Issues in Measuring the Healthiness of Food Environments and Interpreting Relationships with Diet, Obesity and Related Health Outcomes

Validation of secondary data sources of the retail food environment in the capital of Uruguay, an emerging Latin American country

Secondary data sources are frequently used for characterizing physical access to food. Although several studies have reported that they tend to show a moderate agreement with field observation in WEIRD (Western Educated Industrialized Rich and Democratic) countries, little is known about their validity in non-WEIRD countries. The aim of the present research was to assess the validity of secondary data sources of the retail food environment in Montevideo, the capital of Uruguay, an emerging Latin American country. A random sample of 106 census tracts was obtained, covering 12% (62 km2) of the city's total area. Two secondary data sources were considered: administrative records and Google Maps. An aggregate database was created by manually removing duplicates. A total of 1051 unique outlets were listed in the database within the census tracts included in the sample. Field validation was performed by six teams of two observers. A total of 1200 food outlets were identified on the ground, including 463 (38.6%) outlets not listed on any database. On the contrary, 297 outlets listed in the databases (28.3%) were not found or were closed at the time of field validation. At the aggregate level, sensitivity and concordance were moderate (0.614 and 0.487, respectively), whereas positive predictive value was substantial (0.701). However, large heterogeneity in the validity of the database across census tracts was found. Sensitivity, positive predictive value, and concordance were positively associated with the socio-economic status index of the census tract. These results suggest that secondary data sources must be used with caution, particularly for the characterization of areas with low socio-economic status.

Using spatial analysis to examine inequalities and temporal trends in food retail accessibility

OBJECTIVE

In this paper, we examined whether there are inequalities in access to food retail (by type and healthiness) across local government areas (LGA) in Greater Melbourne and by LGA grouped based on their distance from the central business district and Growth Area designation. We also examined whether these inequalities persisted over time.

DESIGN

This is a secondary analysis of a repeated cross-sectional census of food outlets collected at four time points (2008, 2012, 2014 and 2016) across 31 LGA. Using Geographical Information Systems, we present a spatial analysis of food retail environments in Melbourne, Australia, at these four times over eight years.

SETTING

Greater Melbourne, Australia.

PARTICIPANTS

31 LGA in Greater Melbourne.

RESULTS

Findings show significant inequalities in access to healthy food retail persisting over time at the LGA level. Residents in lower density urban growth areas had the least access to healthy food retail. Unhealthy food retail was comparatively more accessible, with a temporal trend indicating increased accessibility over time in urban growth areas only.

CONCLUSION

Accessibility to food outlets, particularly healthy food outlets and supermarkets, in Greater Melbourne is not equal. To identify and address health inequalities associated with rapid urban growth, further understanding of how people interact with the food environment needs to be explored.

The Built Environment and Pediatric Health

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

Systems map of interventions to improve dietary intake of pre-school aged children: A scoping review

Implementation and sustaining impact of early childhood nutrition interventions in practice remains a challenge. An understanding of the extent to which determinants across multiple levels of the food system are being addressed may improve success. This literature review aimed to synthesise the evidence on interventions targeting dietary intake and eating behaviours in preschool children using a systems approach. Eligible studies included intervention studies targeting the dietary intake of preschool children aged 2-5 years in high income countries, published in English after January 2000. Interventions were categorised to the Determinants of Nutrition and Eating (DONE) framework for children developed and evaluated by experts across multiple fields. The framework maps and ranks 411 factors driving eating behaviours and nutrition and can be used to systematically summarise determinants. DONE ranks each determinant for its perceived research priority. A total of 160 eligible studies were identified. Most interventions targeted interpersonal (n = 101, 63.1%) and individual (n = 85, 53.1%) level determinants, with fewer targeting environmental (n = 55, 34.4%) and policy level (n = 17, 10.6%) determinants. The most frequently addressed determinants were Parental Resources and Risk Factors (n = 85) and Children's Food Knowledge, Skills and Abilities (n = 67). These determinants had a Moderate research priority rating. Home Food Availability and Accessibility at the environmental level is classified as the highest research priority, however, only 15 of 160 interventions addressed this determinant. This review highlights home food availability and accessibility as potential leverage points for future interventions to improve children's dietary intake and eating behaviours.

Concepts, Characterizations, and Cautions: A Public Health Guide and Glossary for Planning Food Environment Measurement

Background

There is no singular approach to measuring the food environment suitable for all studies. Understanding terminology, methodology, and common issues is crucial to choosing the best approach.

Objective

This review is designed to support a shared understanding so diverse multi-institutional teams engaged in food environment measurement can justify their measurement choices and have informed discussions about reasons for measurement strategies to vary across projects.

Methods

This guide defines key terms and provides annotated resources identified as a useful starting point for exploring the food environment literature. The writing team was an academic-practice collaboration, reflecting on the experience of a multi-institutional team focused on retail environments across the US relevant to cardiovascular disease.

Results

Terms and annotated resources are divided into three sections: food environment constructs, classification and measures, and errors and strategies to reduce error. Two examples of methods and challenges encountered while measuring the food environment in the context of a US health department are provided. Researchers and practice professionals are directed to the Food Environment Electronic Database Directory (https://www.foodenvironmentdirectory.com/) for comparing available data resources for food environment measurement, focused on the US; this resource incorporates updates informed by user input and literature reviews.

Discussion

Measuring the food environment is complex and risks oversimplification. This guide serves as a starting point but only partially captures some aspects of neighborhood food environment measurement.

Conclusions

No single food environment measure or data source meets all research and practice objectives. This shared starting point can facilitate theoretically grounded food environment measurement.

What counts? Adding nuance to retail food environment measurement tools in a Canadian context

OBJECTIVE

Limitations of traditional geospatial measures, like the modified Retail Food Environment Index (mRFEI), are well documented. In response, we aimed to: (1) extend existing food environment measures by inductively developing subcategories to increase the granularity of healthy v. less healthy food retailers; (2) establish replicable coding processes and procedures; and (3) demonstrate how a food retailer codebook and database can be used in healthy public policy advocacy.

DESIGN

We expanded the mRFEI measure such that 'healthy' food retailers included grocery stores, supermarkets, hypermarkets, wholesalers, bulk food stores, produce outlets, butchers, delis, fish and seafood shops, juice/smoothie bars, and fresh and healthy quick-service retailers; and 'less healthy' food retailers included fast-food restaurants, convenience stores, coffee shops, dollar stores, pharmacies, bubble tea restaurants, candy stores, frozen dessert restaurants, bakeries, and food trucks. Based on 2021 government food premise licences, we used geographic information systems software to evaluate spatial accessibility of healthy and less healthy food retailers across census tracts and in proximity to schools, calculating differences between the traditional v. expanded mRFEI.

SETTING

Calgary and Edmonton, Canada.

PARTICIPANTS

N/A.

RESULTS

Of the 10 828 food retailers geocoded, 26 % were included using traditional mRFEI measures, while 53 % were included using our expanded categorisation. Changes in mean mRFEI across census tracts were minimal, but the healthfulness of food environments surrounding schools significantly decreased.

CONCLUSIONS

Overall, we show how our mRFEI adaptation, and transparent reporting on its use, can promote more nuanced and comprehensive food environment assessments to better support local research, policy and practice innovations.

Impacts of commute mode on body mass index: A longitudinal analysis before and during the COVID-19 pandemic

Introduction

COVID-19 has impacted millions of commuters by decreasing their mobility and transport patterns. While these changes in travel have been studied, less is known about how commute changes may have impacted individuals' body mass index (BMI). The present longitudinal study explores the relationship between commute mode and BMI of employed individuals in Montréal, Canada.

Methods

This study uses panel data drawn from two waves of the Montréal Mobility Survey (MMS) conducted before and during the COVID-19 pandemic (n = 458). BMI was modeled separately for women and men as a function of commuting mode, WalkScore©, sociodemographic, and behavioral covariates using a multilevel regression modeling approach.

Results

For women, BMI significantly increased during the COVID-19 pandemic, but telecommuting frequency, and more specifically telecommuting as a replacement of driving, led to a statistically significant decrease in BMI. For men, higher levels of residential local accessibility decreased BMI, while telecommuting did not have a statistically significant effect on BMI.

Conclusions

This study's findings confirm previously observed gendered differences in the relations between the built environment, transport behaviors, and BMI, while offering new insights regarding the impacts of the changes in commute patterns linked to the COVID-19 pandemic. Since some of the COVID-19 impacts on commute are expected to be lasting, findings from this research can be of use by health and transport practitioners as they work towards generating policies that improve population health.

Who uses what food retailers? A cluster analysis of food retail usage in the Netherlands

The aim of this study is to describe how individuals use different food retailers and how food retail usage varies according to socio-demographic and diet-related characteristics. A cross-sectional survey among Dutch adults (N = 1784) was used. Results from the Two-step cluster analysis indicated that there were five clusters of food retail users. Use of discount supermarkets, organic supermarkets, fast-food outlets, and restaurants contributed to clustering, but use of regular supermarkets, local food shops and whether food retailers were close to home or further from home did not. The clusters included mixed food outlet users, discount supermarket and restaurant users, fast-food and restaurant users, predominant discount supermarket users and supermarkets, fast-food and restaurant users. Participants in each cluster had their own characteristics especially in terms of socio-economic position and diet quality. Future studies need to consider further how food retail selection links physical exposure to the food environment and diet.

The revised Healthy Purchase Index (r-HPI): a validated tool for exploring the nutritional quality of household food purchases

BACKGROUND

The Healthy Purchase Index (HPI) assesses the nutritional quality of food purchases (FP) from food group expenditure shares only. However, it was developed from the FP of a disadvantaged population.

OBJECTIVE

To adapt and validate the HPI for a general population.

METHODS

FP were obtained from a representative sample of French households (Kantar WorldPanel) subdivided into two subsamples. The first sample (n = 4375) was used to adapt and validate the score; the second sample (n = 2188) was used to test external validity. The revised-HPI (r-HPI) includes 2 subscores: the diversity subscore and the quality subscore. Diversity subscore points were awarded when expenditure shares were above the 25th percentile for 5 food groups ("Fruits", "Vegetables", "Starches", "Dairy", "Meat, Fish and Eggs"). Regression models between the expenditure shares of each food group and the Mean Adequacy Ratio (MAR) and the Mean Excess Ratio (MER) of FP were used to select quality subscore components and define cut-offs for point allocation. Construct validity was assessed on the first sample using Spearman's correlations between the r-HPI and the four nutritional quality indicators (NRF9.3, MAR, MER, energy density), and also by comparing the r-HPI of monthly FP of sub-populations defined by criteria known to influence diet quality (age, gender, income, education) and between households having a monthly food basket of higher (MAR > median and MER and energy density < median) vs. lower nutritional quality within the population, using Wilcoxon tests or pairwise comparisons of contrasts. External validity was tested by performing the same analyses on the 2nd sample of 2188 households.

RESULTS

The adaptation led to include new components (e.g. red meat) and define new cut-offs (e.g. - 1 point when budget share for red meat > 21%). The r-HPI (mean = 6.50 ± 3.58) was strongly correlated with NRF9.3, MAR, MER and energy density (0.59, 0.52, - 0.41 and - 0.65, respectively, p < 0.01) and poorly correlated with total energy content (- 0.096, p < 0.001). The r-HPI was significantly higher in women (β = 1.41 [0.20], p < 0.01), households having a food basket of higher nutritional quality (β = 4.15 [0.11], p < 0.001), and increased significantly with age, income and education levels. Similar results were obtained in the 2nd sample.

CONCLUSION

We showed the validity of the r-HPI in a large sample of French households. As it does not require food quantity or nutrient content, it can be used as a valuable tool to explore FP behaviours. Cut-offs can be used in health promotion to provide nutri-economic counselling.

The community food environment and its association with diet, health or weight status in Australia: A systematic review with recommendations for future research

ISSUE ADDRESSED

This study systematically reviewed Australian literature to determine if an association exists between geospatial exposure to food outlets and diet, health or weight status. Recommendations for future research are provided.

METHODS

A systematic literature search was conducted in December 2021 using CINAHL Plus, PubMed and Web of Science databases. Data were extracted, as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using an eight-item checklist. A descriptive synthesis of study characteristics and findings was carried out, stratified via study outcomes.

RESULTS

Of the 36 included articles, the majority were from Victoria (n = 19), involving adult participants (n = 30) and cross-sectional in design (n = 27). Overall, associations were mainly null (nonsignificant) for diet (80%), weight status (75%) and health outcomes (90%). Significant findings were mixed with no positive trend with study quality.

CONCLUSIONS

Six recommendations are suggested to address current knowledge gaps and limitations in the Australian evidence base: (1) Conduct research on different populations; (2) Employ robust study designs that can test the impact of change over time; (3) Improve the accuracy of food outlet data sources; (4) Improve food outlet geospatial exposure measures; (5) Improve measurement of outcome variables; and (6) Incorporate theoretical models into study design and data analysis. SO WHAT?: Improving the quality and consistency of research will be critical to informing locally relevant policy. Despite the present limitations in the evidence base, it is reasonable to assume that decisions to purchase and consume food are driven by availability and access. Thus, policy and planning aimed at improving the overall "healthiness" of the community food environment by increasing access to healthy food outlets is warranted to ensure that healthy options are easier choice for all.

Consumption Frequency and Purchase Locations of Foods Prepared Outside the Home in Australia: 2018 International Food Policy Study

BACKGROUND

Foods prepared outside the home (e.g., fast-food chains, restaurants) represent increasing proportions of diets worldwide, and have been associated with higher energy intakes and BMIs. To improve the healthiness of population diets, it is important to understand patterns of consumption of these foods, and whether related policy measures are effective.

OBJECTIVES

This study aimed to identify the frequency and sources of consumption of foods prepared outside the home in Australia, and to understand the impact of nutrition information in restaurants on related food choices.

METHODS

Data were from a web-based survey (the International Food Policy Study) completed in 2018 by Australian adults aged ≥18 years (n = 4103). The number of meals prepared outside the home, their purchase locations, and the extent to which nutrition information was noticed and influenced purchasing decisions were each analyzed by sociodemographic characteristics and BMI, with linear models also adjusted for sex, age group, education, ethnicity, and BMI.

RESULTS

An average of 2.73 (95% CI, 2.61-2.86) meals per week were prepared outside the home, with higher frequencies among men, younger ages, and more highly educated participants. A wide variety of sources for these foods was observed, with fast-food outlets being most common. Around one-quarter of all foods prepared outside the home were delivered. A small percentage (14.9%; 95% CI, 13.3%-16.7%) of participants reported noticing nutrition information, but among those who did, around half reported that it influenced their behavior.

CONCLUSIONS

Foods prepared outside the home are commonly purchased in Australia, particularly by young adults, from a variety of outlet types. While current menu energy labeling regulations may provide some population health benefit, a broader policy focus on foods prepared outside the home is needed as part of efforts to improve population diets.

Children's Community Nutrition Environment, Food and Drink Purchases and Consumption on Journeys between Home and School: A Wearable Camera Study

Children's community nutrition environments are an important contributor to childhood obesity rates worldwide. This study aimed to measure the type of food outlets on children's journeys to or from school, children's food purchasing and consumption, and to determine differences by ethnicity and socioeconomic status. In this New Zealand study, we analysed photographic images of the journey to or from school from a sample of 147 children aged 11-13 years who wore an Autographer camera which recorded images every 7 s. A total of 444 journeys to or from school were included in the analysis. Camera images captured food outlets in 48% of journeys that had a component of active travel and 20% of journeys by vehicle. Children who used active travel modes had greater odds of exposure to unhealthy food outlets than children who used motorised modes; odds ratio 4.2 (95% CI 1.2-14.4). There were 82 instances of food purchases recorded, 84.1% of which were for discretionary foods. Of the 73 food and drink consumption occasions, 94.5% were for discretionary food or drink. Children on their journeys to or from school are frequently exposed to unhealthy food outlets. Policy interventions are recommended to limit the availability of unhealthy food outlets on school routes.

Associations between retail food environment and the nutritional quality of food purchases in French households: The Mont’Panier cross-sectional study

Purpose

The purpose of this study was to assess whether the retail food environment, measured by multiple indicators around the home and in activity space, was associated with the nutritional quality of food purchases.

Methods

This cross-sectional study included 462 households from a quota sampling survey conducted in the south of France (Montpellier Metropolitan Area). The revised Healthy Purchase Index was implemented in order to assess the nutritional quality of food purchases. Food environment indicators (presence, number, relative density and proximity of food outlets) were calculated around the home and in activity space using a geographical information system. Six different types of food outlets were studied: supermarkets, markets, greengrocers, bakeries, other specialized food stores (butcher’s, fishmonger’s and dairy stores) and small grocery stores. Associations between food environment and the nutritional quality of food purchases were assessed using multilevel models, and geographically weighted regressions to account for spatial non-stationarity. Models were adjusted for households’ socioeconomic and demographic characteristics.

Results

The nutritional quality of food purchases was positively associated with the number of greengrocers around the home (1 vs. 0: β = 0.25, 95%CI = [0.01, 0.49]; >1 vs. 0: β = 0.25, 95%CI = [0.00, 0.50]), but negatively associated with the number of markets around the home (1 vs. 0: β = -0.20, 95%CI = [-0.40, 0.00]; >1 vs. 0: β = -0.37, 95%CI = [-0.69, -0.06]). These associations varied across space in the area studied. For lower income households, the number of greengrocers in activity space was positively associated with the nutritional quality of food purchases (1 vs. 0: β = 0.70, 95%CI = [0.12, 1.3]; >1 vs. 0: β = 0.67, 95%CI = [0.22, 1.1]).

Conclusions

Greengrocers might be an effective type of food store for promoting healthier dietary behaviors. Further studies, particularly interventional studies, are needed to confirm these results in order to guide public health policies in actions designed to improve the food environment.

Evidence Gaps in Assessments of the Healthiness of Online Supermarkets Highlight the Need for New Monitoring Tools: a Systematic Review

PURPOSE OF REVIEW

Online grocery shopping is increasingly popular, but the extent to which these food environments encourage healthy or unhealthy purchases is unclear. This review identifies studies assessing the healthiness of real-world online supermarkets and frameworks to support future efforts.

RECENT FINDINGS

A total of 18 studies were included and 17 assessed aspects of online supermarkets. Pricing and promotional strategies were commonly applied to unhealthy products, while nutrition labelling may not meet regulated requirements or support consumer decision-making. Few studies investigated the different and specific ways online supermarkets can influence consumers. One framework for comprehensively capturing the healthiness of online supermarkets was identified, particularly highlighting the various ways retailers can tailor the environment to target individuals. Comprehensive assessments of online supermarkets can identify the potential to support or undermine healthy choices and dietary patterns. Common, validated instruments to facilitate consistent analysis and comparison are needed, particularly to investigate the new opportunities the online setting offers to influence consumers.

Benchmarking as a Public Health Strategy for Creating Healthy Food Environments: An Evaluation of the INFORMAS Initiative (2012-2020)

Diet-related noncommunicable diseases (NCDs) and obesity are the leading contributors to poor health worldwide. Efforts to improve population diets need to focus on creating healthy food environments. INFORMAS, established in 2012, is an international network that monitors and benchmarks food environments and related policies. By 2020, INFORMAS was active in 58 countries; national government policies were the most frequent aspect benchmarked. INFORMAS has resulted in the development and widespread application of standardized methods for assessing the characteristics of food environments. The activities of INFORMAS have contributed substantially to capacity building, advocacy, stakeholder engagement, and policy evaluation in relation to creating healthy food environments. Future efforts to benchmark food environments need to incorporate measurements related to environmental sustainability. For sustained impact, INFORMAS activities will need to be embedded within other existing monitoring initiatives. The most value will come from repeated assessments that help drive increased accountability for improving food environments.

Development of the University Food Environment Assessment (Uni-Food) Tool and Process to Benchmark the Healthiness, Equity, and Environmental Sustainability of University Food Environments

Globally, there is increasing interest in monitoring actions to create healthy, equitable and environmentally sustainable food environments. Currently, there is a lack of detailed tools for monitoring and benchmarking university food environments. This study aimed to develop the University Food Environment Assessment (Uni-Food) tool and process to benchmark the healthiness, equity, and environmental sustainability of food environments in tertiary education settings, and pilot test its implementation in three Australian universities in 2021. The Uni-Food tool development was informed by a review of the literature and input from an expert advisory panel. It comprises three components: (1) university systems and governance, (2) campus facilities and environments, and (3) food retail outlets. The process for implementing the tool is designed for universities to self-assess the extent to which they have implemented recommended practice in 68 indicators, across 16 domains, weighted based on their relative importance. The pilot implementation of the tool identified moderate diversity in food environments across universities and highlighted several opportunities for improvements at each institution. The assessment process was found to be reliable, with assessors rating the tool as easy to use, requiring minimal resources. Broad application of the tool has the potential to increase accountability and guide best practice in tertiary education and other complex institutional settings.

Ultra-processed food consumption patterns among older adults in the Netherlands and the role of the food environment

PURPOSE

To describe the patterns of ultra-processed foods (UPFs) consumption in the Netherlands; to test if exposure to the food environment is associated with UPFs consumption; and if this association differed across educational levels and neighbourhood urbanisation.

METHODS

Cross-sectional study using 2015-data of 8104 older adults from the Dutch EPIC cohort. Proportion of UPFs consumption was calculated from a validated food-frequency questionnaire. Exposure to the food environment was defined as proximity and availability of supermarkets, fast-food restaurants, full-service restaurants, convenience stores, candy stores and cafés. Consumption of UPFs was expressed as both percentage of total grams and total kilocalories.

RESULTS

The study population was aged 70(± 10 SD) years and 80.5% was female. Average UPFs consumption was 17.8% of total food intake in grams and 37% of total energy intake. Those who consumed greater amounts of UPFs had a poorer overall diet quality. Adjusted linear regression models showed that closer proximity and larger availability to any type of food retailer was associated with lower UPFs consumption (both in grams and kilocalories). Somewhat stronger significant associations were found for proximity to restaurants (β = - 1.6%, 95% confidence interval (CI) = - 2.6; - 0.6), and supermarkets (β = - 2.2%, 95%CI = - 3.3; - 1.1); i.e., Individuals living within 500 m from the closest supermarket, as compared to 1500 m, had 2.6% less calories from UPFs. No differences were found on analyses stratified for urbanisation and education.

CONCLUSIONS

Using various measures of exposure to the food environment, we found that exposure to restaurants and supermarkets was associated with somewhat lower consumption of UPFs.

Contributions of Food Environments to Dietary Quality and Cardiovascular Disease Risk

PURPOSE OF REVIEW

To evaluate the multidimensional influence of food environments on food choice, dietary quality, and diet-related health and identify critical gaps necessary to develop effective population interventions that influence food choice.

RECENT FINDINGS

Multicomponent interventions that interact with multiple layers of the food environment show limited but consistent effects on dietary behaviors and may have wider and substantive population-level reach with greater incorporation of validated, holistic measurement tools. Opportunities to use smartphone technology to measure multiple components of the food environment will facilitate future interventions, particularly as food environments expand into online settings and interact with consumers in novel ways to shape food choice. While studies suggest that all dimensions of the food environment influence diet and health outcomes, robust and consistent measurements of food environments that integrate objective and subjective components are essential for developing stronger evidence needed to shift public policies.

Examining the consumer restaurant environment and dietary intake in children

Within the away-from-home food environment there is a need to account for individual exposure (e.g., frequency of visitation) to that environment. The present study examined the consumer environment in both proximal and visited restaurants and their association with childrens’ diet quality and anthropometrics. A cross-sectional analysis used baseline data from the Neighborhood Impact on Kids (NIK) study (2007–2009). Participants were 6–12-year-olds living in King County, WA and San Diego County, CA. This analysis (conducted 2019–2020) examined relationships between nearby restaurant count, Nutrition Environment Measures Survey in Restaurants (NEMS-R) within the child’s block group, and weighted NEMS-R scores based on the restaurant where the child ate most frequently in relation to child energy intake, Healthy Eating Index (HEI-2010) total score and anthropometrics. Children’s HEI-2010 scores were associated with NEMS-R scores within block groups, with children in the lowest NEMS-R tertile having significantly higher HEI scores than participants in the middle tertile. Weighted NEMS-R scores were significantly associated with waist circumference, with children in the highest NEMS-R tertile having a lower waist circumference than children in the lowest tertile. Nearby restaurant count was not associated with children’s diet quality or anthropometrics. Our findings suggest the relationship between nutrition environment and child diet and anthropometrics varied depending on how nutrition environment was defined. However, findings may be limited by the low frequency of eating out reported in this sample. Food environment measures that account for individual-level behavior are needed to better understand the influence of food environments on diet and anthropometrics

Understanding the healthfulness of outlets providing lunch and dinner meals: a census of a rural food retail environment in Victoria, Australia

OBJECTIVE

To undertake a census of the healthfulness of food venues providing lunch or dinner meals in a rural Australian setting and compare healthfulness by remoteness, using two measurement tools.

METHODS

A census of the rural local government area food venues was undertaken using two validated tools: the Healthfulness Rating Classification System (HRCS) and the Nutrition Environment Measures Survey (NEMS-R). Data were collected covering an area of 3,438 square kilometres in Victoria, Australia, with a population of >21,000. Healthfulness by remoteness was described and variability between tools was explored.

RESULTS

Data were collected from all 95 eligible food venues. Both tools classified the food venues as relatively unhealthy. The mean HRCS score was -2.9 (unhealthy) and the mean NEMS-R score was 10.8 (SD 7.0; possible range -27 to 64). There were no significant differences in healthiness of venues by remoteness (as measured by the Modified Monash Model), although the outer-rural region had lower scores.

CONCLUSIONS

This census of a rural food retail environment showed low access to healthy menu options along with minimal provision of nutrition information and promotion of healthy food in food venues. This environment has the potential to affect the dietary intake of more than 21,000 rural-dwelling Australians and action to improve rural food environments is desperately needed. Implications for public health: If unhealthful rural food environments are not addressed, inequalities in the diet-related disease burden for rural Australians will continue to persist. This study shows that interventions are needed for independent venues that could be targeted by researchers, local health promotion officers, community nutritionists or community education programs.

Junk Food on Demand: A Cross-Sectional Analysis of the Nutritional Quality of Popular Online Food Delivery Outlets in Australia and New Zealand

The demand for convenience and the increasing role of digital technology in everyday life has fueled the use of online food delivery services (OFD’s), of which young people are the largest users globally. OFD’s are disrupting traditional food environments, yet research evaluating the public health implications of such services is lacking. We evaluated the characteristics and nutritional quality of popular food outlets on a market-leading platform (UberEATS^®) in a cross-sectional observational study conducted in two international cities: Sydney (Australia) and Auckland (New Zealand). A systematic search using publicly available population-level data was used to identify geographical areas with above-average concentrations (>30%) of young people (15–34-years). A standardized data extraction protocol was used to identify the ten most popular food outlets within each area. The nutritional quality of food outlets was assessed using the Food Environment Score (FES) (range: −10 ‘unhealthiest’ to 10 ‘healthiest’). Additionally, the most popular menu items from each food outlet were classified as discretionary or core foods/beverages according to the Australian Dietary Guidelines. The majority of popular food outlets were classified as ‘unhealthy’ (FES range −10 to −5; 73.5%, 789/1074) and were predominately takeaway franchise stores (59.6%, 470/789, e.g., McDonald’s^®). 85.9% of all popular menu items were discretionary (n = 4958/5769). This study highlights the pervasion and accessibility of discretionary foods on OFD’s. This study demonstrated that the most popular food outlets on the market-leading online food delivery service are unhealthy and popular menu items are mostly discretionary foods; facilitating the purchase of foods of poor nutritional quality. Consideration of OFD’s in public health nutrition strategies and policies in critical.

The use and misuse of ratio and proportion exposure measures in food environment research

Background

The food stores within residential environments are increasingly investigated as a possible mechanism driving food behaviours and health outcomes. Whilst increased emphasis is being placed on the type of study designs used and how we measure the outcomes, surprisingly little attention gets diverted to the measures of the food environment beyond calls for standardised approaches for food store coding and geographic scales of exposure. Food environments are a challenging concept to measure and model and the use of ratio and proportion measures are becoming more common in food environment research. Whilst these are seemingly an advance on single store type indicators, such as simply counting the number of supermarkets or fast food restaurants present, they have several limitations that do not appear to have been fully considered.

Main body

In this article we report on five issues related to the use of ratio and proportion food environment measures: 1) binary categorisation of food stores; 2) whether they truly reflect a more or less healthy food environment; 3) issues with these measures not reflecting the quantity of food stores; 4) difficulties when no stores are present; and 5) complications in statistical treatment and interpretation of ratio and proportion measures. Each of these issues are underappreciated in the literature to date and highlight that ratio and proportion measures need to be treated with caution.

Conclusion

Calls for the broader adoption of relative food environment measures may be misguided. Whilst we should continue to search for better ways to represent the complexity of food environments, ratio and proportion measures are unlikely to be the answer.

The Application of an Evidence Framework for Obesity Prevention at the Population-Level

PURPOSE OF REVIEW

To review existing frameworks for assessing the evidence of effectiveness of obesity prevention interventions, and discuss the application of a custom-developed evidence framework to inform an obesity prevention priority-setting study in Australia.

RECENT FINDINGS

There are a wide range of frameworks for grading evidence. However, most frameworks are not well suited to assess the effectiveness of obesity prevention interventions because they do not include processes to synthesise evidence from multiple study designs and outcome measures. The key features of the Obesity Prevention Evidence Assessment (OPEA) Framework are: [1] separately assessed weight-, diet- and physical activity-related outcomes; [2] consideration of the balance of evidence from multiple study types; and [3] a summary indication of the degree of certainty of intervention effectiveness. Evidence frameworks that recognise the complexities of obesity prevention research can support decision-makers in prioritising actions to address obesity alongside broader priority-setting considerations.

Food Environment Typology: Advancing an Expanded Definition, Framework, and Methodological Approach for Improved Characterization of Wild, Cultivated, and Built Food Environments toward Sustainable Diets

The food environment is a critical place in the food system to implement interventions to support sustainable diets and address the global syndemic of obesity, undernutrition, and climate change, because it contains the total scope of options within which consumers make decisions about which foods to acquire and consume. In this paper, we build on existing definitions of the food environment, and provide an expanded definition that includes the parameter of sustainability properties of foods and beverages, in order to integrate linkages between food environments and sustainable diets. We further provide a graphical representation of the food environment using a socio-ecological framework. Next, we provide a typology with descriptions of the different types of food environments that consumers have access to in low-, middle-, and high-income countries including wild, cultivated, and built food environments. We characterize the availability, affordability, convenience, promotion and quality (previously termed desirability), and sustainability properties of food and beverages for each food environment type. Lastly, we identify a methodological approach with potential objective and subjective tools and metrics for measuring the different properties of various types of food environments. The definition, framework, typology, and methodological toolbox presented here are intended to facilitate scholars and practitioners to identify entry points in the food environment for implementing and evaluating interventions that support sustainable diets for enhancing human and planetary health.

Food Retail Environments in Greater Melbourne 2008-2016: Longitudinal Analysis of Intra-City Variation in Density and Healthiness of Food Outlets

Obesity prevalence is inequitably distributed across geographic areas. Food environments may contribute to health disparities, yet little is known about how food environments are evolving over time and how this may influence dietary intake and weight. This study aimed to analyse intra-city variation in density and healthiness of food outlets between 2008 and 2016 in Melbourne, Australia. Food outlet data were classified by location, type and healthiness. Local government areas (LGAs) were classified into four groups representing distance from the central business district. Residential population estimates for each LGA were used to calculate the density of food outlets per 10,000 residents. Linear mixed models were fitted to estimate the mean density and ratio of ‘healthy’ to ‘unhealthy’ food outlets and food outlet ‘types’ by LGA group over time. The number of food outlets increased at a faster rate than the residential population, driven by an increasing density of both ‘unhealthy’ and ‘healthy’ outlets. Across all years, ratios of ‘unhealthy’ to ‘healthy’ outlets were highest in LGAs located in designated Growth Areas. Melbourne’s metropolitan food environment is saturated by ‘unhealthy’ and ‘less healthy’ food outlets, relative to ‘healthy’ ones. Melbourne’s urban growth areas had the least healthy food environments.

A Systematic Review on Socioeconomic Differences in the Association between the Food Environment and Dietary Behaviors

Little is known about socioeconomic differences in the association between the food environment and dietary behavior. We systematically reviewed four databases for original studies conducted in adolescents and adults. Food environments were defined as all objective and perceived aspects of the physical and economic food environment outside the home. The 43 included studies were diverse in the measures used to define the food environment, socioeconomic position (SEP) and dietary behavior, as well as in their results. Based on studies investigating the economic (n = 6) and school food environment (n = 4), somewhat consistent evidence suggests that low SEP individuals are more responsive to changes in food prices and benefit more from healthy options in the school food environment. Evidence for different effects of availability of foods and objectively measured access, proximity and quality of food stores on dietary behavior across SEP groups was inconsistent. In conclusion, there was no clear evidence for socioeconomic differences in the association between food environments and dietary behavior, although a limited number of studies focusing on economic and school food environments generally observed stronger associations in low SEP populations. (Prospero registration: CRD42017073587)