (n=13); promotion (n=6); product placement (n=6); advertisement (n=5); shelf space (n=3); display (n=3); store features or characteristics (n=2); marketing (n=2); accessibility; nutrition information; visibility; food variety; signage. There are differences on the conceptual definition of each constructs across the checklists. Only half of studies pursued fully systematic steps for the measures development.

Conclusion:

Consensus for definition of constructs of food store measurement is necessary. Besides, the development of the measures of checklists needs to be done by high-quality methods.

The impact of socioeconomic and environmental determinants on Mediterranean diet adherence: a municipal-level spatial analysis in Athens metropolitan area, Greece

The aim of this study was to identify the geographical variability, the socio-economic and the environmental determinants of adherence to the Mediterranean diet in a general population sample. Level of adherence to the Mediterranean diet was estimated by the ATTICA epidemiological study for 2,749 participants, while socio-economic, demographic, and environmental characteristics were provided by official national and international databases. Higher adherence to the Mediterranean diet was detected in areas with a greater proportion of females and older people, with lower unemployment rate and immigrant population, as well as, in areas covered at a greater extent by green and with higher frequency of supermarkets and street markets. The present findings provide evidence for policy makers to better understand how layers of influence intersect to shape individuals' eating habits, while they may also contribute in identifying areas of emerging interventions needed.

Predicting access to healthful food retailers with machine learning

Many U.S. households lack access to healthful food and rely on inexpensive, processed food with low nutritional value. Surveying access to healthful food is costly and finding the factors that affect access remains convoluted owing to the multidimensional nature of socioeconomic variables. We utilize machine learning with census tract data to predict the modified Retail Food Environment Index (mRFEI), which refers to the percentage of healthful food retailers in a tract and agnostically extract the features of no access-corresponding to a "food desert" and low access-corresponding to a "food swamp." Our model detects food deserts and food swamps with a prediction accuracy of 72% out of the sample. We find that food deserts and food swamps are intrinsically different and require separate policy attention. Food deserts are lightly populated rural tracts with low ethnic diversity, whereas swamps are predominantly small, densely populated, urban tracts, with more non-white residents who lack vehicle access. Overall access to healthful food retailers is mainly explained by population density, presence of black population, property value, and income. We also show that our model can be used to obtain sensible predictions of access to healthful food retailers for any U.S. census tract.

Self-perceived risk for diabetes among non-diabetic adolescents with overweight/obesity: Findings from NHANES

AIMS

The prevalence of Type 2 Diabetes Mellitus among adolescents in the United States continues to rise, following the trajectory of the obesity epidemic which posits not only a substantial health burden to our society, but also a significant threat to the wellbeing of America's youth. While a number of studies have explored the perception of the risk for developing diabetes in the adult population in the United States, this data is minimal for the adolescent population. In this study, we examined the self-perceived risk of diabetes among adolescents with overweight/obesity.

METHODS

Cross-sectional study of 808 non-diabetic U.S. adolescents overweight or obese, ages 12-19, who completed a physical exam and in-home interview during the 2011-2014 National Heath and Nutritional Examination Survey (NHANES).

RESULTS

Of adolescents with obesity, African Americans (aOR 0.27, 95% CI: 0.15, 0.51) and Hispanic Americans (aOR 0.50, 95% CI: 0.28, 0.90) were significantly less likely to perceive themselves as being at risk for developing diabetes/prediabetes compared to Non-Hispanic Whites. Additionally, individuals with overweight (aOR 13.1, 95% CI: 4.54, 37.5) and obesity (aOR 3.40, 95% CI: 1.71, 6.74) who had been informed by their physician that they were at risk for diabetes, were significantly more likely to perceive themselves to be at risk for diabetes.

CONCLUSIONS

Significant racial differences exist in the self-perceived risk for diabetes among U.S. adolescents with overweight and obesity. Further investigation focused on preventing the development of diabetes among at-risk adolescents who do not comprehend their risk, i.e. through more effective healthcare communication, is warranted.

Urban poverty and nutrition challenges associated with accessibility to a healthy diet: a global systematic literature review

BACKGROUND

There is an increasing global trend towards urbanization. In general, there are less food access issues in urban than rural areas, but this "urban advantage" does not benefit the poorest who face disproportionate barriers to accessing healthy food and have an increased risk of malnutrition.

OBJECTIVES

This systematic literature review aimed to assess urban poverty as a determinant of access to a healthy diet, and to examine the contribution of urban poverty to the nutritional status of individuals.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology, our review included quantitative and qualitative studies published in English or in Spanish between 2000 and 2019. The articles were eligible if they focused on nutrition access (i.e. access to a healthy diet) or nutrition outcomes (i.e., anemia, overweight and obesity, micronutrient deficiency, micronutrient malnutrition) among urban poor populations. Articles were excluded if they did not meet pre-established criteria. The quality of the quantitative studies was assessed by applying Khan et al.'s methodology. Similarly, we assessed the quality of qualitative articles through an adapted version of the National Institute for Health and Care Excellence (NICE) methodology checklist. Finally, we systematically analyzed all papers that met the inclusion criteria based on a qualitative content and thematic analysis.

RESULTS

Of the 68 papers included in the systematic review, 55 used quantitative and 13 used qualitative methods. Through the analysis of the literature we found four key themes: (i) elements that affect access to healthy eating in individuals in urban poverty, (ii) food insecurity and urban poverty, (iii) risk factors for the nutritional status of urban poor and (iv) coping strategies to limited access to food. Based on the systematization of the literature on these themes, we then proposed a conceptual framework of urban poverty and nutrition.

CONCLUSIONS

This systematic review identified distinct barriers posed by urban poverty in accessing healthy diets and its association with poorer nutrition outcomes, hence, questioning the "urban advantage". A conceptual framework emerging from the existing literature is proposed to guide future studies and policies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration number: CRD42018089788 .

Distributing and Sourcing Local Produce in Latino-focused Food Stores: A Qualitative Study with Stores and Small Farmers in San Diego County

A strategy to address challenges in sourcing and maintaining produce in tiendas is to build a new localized food economy. Key informant interviews were conducted with tienda owners and managers and small produce farmers to understand produce distribution and sourcing behaviors, and to identify the potential to connect tiendas with small produce farmers. Interviews were analyzed using an inductive coding approach and were summarized into three themes: people, place, and product. Results provide context for understanding factors that affect access to local produce in Latino communities. Future research should be conducted with produce distributors, and policy-level strategies should be considered.

Examining Trends in Beverage Sales in New York City During Comprehensive Efforts to Reduce Sugary Drink Consumption, 2010-2015

Since 2006, New York City (NYC) has attempted to reduce sugary drink consumption through several population-based initiatives, media campaigns and policy proposals. We estimated trends in the relative market share of sugary drinks and other beverage categories in NYC, using over 5 years of weekly, point-of-sale data from a retailer sample. We used an interrupted time series approach to assess whether changes in NYC beverage purchasing patterns occurred following the announcement of a proposed portion cap rule for consumer purchases of sugary drinks. Overall, market share of sugary drinks declined in NYC between 2010 and 2015. While the proportion of beverage volume sold that was sugary drinks was stable prior to the May 2012 portion cap rule announcement, decreases of 1.25% per year were observed in the period following the announcement compared to the period before (95% confidence interval (CI) - 1.60, - 0.90). Water/seltzer market share was increasing prior to the announcement and increased by an additional 1.03% per year in the post-announcement period (95% CI 0.48, 1.57). City-led efforts to increase public awareness about sugary drink-associated health risks in NYC may have led to reductions in consumer purchases of these beverages. Though never implemented, the portion cap proposal and accompanying media coverage may have contributed to decreases in sugary drink sales.

Healthy and unhealthy food environments are linked with neighbourhood socio-economic disadvantage: an innovative geospatial approach to understanding food access inequities

Objective:

This study examined the separate relationships between socio-economic disadvantage and the density of multiple types of food outlets, and relationships between socio-economic disadvantage and composite food environment indices.

Design:

Cross-sectional data were analysed using geospatial kernel density techniques. Food outlet data included convenience stores, discount stores, fast-food and fast casual restaurants, and grocery stores. Controlling for urbanicity and race/ethnicity, multivariate linear regression was used to examine the relationships between socio-economic disadvantage and density of food outlets.

Setting:

This study occurred in a large Southeastern US county containing 255 census block groups with a total population of 474 266, of which 77·1 % was Non-Hispanic White, the median household income was $48 886 and 15·0 % of residents lived below 125 % of the federal poverty line.

Participants:

The unit of analysis was block groups; all data about neighbourhood socio-economic disadvantage and food outlets were publicly available.

Results:

As block group socio-economic disadvantage increased, so too did access to all types of food outlets. The total food environment index, calculated as the ratio of unhealthy food outlets to all food outlets, decreased as block group disadvantage increased.

Conclusions:

Those who reside in more disadvantaged block groups have greater access to both healthy and unhealthy food outlets. The density of unhealthy establishments was greater in more disadvantaged areas; however, because of having greater access to grocery stores, disadvantaged populations have less obesogenic total food environments. Structural changes are needed to reduce access to unhealthy food outlets to ensure environmental injustice and reduce obesity risk.

Race/ethnicity, neighborhood socioeconomic status and cardio-metabolic risk

Objective

To determine the association between neighborhood socioeconomic status (NSES) and cardio-metabolic risk and whether this relationship differs by race/ethnicity.

Methods

Participants in the Multi-Ethnic Study of Atherosclerosis (n = 5750), ages 45–84 years, from 6 US counties, including 5 examinations from 2000 to 2012. We calculated a modified allostatic load (AL) index, indicating cardio-metabolic risk. NSES score included census-derived measures at census tract of residence. Mixed effects growth curve models were used to assess linear and non-linear associations between NSES and AL at baseline and over time.

Results

Higher NSES was associated with lower AL across race/ethnic groups; considering NSES quintiles, significant associations were found only for the highest NSES quintiles (difference of -0.86 and -1.15 for white and Hispanic participants) vs. the lowest. We found no significant association between NSES and change in AL over time.

Discussion

Our findings suggest that the relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods.

Public health implications

Understanding the impact of higher NSES on health effects may help identify interventions to effectively target high risk neighborhoods.

•

These findings confirm the association between high NSES and low AL; pattern is similar across race/ethnic groups.

•

The relationship between NSES and AL reflects the health benefits of living in the most advantaged neighborhoods.

•

Identifying neighborhood factors that impact health is crucial to effectively target high risk neighborhoods.

Exploring Dietary Behavior Differences among Children by Race/Ethnicity and Socioeconomic Status

BACKGROUND

In Spartanburg County, SC, nearly 33.7% of children are overweight or obese. The purpose of this study was to investigate differences in eating behavior of youth by race/ethnicity and socioeconomic status.

METHODS

Students (N = 997) in 4th to 5th grades completed the School Nutrition and Physical Activity Survey. School databases categorized students as either White or racial/ethnic minority and free/reduced or full paid lunch status. Dietary behaviors included 13 composite measures: unhealthy proteins, healthy proteins, dairy, refined grains, whole grains, vegetables, fruit, fried snacks, sugar-sweetened beverages, sweets, and consumption of a breakfast, evening, and/or restaurant meal. Logistic regression, controlling for sex, was used to analyze differences in consumption for each nutrition variable.

RESULTS

Minority youth were less likely to consume healthy proteins (odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.55-0.92) and more likely to eat at a restaurant (OR = 1.32, 95% CI = 1.02-1.70) compared to white youth. Lower socioeconomic status youth were less likely to eat an evening meal compared to higher socioeconomic status youth (OR = 0.59, 95% CI = 0.39-0.89).

CONCLUSIONS

Differences in dietary behaviors may result from food accessibility and insecurity in minority and/or low-income neighborhoods. Future research should explore policy strategies that can help ensure all youth maintain healthy eating habits and weight status.

GIS-Based Home Neighborhood Food Outlet Counts, Street Connectivity, and Frequency of Use of Neighborhood Restaurants and Food Stores

Researchers have linked neighborhood food availability to the overall frequency of using food outlets without noting if those outlets were within or outside of participants' neighborhoods. We aimed to examine the association of neighborhood restaurant and food store availability with frequency of use of neighborhood food outlets, and whether such an association was modified by neighborhood street connectivity using a large and diverse population-based cohort of middle-aged U.S. adults. We used self-reported frequency of use of fast food restaurants, sit-down restaurants, and grocery stores in respondents' home neighborhoods using data from the Coronary Artery Risk Development in Young Adults study Year 20 exam in 2005-2006 (n = 2860; Birmingham, AL; Chicago, IL; Minneapolis, MN; and Oakland, CA) and geographically matched GIS-measured neighborhood-level food resource, street, and U.S. Census data. We used mixed-effects logistic regression to examine the associations of the GIS-measured count of neighborhood fast food restaurants, sit-down restaurants, and grocery stores with self-reported frequency of using neighborhood restaurants and food stores and whether such associations differed by GIS-measured neighborhood street connectivity among those who perceived at least one such food outlet. In multivariate analyses, we observed a positive association between the GIS-measured count of neighborhood sit-down restaurants (OR = 1.02, 95% CI 1.00-1.04) and the self-reported frequency of using neighborhood sit-down restaurants. We observed no statistically significant association between GIS-measured count of neighborhood fast food restaurants and self-reported frequency of using neighborhood fast food restaurants, nor did we observe a statistically significant association between GIS-measured count of neighborhood grocery stores and self-reported frequency of using neighborhood grocery stores. We observed inverse associations between GIS-measured neighborhood street connectivity and the self-reported frequencies of using neighborhood fast food restaurants (OR = 0.42, 95% CI 0.26-0.68) and grocery stores (OR = - 2.26, 95% CI - 4.52 to - 0.01). Neighborhood street connectivity did not modify the association between GIS-measured neighborhood restaurant and food store count and the self-reported frequency of using neighborhood restaurants and food stores. Our findings suggest that, for those who perceived at least one sit-down restaurant in their neighborhood, individuals who have more GIS-measured sit-down restaurants in their neighborhoods reported more frequent use of sit-down restaurants than those whose neighborhoods contain fewer such restaurants. Our results also suggest that, for those who perceived at least one fast food restaurant in their neighborhood, individuals who live in neighborhoods with greater GIS-measured street connectivity reported less use of neighborhood fast food restaurants than those who live in neighborhoods with less street connectivity. The count of neighborhood sit-down restaurants and the connectivity of neighborhood street networks appear important in understanding the use of neighborhood food resources.

Individual and Community Engagement in Response to Environmental Challenges Experienced in Four Low-Income Urban Neighborhoods

Low-income urban communities, and the individuals that live within them, continue to face disproportionate interconnected social, economic, and environmental challenges related to their built, natural, and social environments. The aim of our phenomenological research study was to elevate the experiences of residents living in low-income urban neighborhoods in terms of their communities' environmental challenges. Our objectives were to (1) identify challenges across neighborhoods, (2) identify ways individuals and communities are addressing those challenges, and (3) assess the individual and collective efficacy and engagement of communities to lead environmental improvements in neighborhoods. This study brings forward the voices that are often ignored or misunderstood in these communities and uses an ecological-social perspective. We conducted focus groups (N = 68) in four low-income urban neighborhoods across two Ohio cities in the United States. Participants described five key challenges in their communities: Pollution, abandoned buildings with associated crime, low food access and health concerns, trash and illegal dumping, and lack of trees. We assessed engagement and efficacy using two frameworks focused on individual and community readiness to engage in and lead community change. Policymakers should acknowledge the valuable contributions and leadership capacity of residents in low-income communities to implement environmental initiatives.

Diabetes-related nutrition knowledge and dietary adherence in patients with Type 2 diabetes mellitus: A mixed-methods exploratory study

Aim:

The aim of the study is to gain insights into the relationship between diabetes-related nutrition knowledge (DRNK) and diet quality in Singapore.

Methods:

Forty-two participants were recruited from a tertiary hospital. DRNK and diet quality were ascertained with the DRNK questionnaire and Alternate Healthy Eating Index 2010, respectively. Twenty-one semi-structured interviews of perceived barriers and enablers to adherence to dietary guidelines were audio recorded, transcribed and analysed.

Results:

Participants had a poor mean percentage DRNK score of 39.7% (±17.7) and diet quality of 54.2% (±9.4). Pearson’s correlation tests revealed no correlation between DRNK and diet quality ( r –0.29; p=0.065) but suggest a moderate positive correlation between DRNK and psychosocial self-efficacy ( r 0.41; p=0.008). Thematic analysis revealed six barriers (obesogenic environment; lack of time; conflict between advice and personal values; stress from external sources; lack of personal motivation; gaps in DRNK) and four enablers (personal motivation to improve condition; fear of T2DM complications; sufficient DRNK; presence of social support) to adherence to dietary guidelines.

Conclusion:

DRNK may not correlate with adherence to dietary guidelines; multiple mediating factors are identified when translating DRNK to practice.

How patient and community involvement in diabetes research influences health outcomes: A realist review

BACKGROUND

Patient and public involvement in diabetes research is an international requirement, but little is known about the relationship between the process of involvement and health outcomes.

OBJECTIVE

This realist review identifies who benefits from different types of involvement across different contexts and circumstances. Search strategies Medline, CINAHL and EMBASE were searched to identify interventions using targeted, embedded or collaborative involvement to reduce risk and promote self-management of diabetes. People at risk/with diabetes, providers and community organizations with an interest in addressing diabetes were included. There were no limitations on date, language or study type.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from 29 projects using elements from involvement frameworks. A conceptual analysis of involvement types was used to complete the synthesis.

MAIN RESULTS

Projects used targeted (4), embedded (8) and collaborative (17) involvement. Productive interaction facilitated over a sufficient period of time enabled people to set priorities for research. Partnerships that committed to collaboration increased awareness of diabetes risk and mobilized people to co-design and co-deliver diabetes interventions. Cultural adaptation increased relevance and acceptance of the intervention because they trusted local delivery approaches. Local implementation produced high levels of recruitment and retention, which project teams associated with achieving diabetes health outcomes.

DISCUSSION AND CONCLUSIONS

Achieving understanding of community context, developing trusting relationships across sectors and developing productive partnerships were prerequisites for designing research that was feasible and locally relevant. The proportion of diabetes studies incorporating these elements is surprisingly low. Barriers to resourcing partnerships need to be systematically addressed.

Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study

INTRODUCTION

Latinos face unique challenges engaging with their health care providers for risk management of cardiovascular disease (CVD).

OBJECTIVE

To better understand differences in how Latinos and non-Latino whites (NLWs) experience CVD care.

METHODS

We examined self-reported activation, engagement, confidence, and communication comparing Latinos (n = 194) and NLWs (n = 208). Data were taken from baseline survey assessments of participants in the CREATE Wellness Study (NCT02302612), designed to help patients with poorly controlled CVD risk factors more actively engage in their care. The groups were compared using χ² tests and separate logistic regression models adjusting for age, age and income, and age and educational attainment.

RESULTS

Latinos in this cohort were younger, were less educated, and had lower incomes than did NLWs. In age-adjusted models, Latinos were significantly less likely to report knowing how to ask good questions about their health (71.1% vs 83.7% for NLW, p < 0.01; adjusted odds ratio = 0.49, 95% confidence interval = 0.29-0.83). Further adjustment by educational attainment or income did not attenuate this association. Latinos were also significantly more likely to report positive experiences and confidence with several measures of chronic illness care (adjusted odds ratio range = 1.57-2.01). Further adjustment by educational attainment eliminated these associations.

CONCLUSION

We found notable differences between Latinos and NLWs in their experience of health care. These results provide insights into how CVD risk management programs can be tailored for Latinos. Interventions to improve patient activation and engagement for Latinos with CVD should emphasize question-asking skills.

Variation in the food environment of small and non-traditional stores across racial segregation and corporate status

OBJECTIVE

We examined differences in consumer-level characteristics and structural resources and capabilities of small and non-traditional food retailers (i.e. corner stores, gas-marts, pharmacies, dollar stores) by racial segregation of store neighbourhood and corporate status (corporate/franchise- v. independently owned).

DESIGN

Observational store assessments and manager surveys were used to examine availability-, affordability- and marketing-related characteristics experienced by consumers as well as store resources (e.g. access to distributors) and perceived capabilities for healthful changes (e.g. reduce pricing on healthy foods). Cross-sectional regression analyses of store and manager data based on neighbourhood segregation and store corporate status were conducted.

SETTING

Small and non-traditional food stores in Minneapolis and St. Paul, MN, USA.ParticipantsOne hundred and thirty-nine stores; seventy-eight managers.

RESULTS

Several consumer- and structural-level differences occurred by corporate status, independent of residential segregation. Compared with independently owned stores, corporate/franchise-owned stores were more likely to: not offer fresh produce; when offered, receive produce via direct delivery and charge higher prices; promote unhealthier consumer purchases; and have managers that perceived greater difficulty in making healthful changes (P≤0·05). Only two significant differences were identified by residential racial segregation. Stores in predominantly people of colour communities (&lt;30 % non-Hispanic White) had less availability of fresh fruit and less promotion of unhealthy impulse buys relative to stores in predominantly White communities (P≤0·05).

CONCLUSIONS

Corporate status appears to be a relevant determinant of the consumer-level food environment of small and non-traditional stores. Policies and interventions aimed at making these settings healthier may need to consider multiple social determinants to enable successful implementation.

Influence of the Local Food Environment on Hispanics' Perceptions of Healthy Food Access in New York City

INTRODUCTION

Studies have characterized food environments and documented its impact on access and consumption of healthy foods as well as diet-related health conditions. This study aims to characterize the local food environment in New York City's Washington Heights and Inwood community and to examine its influence on Hispanics' perceptions of healthy food access.

METHODS

Person-level local food environments were created by spatially modeling food retailers selling fresh fruits and vegetables or low-fat products within a participant's 400- and 800-m residential radius buffers. Data were analyzed using multivariate binary logistic regression.

RESULTS

Fruit/vegetable markets significantly increased participants' odds of perceiving the availability of a large selection as well as the high quality of fresh fruits and vegetables in their neighborhood. Medium-/large-size supermarkets/groceries within 400-m radius significantly increased participants' odds of perceiving the high quality of fresh fruits and vegetables in their neighborhood, whereas meat markets significantly lowered the odds. Fruit/vegetable markets and medium-/large-size supermarkets/groceries significantly increased participants' odds of perceiving the availability of a large selection of low-fat products in their neighborhood.

CONCLUSION

Study findings advance our understanding of the relationships between local food environment and perceived healthy food access among urban Hispanics.

Racial/Ethnic Residential Segregation, the Distribution of Physician’s Offices and Access to Health Care: The Case of Houston, Texas

Previous research has demonstrated the impacts of racial/ethnic residential segregation on access to health care, but little work has been conducted to tease out the mechanisms at play. I posit that the distribution of health care facilities may contribute to poor access to health care. In a study of the Houston area, I examine the association between residential segregation, the distribution of physician’s offices, and two health care access outcomes of having a personal physician, as well as the travel time to their office location. Using the 2010 Health of Houston Survey combined with several census products, I test these relationships in a series of spatial and multilevel models. I find that Black segregation is related to a lower density of physician’s offices. However, I find that this distribution is not related to having a personal physician, but is related to travel times, with a greater number of facilities leading to shorter travel times to the doctor. I also find that Black segregation is positively associated with travel times, and that the distribution of physician’s offices partially mediates this relationship. In sum, these findings suggest that a more equitable provision of health care resources across urban neighborhoods would mitigate some of the negative effects of segregation.

Urban foodscape trends: Disparities in healthy food access in Chicago, 2007-2014

We investigated changes in supermarket access in Chicago between 2007 and 2014, spanning The Great Recession, which we hypothesized worsened local food inequity. We mapped the average street network distance to the nearest supermarket across census tracts in 2007, 2011, and 2014, and identified spatial clusters of persistently low, high or changing access over time. Although the total number of supermarkets increased city-wide, extremely low food access areas in segregated, low income regions did not benefit. Among black and socioeconomically disadvantaged residents of Chicago, access to healthy food is persistently poor and worsened in some areas following recent economic shocks.

A spatial analysis of dietary patterns in a large representative population in the north of The Netherlands - the Lifelines cohort study

BACKGROUND

Diet is an important modifiable risk factor for chronic diseases. In the search for effective strategies to improve dietary patterns in order to promote healthy ageing, new approaches considering contextual factors in public health medicine are warranted. The aim of this study is to examine the spatial clustering of dietary patterns in a large representative sample of adults.

METHODS

Dietary patterns were defined on the basis of a 111 item Food Frequency Questionnaire among n = 117,570 adults using principal components analysis. We quantified the spatial clustering of dietary pattern scores at the neighborhood level using the Global Moran's I spatial statistic, taking into consideration individual demographic and (neighborhood) socioeconomic indicators.

RESULTS

Four dietary patterns explaining 27% of the variance in dietary data were extracted in this population and named the "bread and cookies" pattern, the "snack" pattern, the "meat and alcohol" pattern and the "vegetable, fruit and fish" pattern. Significant spatial clustering of high (hot spot) and low (cold spot) dietary pattern scores was found for all four dietary patterns irrespective of age and gender differences. Educational attainment and neighborhood income explained the global clustering to some extent, although clustering at smaller regional scales persisted.

CONCLUSION

The significant region-specific hot and cold spots of the four dietary patterns illustrate the existence of regional "food cultures" and underscore the need for interventions targeted at the sub-national level in order to tackle unhealthy dietary behavior and to stimulate people to make healthy dietary choices.

Food Insecurity, CKD, and Subsequent ESRD in US Adults

BACKGROUND

Poor access to food among low-income adults has been recognized as a risk factor for chronic kidney disease (CKD), but there are no data for the impact of food insecurity on progression to end-stage renal disease (ESRD). We hypothesized that food insecurity would be independently associated with risk for ESRD among persons with and without earlier stages of CKD.

STUDY DESIGN

Longitudinal cohort study.

SETTING & PARTICIPANTS

2,320 adults (aged ≥ 20 years) with CKD and 10,448 adults with no CKD enrolled in NHANES III (1988-1994) with household income ≤ 400% of the federal poverty level linked to the Medicare ESRD Registry for a median follow-up of 12 years.

PREDICTOR

Food insecurity, defined as an affirmative response to the food-insecurity screening question.

OUTCOME

Development of ESRD.

MEASUREMENTS

Demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. Dietary acid load was estimated from 24-hour dietary recall. We used a Fine-Gray competing-risk model to estimate the relative hazard (RH) for ESRD associated with food insecurity after adjusting for covariates.

RESULTS

4.5% of adults with CKD were food insecure. Food-insecure individuals were more likely to be younger and have diabetes (29.9%), hypertension (73.9%), or albuminuria (90.4%) as compared with their counterparts (P<0.05). Median dietary acid load in the food-secure versus food-insecure group was 51.2 mEq/d versus 55.6 mEq/d, respectively (P=0.05). Food-insecure adults were more likely to develop ESRD (RH, 1.38; 95% CI, 1.08-3.10) compared with food-secure adults after adjustment for demographics, income, diabetes, hypertension, estimated glomerular filtration rate, and albuminuria. In the non-CKD group, 5.7% were food insecure. We did not find a significant association between food insecurity and ESRD (RH, 0.77; 95% CI, 0.40-1.49).

LIMITATIONS

Use of single 24-hour diet recall; lack of laboratory follow-up data and measure of changes in food insecurity over time; follow-up of cohort ended 10 years ago.

CONCLUSIONS

Among adults with CKD, food insecurity was independently associated with a higher likelihood of developing ESRD. Innovative approaches to address food insecurity should be tested for their impact on CKD outcomes.

Beyond Food Access: The Impact of Parent-, Home-, and Neighborhood-Level Factors on Children's Diets

Despite the growth in empirical research on neighborhood environmental characteristics and their influence on children’s diets, physical activity, and obesity, much remains to be learned, as few have examined the relationship between neighborhood food availability on dietary behavior in children, specifically. This analysis utilized data from a community-based, cross-sectional sample of children (n = 199) that was collected in New Orleans, Louisiana, in 2010. This dataset was linked to food environment data to assess the impact of neighborhood food access as well as household and parent factors on children’s diets. We observed a negligible impact of the neighborhood food environment on children’s diets, except with respect to fast food, with children who had access to fast food within 500 m around their home significantly less likely (OR = 0.35, 95% CI: 0.1, 0.8) to consume vegetables. Key parental and household factors did play a role in diet, including receipt of public assistance and cooking meals at home. Children receiving public assistance were 2.5 times (95% CI: 1.1, 5.4) more likely to consume fruit more than twice per day compared with children not receiving public assistance. Children whose family cooked dinner at home more than 5 times per week had significantly more consumption of fruit (64% vs. 58%) and vegetables (55% vs. 39%), but less soda (27% vs. 43%). Findings highlight the need for future research that focuses on the dynamic and complex relationships between built and social factors in the communities and homes of children that impact their diet in order to develop multilevel prevention approaches that address childhood obesity.

Association Between Neighborhood Supermarket Presence and Glycated Hemoglobin Levels Among Patients With Type 2 Diabetes Mellitus

We estimated associations between neighborhood supermarket gain or loss and glycemic control (assessed by glycated hemoglobin (HbA1c) values) in patients from the Kaiser Permanente Northern California Diabetes Registry (n = 434,806 person-years; 2007-2010). Annual clinical measures were linked to metrics from a geographic information system for each patient's address of longest residence. We estimated the association between change in supermarket presence (gain, loss, or no change) and change in HbA1c value, adjusting for individual- and area-level attributes and according to baseline glycemic control (near normal, <6.5%; good, 6.5%-7.9%; moderate, 8.0%-8.9%; and poor, ≥9.0%). Supermarket loss was associated with worse HbA1c trajectories for those with good, moderate, and poor glycemic control at baseline, while supermarket gain was associated with marginally better HbA1c outcomes only among patients with near normal HbA1c values at baseline. Patients with the poorest baseline HbA1c values (≥9.0%) had the worst associated changes in glycemic control following either supermarket loss or gain. Differences were not clinically meaningful relative to no change in supermarket presence. For patients with type 2 diabetes mellitus, gaining neighborhood supermarket presence did not benefit glycemic control in a substantive way. The significance of supermarket changes on health depends on a complex interaction of resident, neighborhood, and store characteristics.

Community Priorities for Healthy Eating in Older Adults

Community planners such as policymakers and health care and nutrition service providers can create an "age-friendly" environment to support healthy eating in older residents by addressing the highest priorities that enable older adults to improve their dietary intake through different food-related community settings. To identify and prioritize these factors that facilitate behavioral change (enablers) and behavioral settings important for older adult nutrition based on the social ecological model, nutrition and aging professionals (n = 30) from two rural (West Virginia, Iowa) and two urban (Massachusetts, New York) city/county regions (communities) participated in an online or live focus group discussion and completed an analytic hierarchy process survey online. Overall, the most important perceived enablers were accessibility and cost, followed by transportation and social support, but their relative importance varied by community. Participants from all communities considered congregate meal sites and food banks among the most important behavioral settings. Participants from most communities considered food stores to be important and also highlighted other settings unique to the area, such as senior housing, neighborhood, and farmers' markets. By targeting interventions to address the most notable enablers and behavioral settings specific to their community, planning groups can enhance their older residents' ability to achieve optimal nutritional health.

Comparison of the Availability and Cost of Foods Compatible With a Renal Diet Versus an Unrestricted Diet Using the Nutrition Environment Measures Survey

OBJECTIVE

Hemodialysis patients' ability to access food that is both compatible with a renal diet and affordable is affected by the local food environment. Comparisons of the availability and cost of food items suitable for the renal diet versus a typical unrestricted diet were completed using the standard Nutrition Environment Measures Survey and a renal diet-modified Nutrition Environment Measures Survey.

DESIGN

Cross-sectional study.

SETTING

Twelve grocery stores in Northeast Ohio.

MAIN OUTCOME MEASURE

Availability and cost of food items in 12 categories.

RESULTS

The mean total number of food items available differed significantly (P ≤ .001) between the unrestricted diet (38.9 ± 4.5) and renal diet (32.2 ± 4.7). The mean total cost per serving did not differ significantly (P = 0.48) between the unrestricted diet ($5.67 ± 2.50) and renal diet ($5.76 ± 2.74).

CONCLUSION

The availability of renal diet food items is significantly less than that of unrestricted diet food items, but there is no difference in the cost of items that are available in grocery stores. Further work is needed to determine how to improve the food environment for patients with chronic diseases.

Evaluation of a Behavioral Intervention With Multiple Components Among Low-Income and Uninsured Adults With Obesity and Diabetes

Purpose:

To examine the effects of a community-based behavioral intervention with multiple components on health outcomes among low-income and uninsured adults who were obese and had diabetes and treated in a “real-world” setting.

Design:

A longitudinal design with a retrospective comparison group was used to examine the ability of a health promotion program to improve body mass index (BMI) and hemoglobin A1c (HbA1c) among 87 treatment group and 62 comparison group participants.

Setting:

Urban/metropolitan city in the United States.

Intervention:

A community-based behavioral intervention with 3 components including health-coach visits, registered dietitian visits, and exercise consultations delivered over 12 months.

Measures:

Biometric measurements were collected at baseline, 3, 6, 9, 12, and 18 months, whereas self-reported measurements were collected at baseline, 6 months, and 12 months.

Analysis:

Linear mixed models with participant-level random intercepts were fitted for BMI and HbA1c.

Results:

The treatment group demonstrated reductions in BMI (percentage change = −2.1%, P < .001) and HbA1c (−0.6%, P < .001) as well as improvement in diabetes knowledge (+5.4%, P = .025), whereas the comparison group did not show any improvements in biometric measures. Dietitian visits were the most effective treatment component to reduce HbA1c (coefficient = −0.08, P = .025).

Conclusion:

Multiple component behavioral intervention in community settings, particularly when delivered by registered dietitians, shows promise to combat the dual epidemic of obesity and diabetes among low-income and uninsured patients.

Choice architecture to promote fruit and vegetable purchases by families participating in the Special Supplemental Program for Women, Infants, and Children (WIC): randomized corner store pilot study

OBJECTIVE

To conduct a pilot study to determine if improving the visibility and quality of fresh produce (choice architecture) in corner stores would increase fruit/vegetable purchases by families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Six stores were randomly assigned to choice architecture intervention or control. Store-level WIC sales data were provided by the state. Primary outcomes were WIC fruit/vegetable voucher and non-fruit/vegetable voucher sales, comparing trends from baseline (December 2012-October 2013) with the five-month intervention period (December 2013-April 2014). Secondary outcomes were differences in customer self-reported fruit/vegetable purchases between baseline and end of the intervention.

SETTING

Chelsea, MA, USA, a low-income urban community.

SUBJECTS

Adult customers (n 575) completing store exit interviews.

RESULTS

During baseline, WIC fruit/vegetable and non-fruit/vegetable sales decreased in both intervention and control stores by $US 16/month. During the intervention period, WIC fruit/vegetable sales increased in intervention stores by $US 40/month but decreased in control stores by $US 23/month (difference in trends: $US 63/month; 95 % CI 4, 121 $US/month; P=0·036); WIC non-fruit/vegetable sales were not different (P=0·45). Comparing baseline and intervention-period exit interview responses by customers participating in WIC (n 134), intervention store customers reported increased fruit/vegetable purchases compared with control store customers (18 v. -2 %), but this did not achieve statistical significance (P=0·11).

CONCLUSIONS

Placement of fruits/vegetables near the front of corner stores increased purchase of produce by customers using WIC. New policies that incentivize stores to stock and prominently display good-quality produce could promote healthier food choices of low-income families.

In our country tortilla doesn't make us fat: cultural factors influencing lifestyle goal-setting for overweight and obese Urban, Latina patients

Obesity disproportionately affects Latina adults, and goal-setting is a technique often used to promote lifestyle behavior change and weight loss. To explore the meanings and dimensions of goal-setting in immigrant Latinas, we conducted four focus groups arranged by language ability and country of origin in an urban, public, primary care clinic. We used a narrative analytic approach to identify the following themes: the immigrant experience, family dynamics, and health care. Support was a common sub-theme that threaded throughout, with participants relying on the immigrant community, family, and the health care system to support their goals. Participants derived satisfaction from setting and achieving goals and emphasized personal willpower as crucial for success. These findings should inform future research on how goal-setting can be used to foster lifestyle behavior change and illustrate the importance of exploring the needs of Latino sub-groups in order to improve lifestyle behaviors in diverse Latino populations.