Associations between county and municipality zoning ordinances and access to fruit and vegetable outlets in rural North Carolina, 2012

Perceived Availability of Healthy and Unhealthy Foods in the Community, Work, and Higher Education Settings across Five Countries: Findings from the International Food Policy Study 2018

BACKGROUND

Food environments play a key role in dietary behavior and vary due to different contexts, regulations, and policies.

OBJECTIVES

This study aimed to characterize the perceived availability of healthy and unhealthy foods in 3 different settings in 5 countries.

METHODS

We analyzed data from the 2018 International Food Policy Study, a cross-sectional survey of adults (18-100 y, n = 22,824) from Australia, Canada, Mexico, the United Kingdom (UK), and the USA. Perceived availability of unhealthy (junk food and sugary drinks) and healthy foods (fruit or vegetables, healthy snacks, and water) in the community, workplace, and university settings were measured (i.e. not available, available for purchase, or available for free). Differences in perceived availability across countries were tested using adjusted multinomial logistic regression models.

RESULTS

Across countries, unhealthy foods were perceived as highly available in all settings; in university and work settings unhealthy foods were perceived as more available than healthy foods. Australia and Canada had the highest perceived availability of unhealthy foods (range 87.5-90.6% between categories), and the UK had the highest perceived availability of fruits and vegetables for purchase (89.3%) in the community. In university and work settings, Mexico had the highest perceived availability for purchase of unhealthy foods (range 69.9-84.9%). The USA and the UK had the highest perceived availability of fruits and vegetables for purchase (65.3-66.3%) or for free (21.2-22.8%) in the university. In the workplace, the UK had high perceived availability of fruits and vegetables for purchase (40.2%) or for free (18.5%), and the USA had the highest perceived availability of junk food for free (17.3%).

CONCLUSIONS

Across countries, unhealthy foods were perceived as highly available in all settings. Variability between countries may reflect differences in policies and regulations. Results underscore the need for the continuation and improvement of policy efforts to generate healthier food environments.

OUP accepted manuscript

Context

Policy-specific actions to improve food environments will support healthy population diets.

Objective

To identify cited barriers and facilitators to food environment policy (FEP) processes reported in the literature, exploring these according to the nature of the policy (voluntary or mandatory) and country development status.

Data sources

A systematic search was conducted of 10 academic and 7 grey-literature databases, national websites, and manual searches of publication references.

Data extraction

Data on government-led FEPs, barriers, and facilitators from key informants were collected.

Data synthesis

The constant-comparison approach generated core themes for barriers and facilitators. The appraisal tool developed by Hawker et al. was adopted to determine the quality of qualitative and quantitative studies.

Results

A total of 142 eligible studies were identified. Industry resistance or disincentive was the most cited barrier in policy development. Technical challenges were most frequently a barrier for policy implementation. Frequently cited facilitators included resource availability or maximization, strategies in policy process, and stakeholder partnership or support.

Conclusions

The findings from this study will strategically inform health-reform stakeholders about key elements of public health policy processes. More evidence is required from countries with human development indices ranging from low to high and on voluntary policies.

Systematic Review Registration

PROSPERO registration no. CRD42018115034.

Markets in Municipal Code: The Case of Michigan Cities

Food’s place on the urban, municipal agenda has become an increasing focus in the emergent fields of food policy and food planning, whose leaders argue that food needs to be more explicitly added to the urban agenda. Yet, public food markets are a food system activity that municipal governments have been long engaged in. Reports from leading health, planning, and food organizations assert that farmers markets—the dominant form of public retail food markets in the US today—should be explicitly included in zoning and other municipal codes to ensure that they can be created and sustained. Despite their popularity as a local sustainable food system and healthy food access strategy, it is unclear whether markets have been codified through municipalities’ planning and policy instruments, and research has largely not addressed this topic. This study aims to elicit whether markets have been codified into law, focusing on US municipal charters, codes and zoning ordinances, using Michigan, an upper Midwest state, as a case. After analyzing municipal documents to determine whether and where markets have been codified into law in ninety Michigan cities, this study concludes that markets are highly underrepresented in municipal policy, rarely defined in code, and mostly absent from zoning ordinances, even among those cities with currently operating markets. Market presence in code is, however, associated with the presence of historically operated markets. These findings raise questions about why markets are missing from codified food policy and what risks this poses to the future of markets. They also highlight the need to better document the market sector and underline the importance of including historic perspectives when examining the efficacy of current food policy efforts.

Healthy Eating Policy Strategies in Community Health Improvement Plans: A Cross-Sectional Survey of US Local Health Departments

CONTEXT

Policies (eg, regulations, taxes, and zoning ordinances) can increase opportunities for healthy eating. Community Health Improvement Plans (CHIP) may foster collaboration and local health department (LHD) engagement in policy decision making to improve local food environments. Limited research describes what policies supportive of healthy food environments are included in CHIPs nationally and relationships between LHD characteristics and participation in plans including such policies.

OBJECTIVES

To determine the proportion of US LHDs who participated in development of a CHIP containing healthy eating policy strategies and assess the association between LHD characteristics and inclusion of any healthy eating policy strategy in a CHIP.

DESIGN

A cross-sectional national probability survey.

PARTICIPANTS

Of the 209 US LHDs (serving populations <500 000) (response rate: 30.2%), 176 LHDs with complete data on CHIP status, outcomes, and covariates were eligible for analysis.

MAIN OUTCOME MEASURES

Thirteen healthy eating policy strategies were organized into 3 categories: increasing availability/identification of healthy foods, reducing access to unhealthy foods, and improving school food environments. Strategies and categories were identified from literature and public health recommendations.

RESULTS

In total, 32.2% of LHDs reported inclusion of 1 or more healthy eating policy strategies in a CHIP. The proportion of departments reporting specific strategies ranged from 20.8% for school district policies to 1.1% for sugar-sweetened beverage taxes. Local health departments serving 25 000 to 49 999 residents (odds ratio [OR]: 5.00; 95% confidence interval [CI]: 1.71-14.63), 100 000 to 499 999 residents (OR: 3.66; 95% CI: 1.12-11.95), pursuing national accreditation (OR: 4.46; 95% CI: 1.83-10.83), or accredited (OR: 3.22; 95% CI: 1.08-9.63) were more likely to include 1 or more healthy eating policy strategies in a CHIP than smaller LHDs (<25 000) and LHDs not seeking accreditation, respectively, after adjusting for covariates.

CONCLUSIONS

Few LHDs serving less than 500 000 residents reported CHIPs that included a policy-based approach to improve food environments, indicating room for improvement. Population size served and accreditation may affect LHD policy engagement to enhance local food environments.

Cross-Country Comparison of School Neighborhood Food Environments in Houston, Texas and Guadalajara, Mexico

Studies in the U.S. and Mexico have observed the clustering of food resources around schools, which may promote the use of these resources. Our study characterized and compared school neighborhood food environments in Guadalajara, Jalisco, and Houston, Texas, and examined socioeconomic disparities in food resource availability across school neighborhoods. We used the Goods and Services Inventory to document the frequency and type of resources within each school neighborhood. School neighborhoods in Guadalajara had significantly more food resources than those in Houston. We found that convenience stores and table service restaurants were the most prevalent food resources in school neighborhoods in both cities. Guadalajara school neighborhoods had a higher prevalence of supermarkets and grocery stores than Houston. Low-income school neighborhoods in Guadalajara with poorly educated residents had significantly more food carts than high-income neighborhoods with more educated residents. In Houston, we found significantly more fast food restaurants and convenience stores in school neighborhoods with more educated residents than school neighborhoods with less educated residents. The influence of food resources within school neighborhoods on the dietary habits of schoolchildren should be further explored in both the U.S. and Mexico. The characterization of school neighborhood food environments can inform policymakers, city planners, and school officials who seek to implement policies to create healthier food environments.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

Food Swamps Predict Obesity Rates Better Than Food Deserts in the United States

This paper investigates the effect of food environments, characterized as food swamps, on adult obesity rates. Food swamps have been described as areas with a high-density of establishments selling high-calorie fast food and junk food, relative to healthier food options. This study examines multiple ways of categorizing food environments as food swamps and food deserts, including alternate versions of the Retail Food Environment Index. We merged food outlet, sociodemographic and obesity data from the United States Department of Agriculture (USDA) Food Environment Atlas, the American Community Survey, and a commercial street reference dataset. We employed an instrumental variables (IV) strategy to correct for the endogeneity of food environments (i.e., that individuals self-select into neighborhoods and may consider food availability in their decision). Our results suggest that the presence of a food swamp is a stronger predictor of obesity rates than the absence of full-service grocery stores. We found, even after controlling for food desert effects, food swamps have a positive, statistically significant effect on adult obesity rates. All three food swamp measures indicated the same positive association, but reflected different magnitudes of the food swamp effect on rates of adult obesity (p values ranged from 0.00 to 0.16). Our adjustment for reverse causality, using an IV approach, revealed a stronger effect of food swamps than would have been obtained by naïve ordinary least squares (OLS) estimates. The food swamp effect was stronger in counties with greater income inequality (p < 0.05) and where residents are less mobile (p < 0.01). Based on these findings, local government policies such as zoning laws simultaneously restricting access to unhealthy food outlets and incentivizing healthy food retailers to locate in underserved neighborhoods warrant consideration as strategies to increase health equity.

Does unmeasured confounding influence associations between the retail food environment and body mass index over time? The Coronary Artery Risk Development in Young Adults (CARDIA) study

Background

Findings in the observational retail food environment and obesity literature are inconsistent, potentially due to a lack of adjustment for residual confounding.

Methods

Using data from the CARDIA study (n = 12 174 person-observations; 6 examinations; 1985-2011) across four US cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA), we used instrumental-variables (IV) regression to obtain causal estimates of the longitudinal associations between the percentage of neighbourhood food stores or restaurants (per total food outlets within 1 km network distance of respondent residence) with body mass index (BMI), adjusting for individual-level socio-demographics, health behaviours, city, year, total food outlets and market-level prices. To determine the presence and extent of bias, we compared the magnitude and direction of results with ordinary least squares (OLS) and random effects (RE) regression, which do not control for residual confounding, and with fixed effects (FE) regression, which does not control for time-varying residual confounding.

Results

Relative to neighbourhood supermarkets (which tend to be larger and have healthier options than grocery stores), a higher percentage of grocery stores [mean = 53.4%; standard deviation (SD) = 31.8%] was positively associated with BMI [β = 0.05; 95% confidence interval (CI) = 0.01, 0.10] using IV regression. However, associations were negligible or null using OLS (β = -0.001; 95% CI = -0.01, 0.01), RE (β = -0.003; 95% CI = -0.01, 0.0001) and FE (β = -0.003; 95% CI = -0.01, 0.0002) regression. Neighbourhood convenience stores and fast-food restaurants were not associated with BMI in any model.

Conclusions

Longitudinal associations between neighbourhood food outlets and BMI were greater in magnitude using a causal model, suggesting that weak findings in the literature may be due to residual confounding.

Beyond Supermarkets: Food Outlet Location Selection in Four U.S. Cities Over Time

INTRODUCTION

Understanding what influences where food outlets locate is important for mitigating disparities in access to healthy food outlets. However, few studies have examined how neighborhood characteristics influence the neighborhood food environment over time, and whether these relationships differ by neighborhood-level income.

METHODS

Neighborhood-level data from four U.S. cities (Birmingham, AL; Chicago, IL; Minneapolis, MN; Oakland, CA) from 1986, 1993, 1996, 2001, 2006, and 2011 were used with two-step econometric models to estimate longitudinal associations between neighborhood-level characteristics (z-scores) and the log-transformed count/km² (density) of food outlets within real estate-derived neighborhoods. Associations were examined with lagged neighborhood-level sociodemographics and lagged density of food outlets, with interaction terms for neighborhood-level income. Data were analyzed in 2016.

RESULTS

Neighborhood-level income at earlier years was negatively associated with the current density of convenience stores (β= -0.27, 95% CI= -0.16, -0.38, p<0.001). The percentage of neighborhood white population was negatively associated with fast food restaurant density in low-income neighborhoods (10th percentile of income: β= -0.17, 95% CI= -0.34, -0.002, p=0.05), and the density of smaller grocery stores across all income levels (β= -0.27, 95% CI= -0.45, -0.09, p=0.003). There was a lack of policy-relevant associations between the pre-existing food environment and the current density of food outlet types, including supermarkets.

CONCLUSIONS

Socioeconomically disadvantaged and minority populations may attract "unhealthy" food outlets over time. To support equal access to healthy food outlets, the availability of "less healthy" food outlets types may be relatively more important than the potential lack of supermarkets or full-service restaurants.

Association between junk food consumption and fast-food outlet access near school among Quebec secondary-school children: findings from the Quebec Health Survey of High School Students (QHSHSS) 2010–11

Objective

We investigated the association between junk food consumption at lunchtime (JCL) and fast-food outlet access near school among secondary-school children in Quebec.

Design

A geographic information system database was used to characterize the food environment around a sub-sample of 374 public schools in which 26 655 students were enrolled. The outcome variable was JCL during the previous week, dichotomized into low JCL (none or once)v. high JCL (twice or more). Access to fast-food outlets near school was assessed using an existing database of fast-food outlets in Quebec. Covariates included student (age, sex and self-rated perceived health), family (familial status and parental education) and school (urban/rural status and deprivation) variables. Hierarchical logistic regression models were employed for analyses using PROC GLIMMIX of SAS version 9.3.

Setting

Province of Quebec, Canada.

Subjects

We used data from the Quebec Health Survey of High School Students (QHSHSS) 2010–11, a survey of secondary-school Quebec students.

Results

Exposure to two or more fast-food outlets within a radius of 750 m around schools was associated with a higher likelihood of excess JCL (OR=1·50; 95 % CI 1·28, 1·75), controlling for the characteristics of the students, their families and their schools.

Conclusions

The food environment surrounding schools can constitute a target for interventions to improve food choices among secondary-school children living in the province of Quebec. Transforming environments around schools to promote healthy eating includes modifying zoning regulations that restrict access to fast-food outlets around schools.

A Transdisciplinary Approach to Public Health Law: The Emerging Practice of Legal Epidemiology

Public health law has roots in both law and science. For more than a century, lawyers have helped develop and implement health laws; over the past 50 years, scientific evaluation of the health effects of laws and legal practices has achieved high levels of rigor and influence. We describe an emerging model of public health law that unites these two traditions. This transdisciplinary model adds scientific practices to the lawyerly functions of normative and doctrinal research, counseling, and representation. These practices include policy surveillance and empirical public health law research on the efficacy of legal interventions and the impact of laws and legal practices on health and health system operation. A transdisciplinary model of public health law, melding its legal and scientific facets, can help break down enduring cultural, disciplinary, and resource barriers that have prevented the full recognition and optimal role of law in public health.

Disparities in healthy food zoning, farmers' market availability, and fruit and vegetable consumption among North Carolina residents

Background

Context and purpose of the study. To examine (1) associations between county-level zoning to support farmers’ market placement and county-level farmers’ market availability, rural/urban designation, percent African American residents, and percent of residents living below poverty and (2) individual-level associations between zoning to support farmers’ markets; fruit and vegetable consumption and body mass index (BMI) among a random sample of residents of six North Carolina (NC) counties.

Methods

Zoning ordinances were scored to indicate supportiveness for healthy food outlets. Number of farmers’ markets (per capita) was obtained from the NC-Community Transformation Grant Project Fruit and Vegetable Outlet Inventory (2013). County-level census data on rural/urban status, percent African American, and percent poverty were obtained. For data on farmers’ market shopping, fruit and vegetable consumption, and BMI, trained interviewers conducted a random digit dial telephone survey of residents of six NC counties (3 urban and 3 rural). Pearson correlation coefficients and multilevel linear regression models were used to examine county-level and individual-level associations between zoning supportiveness, farmers’ market availability, and fruit and vegetable consumption and BMI.

Results

At the county-level, healthier food zoning was greater in more urban areas and areas with less poverty. At the individual-level, self-reported fruit and vegetable consumption was associated with healthier food zoning.

Conclusions

Disparities in zoning to promote healthy eating should be further examined, and future studies should assess whether amending zoning ordinances will lead to greater availability of healthy foods and changes in dietary behavior and health outcomes.

Changing the Food Environment for Obesity Prevention: Key Gaps and Future Directions

The food environment has a great impact on the nutritional health of the population. Food environment interventions have become a popular strategy to address the obesity epidemic. However, there are still significant gaps in our understanding of the most effective strategies to modify the food environment to improve health. In this review, we examine key gaps in the food environment intervention literature, including the need for: developing appropriate formative research plans when addressing the food environment; methods for selecting intervention domains and components; incorporating food producers and distributors in intervention strategies; strengthening evaluation of environmental interventions; building the evidence base for food environment interventions in diverse settings; engaging policy makers in the process of modifying the food environment; and creating systems science models to examine the costs and benefits of a potential program or policy on the food environment prior to implementation. In addition, we outline the need for strategies for addressing these issues including conducting additional pilot interventions, developing additional methodologies, and embracing the use of simulation models.