Neighbourhood socioeconomic inequalities in food access and affordability

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.

Heat-related first cardiovascular event incidence in the city of Madrid (Spain): Vulnerability assessment by demographic, socioeconomic, and health indicators

While climate change and population ageing are expected to increase the exposure and vulnerability to extreme heat events, there is emerging evidence suggesting that social inequalities would additionally magnify the projected health impacts. However, limited evidence exists on how social determinants modify heat-related cardiovascular morbidity. This study aims to explore the association between heat and the incidence of first acute cardiovascular event (CVE) in adults in Madrid between 2015 and 2018, and to assess how social context and other individual characteristics modify the estimated association. We performed a case-crossover study using the individual information collected from electronic medical records of 6514 adults aged 40-75 living in Madrid city that suffered a first CVE during summer (June-September) between 2015 and 2018. We applied conditional logistic regression with a distributed lag non-linear model to analyse the heat-CVE association. Estimates were expressed as Odds Ratio (OR) for extreme heat (at 97.5th percentile of daily maximum temperature distribution), compared to the minimum risk temperature. We performed stratified analyses by specific diagnosis, sex, age (40-64, 65-75), country of origin, area-level deprivation, and presence of comorbidities. Overall, the risk of suffering CVE increased by 15.3% (OR: 1.153 [95%CI 1.010-1.317]) during extreme heat. Males were particularly more affected (1.248, [1.059-1.471]), vs 1.039 [0.810-1.331] in females), and non-Spanish population (1.869 [1.28-2.728]), vs 1.084 [0.940-1.250] in Spanish). Similar estimates were found by age groups. We observed a dose-response pattern across deprivation levels, with larger risks in populations with higher deprivation (1.228 [1.031-1.462]) and almost null association in the lowest deprivation group (1.062 [0.836-1.349]). No clear patterns of larger vulnerability were found by presence of comorbidity. We found that heat unequally increased the risk of suffering CVE in adults in Madrid, affecting mainly males and deprived populations. Local measures should pay special attention to vulnerable populations.

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.

Neighbourhood socioeconomic disadvantage and body size in Australia's capital cities: The contribution of obesogenic environments

Residents of socioeconomically disadvantaged neighbourhoods have higher rates of overweight and obesity and chronic disease than their counterparts from advantaged neighbourhoods. This study assessed whether associations between neighbourhood disadvantage and measured body mass index (BMI) and waist circumference, are accounted for by obesogenic environments (i.e., residential distance to the Central Business District [CBD], supermarket availability, access to walkable destinations). The study used 2017-18 National Health Survey data for working-aged adults (aged ≥18 years, n = 9,367) residing in 3,454 neighbourhoods across Australia's state and territory capital cities. In five of eight cities (i.e., Sydney, Melbourne, Brisbane, Adelaide, and Perth) residents of disadvantaged neighbourhoods had significantly higher BMI and a larger waist circumference than residents of more advantaged areas. There was no association between neighbourhood disadvantage and body size in Hobart, Darwin, and Canberra. Associations between neighbourhood disadvantage and body size were partially explained by neighbourhood differences in distance to the CBD but not supermarket availability or walkable amenities. The results of this study point to the role of urban design and city planning as mechanisms for addressing social and economic inequities in Australia's capital cities, and as solutions to this country's overweight and obesity epidemic and associated rising rates of chronic disease.

Socio-economic difference in purchases of ultra-processed foods in Australia: an analysis of a nationally representative household grocery purchasing panel

BACKGROUND

Consumption of ultra-processed foods is associated with increased risk of obesity and non-communicable diseases. Little is known about current patterns of ultra-processed foods intake in Australia. The aim of this study was to examine the amount and type of ultra-processed foods purchased by Australian households in 2019 and determine whether purchases differed by socio-economic status (SES). We also assessed whether purchases of ultra-processed foods changed between 2015 and 2019.  METHODS: We used grocery purchase data from a nationally representative consumer panel in Australia to assess packaged and unpackaged grocery purchases that were brought home between 2015 to 2019. Ultra-processed foods were identified according to the NOVA system, which classifies foods according to the nature, extent and purpose of industrial food processing. Purchases of ultra-processed foods were calculated per capita, using two outcomes: grams/day and percent of total energy. The top food categories contributing to purchases of ultra-processed foods in 2019 were identified, and differences in ultra-processed food purchases by SES (Index of Relative Social Advantage and Disadvantage) were assessed using survey-weighted linear regression. Changes in purchases of ultra-processed foods between 2015 to 2019 were examined overall and by SES using mixed linear models.

RESULTS

In 2019, the mean ± SD total grocery purchases made by Australian households was 881.1 ± 511.9 g/d per capita. Of this, 424.2 ± 319.0 g/d per capita was attributable to purchases of ultra-processed foods, which represented 56.4% of total energy purchased. The largest food categories contributing to total energy purchased included mass-produced, packaged breads (8.2% of total energy purchased), chocolate and sweets (5.7%), biscuits and crackers (5.7%) and ice-cream and edible ices (4.3%). In 2019, purchases of ultra-processed foods were significantly higher for the lowest SES households compared to all other SES quintiles (P < 0.001). There were no major changes in purchases of ultra-processed foods overall or by SES over the five-year period.

CONCLUSIONS

Between 2015 and 2019, ultra-processed foods have consistently made up the majority of groceries purchased by Australians, particularly for the lowest SES households. Policies that reduce ultra-processed food consumption may reduce diet-related health inequalities.

LGBTQ+ food insufficiency in New England

As a group, LGBTQ+ people experience food insecurity at a disproportionately high rate, yet food security scholars and practitioners are only beginning to uncover patterns in how food insecurity varies by subgroups of this diverse community. In this paper, we use data from the U.S. Census Bureau's Household Pulse Survey-which added measures of gender identity and sexuality for the first time in 2021-to analyze New Englanders' food insufficiency rates by gender, sexuality, race, and ethnicity. We find that (1) in the past seven days, 13.0 percent of LGB + (lesbian, gay, bisexual, and other non-heterosexual) New Englanders experience food insufficiency-which is nearly twice the rate of heterosexual people-and 19.8 percent of transgender+ (transgender, genderqueer, gender non-binary, and other non-cisgender people) New Englanders experience food insufficiency-which is two to three times the rate of cisgender men and women. (2) Whereas cisgender New Englanders experience food insufficiency at a lower rate than their counterparts in the rest of the nation (about two percentage points lower for both cisgender men and women), transgender+ New Englanders experience no such New England advantage compared to transgender+ people in the country as a whole. (3) LGBTQ+ New Englanders of color experience devastatingly high rates of food insufficiency, with, for example, one in three Black transgender+ New Englanders not having enough food to eat in the past seven days. These findings suggest that addressing food insecurity in New England demands approaching the problem with an intersectional queer lens, with attention to the ways in which racism, cissexism, and heterosexism are creating a systemic, ongoing food crisis for LGBTQ+ New Englanders, especially those who are transgender+ and/or people of color.

The 5 A's Approach for Contextual Assessment of Food Environment

OBJECTIVE

To develop a context-specific methodology to assess the 5 A's of food environment: availability, accessibility, affordability, acceptability, and accommodation.

DESIGN

Cross-sectional mixed-methods study. Availability of foods was assessed by on-site observation and interviewing vendors. To assess accessibility, buffer zones around food stores were created using geographic information systems. Affordability was controlled by selecting participants from the middle-income group. Accommodation and acceptability were assessed by interviewing vendors and caregivers.

SETTING

Villages of Ghatkesar subdistrict (n = 4), Telangana, South India.

PARTICIPANTS

Caregivers of children aged 6-10 years (n = 160) and food vendors (n = 68).

ANALYSIS

The quality of the 5 A's was graded on the basis of concurrence between actual and perceived measures.

RESULTS

The actual and perceived 5 A's for semiperishable foods matched, and hence the food environment was graded as good across the villages. However, for perishable foods, the food environment was graded as poor with respect to accommodation and acceptability in all villages; and with respect to availability and affordability in at least 2 villages as the actual and perceived measures did not match.

CONCLUSIONS AND IMPLICATIONS

This study demonstrated the use of context-specific methods to assess the 5 key dimensions of the food environment, which can be attempted in other contexts with suitable modifications.

Food Retail Network Spatial Matching and Urban Planning Policy Implications: The Case of Beijing, China

Food is the core of urban daily life and socio-economic activities but is rarely the focus of urban planning. The spatial layout of food retail outlets is important for optimizing the urban food system, improving land resource allocation, and encouraging healthy food consumption. Based on food retail POI data, this study employed kernel density estimation, road network centrality, spatial autocorrelation analysis, and locational entropy to analyze the spatial characteristics of supermarkets, produce markets, and small stores in an urban center in Beijing, and explored street coupling and supply-demand matching. The results indicated that within the study area: (1) supermarkets had an obvious “core-periphery” distribution, produce markets had a polycentric distribution, and small stores had a relatively uniform distribution; (2) road network centrality indices revealed a differentiated multi-core-edge distribution; (3) streets with high locational entropy values for supermarkets and produce markets were mostly concentrated in the central area, whereas the matching distribution of small stores was relatively balanced. From the perspective of urban planning, policy implications are proposed based on spatial and social equity, urban-rural differences, population structure and distribution status, and a resilient supply chain. The study findings have practical significance for guiding the development of urban food systems in a healthy, just, and sustainable direction, as well as rational urban land planning.

Access to Healthy Wheat and Maize Processed Foods in Mexico City: Comparisons across Socioeconomic Areas and Store Types

The contributions of processed foods to the overweight and obesity problem in Latin America are well known. Engagement with the private and public sectors on possible solutions requires deeper insights into where and how these products are sold and the related implications for diet quality. This article characterizes the diversity of wheat and maize processed foods (WMPFs) available to consumers in Mexico City. Data were gathered across nine product categories at different points of sale (supermarkets, small grocery stores, convenience stores) in high and low socioeconomic (SE) areas. We assessed WMPFs based on Nutri-Score profile, price, and health and nutrition claims. Roughly 17.4% of the WMPFs were considered healthy, of which 62.2% were pastas and breads. Availability of healthy WMPFs was scarce in most stores, particularly in convenience stores Compared to supermarkets in the low SE area, those in the high SE area exhibited greater variety in access to healthy WMPFs across all product categories. In the low SE area, healthy WMPFs were priced 16–69% lower than unhealthy WMPFs across product categories. The extensive variety of unhealthy WMPFs, the limited stock of healthy WMPFs in most retail outlets, and the confusing health and nutrition claims on packaging make it difficult for urban consumers to find and choose healthy WMPFs.

Impact of Grocery Store Proximity on Store Preference Among Atlanta SNAP-Ed Participants

OBJECTIVE

To assess the association between grocery store proximities and the individual's grocery store preferences among Supplemental Nutrition Assistance Program Education participants in Atlanta.

METHODS

University of Georgia Supplemental Nutrition Assistance Program Education participants (n = 615, response rate is 36%) in 3 counties provided their preferred grocery store chains. The association between store proximity (both network distance and driving time) and store preference was measured through logistic regression controlling for age, sex, and race.

RESULTS

Descriptive statistics showed participants had widely varying proximities to grocery stores. Model results were significant for all smaller chains (Aldi, Big Bear, Wayfield, Food Depot, and Save-A-Lot), Kroger (P < 0.01), as well as for Walmart (time only, P = 0.002).

CONCLUSIONS AND IMPLICATIONS

Future studies might identify whether local groceries are more willing to partner on interventions or are more effective at reaching local residents. Surveys or techniques such as sketch mapping could also show whether individuals shop in neighborhoods close to work or friends and family.

Assessing the Cost of Healthy and Unhealthy Diets: A Systematic Review of Methods

PURPOSE OF REVIEW

Poor diets are a leading risk factor for chronic disease globally. Research suggests healthy foods are often harder to access, more expensive, and of a lower quality in rural/remote or low-income/high minority areas. Food pricing studies are frequently undertaken to explore food affordability. We aimed to capture and summarise food environment costing methodologies used in both urban and rural settings.

RECENT FINDINGS

Our systematic review of high-income countries between 2006 and 2021 found 100 relevant food pricing studies. Most were conducted in the USA (n = 47) and Australia (n = 24), predominantly in urban areas (n = 74) and cross-sectional in design (n = 76). All described a data collection methodology, with just over half (n = 57) using a named instrument. The main purpose for studies was to monitor food pricing, predominantly using the 'food basket', followed by the Nutrition Environment Measures Survey for Stores (NEMS-S). Comparatively, the Healthy Diets Australian Standardised Affordability and Price (ASAP) instrument supplied data on relative affordability to household incomes. Future research would benefit from a universal instrument reflecting geographic and socio-cultural context and collecting longitudinal data to inform and evaluate initiatives targeting food affordability, availability, and accessibility.

Development and Interrater Reliability of a Street Food Stand Assessment Tool

OBJECTIVE

To design and test the interrater reliability of a Street Food Stand Assessment Tool (SFSAT).

DESIGN

Variables were adapted from validated assessment tools, field observations, and the Mexican Dietary Guidelines. Two researchers tested the SFSAT by observing street food stands (SFS) in 3 middle- to high-income neighborhoods.

SETTING

Mexico City.

PARTICIPANTS

Fifty-two SFS.

VARIABLES MEASURED

The SFSAT contains 14 items for SFS characteristics and 44 items for food and beverages.

ANALYSIS

Percent agreement and kappa interrater reliability scores were calculated for each variable.

RESULTS

Almost perfect kappa interrater reliability scores (0.81-1.00) were reported for 62.7% of SFS characteristic items. Interrater reliability scores for food and beverage availability and variety ranged from 0.00-1.00, whereas the percent agreement for these items ranged from 59.6%-100.0%.

CONCLUSIONS AND IMPLICATIONS

The SFSAT is a reliable assessment tool to measure the availability and variety of street foods and beverages in Mexico City. Future research can update and adapt the SFSAT to the street food environment of other cities-in Mexico and abroad.

Community-based culinary and nutrition education intervention promotes fruit and vegetable consumption

OBJECTIVE

The main objective of this study was to evaluate the impact of the Market to MyPlate (M2MP) program on fruit and vegetable consumption and cooking behaviours. Secondary objectives were to examine factors that affected participant retention and program completion, and analyse program feedback provided by participants.

DESIGN

This study conducted a mixed methods evaluation embedded within a cluster randomised controlled trial of the M2MP intervention. Adult participants completed a pre- and post-program survey reporting on their fruit and vegetable consumption and cooking behaviours. A subsample participated in structured interviews, providing feedback about M2MP and the impact of the program.

SETTING

Seven weekly classes took place in community centres and extension offices in central Illinois.

PARTICIPANTS

120 adults and their families participated. Class cohorts were randomly assigned to one of three treatment groups: (1) nutrition education and cooking classes with produce allocations (PAE, n 39); (2) nutrition education and cooking classes only (EO, n 36) or (3) control group (n 45).

RESULTS

Compared to control, PAE participants reported larger increases from pre- to post-intervention in fruit (P = 0·001) and vegetable consumption (P = 0·002), with no differences in cooking frequency. Interview analyses identified key themes in behaviour changes due to M2MP, including reported increases in dietary variety, cooking self-efficacy and children's participation in cooking.

CONCLUSIONS

PAE participants who received an intervention that directly increased their access to fresh produce (via produce allocations) increased their reported fruit and vegetable consumption. Though participants' cooking frequency did not change, interviewees reported increased variety, cooking confidence and family participation in cooking.

Socioeconomic Inequalities in Food Consumption: A Cross-Sectional Study in Portuguese Adults

<b><i>Background:</i></b> Food is a major determinant of chronic noncommunicable diseases. Because of this, social inequalities in food consumption will likely produce social inequalities in disease and life expectancy. <b><i>Objectives:</i></b> This study analyses the social inequalities in food consumption in Portugal and whether they differ between men and women and between younger and older people. <b><i>Methods:</i></b> Following a cross-sectional observational study, we analyzed data from 11,085 individuals aged 25–64 years who participated in the 2014 National Health Interview Survey (NHIS). Logistic regression models were used to measure the association between socioeconomic conditions, i.e., education and income, and food consumption. The analysis was then stratified by sex and age. <b><i>Results:</i></b> A positive gradient for income and education was observed in the consumption of fish, cakes, natural juices, and dairy products. The consumption of legumes and soft drinks was inversely related to income and education. A socioeconomic gradient for fruits and vegetables was observed only among women and older people. Worse-off people consumed less soup, and underprivileged women consumed fewer fast-food products. <b><i>Conclusion:</i></b> The food consumption patterns of Portuguese adults are related to their socioeconomic condition, with few variations across demographic categories.

Green space and cardiovascular health in people with type 2 diabetes

Associations between green space type and 9-year risk of incident cardiovascular disease (CVD) hospitalisations and deaths were analysed in 4166 people with type 2 diabetes in the Sax Institute's 45 and Up Study. Incidence of all-cause mortality, cardiovascular mortality, fatal or non-fatal CVD events and acute myocardial infarctions (AMI) were 14.67%, 7.23%, 47.36%, and 4.51%, respectively. After full adjustment, more tree canopy was associated with lower CVD mortality, lower fatal or non-fatal CVD events, and lower AMI risk. More open grass was associated with lower all-cause mortality, lower CVD mortality and lower fatal or non-fatal CVD events, but higher AMI risk.

An Emergent Framework of the Market Food Environment in Low- and Middle-Income Countries

BACKGROUND

Food systems are increasingly recognized as critical for advancing nutrition, and the food environment is viewed as the nexus between those systems and dietary consumption. Developing a measurement framework of the market food environment is a research priority, particularly for low- and middle-income countries (LMICs), which face rapid shifts in markets, dietary patterns, and nutrition outcomes.

OBJECTIVES

In this study, we sought to assess current conceptions and measures of the market food environment that could be adapted for use in LMICs.

METHODS

We conducted a narrative review of the literature to identify measures of the market food environment in recent use. First, we identified and reviewed frameworks of the food environment for LMICs with a specific focus on the market food environment. Second, we compiled 141 unique measures of the market food environment from 20 articles into a list that was pile-sorted by 5 nutrition experts into domains. We then categorized the measures based on percentage agreement across all sorts. Finally, we compared measured and conceptual domains of the market food environment to identify measurement gaps and needed adaptations.

RESULTS

Conceptual frameworks provide differing definitions of the market food environment but conform in their definitions of food availability, price, marketing, and product characteristics. Greater clarity is needed in defining relevant vendor and product characteristics. Eight measured domains of the market food environment emerged from the literature review, with significant overlap among conceptual domains. Measurement gaps exist for food quality, safety, packaging, desirability, and convenience. Personal characteristics also emerged as measured domains, although these are not part of the food environment per se.

CONCLUSIONS

These results are a step toward elucidating how, why, and where we measure the market food environment in LMICs. Future research should focus on prioritizing the most meaningful methods and metrics and on developing new measures where gaps exist.

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.

Race, socioeconomic status, and low-grade inflammatory biomarkers across the lifecourse: A pooled analysis of seven studies

Cardiovascular diseases are patterned by race and socioeconomic status, and chronic low-grade inflammation is proposed as a key underlying mechanism. Theories for how racial and socioeconomic disadvantages foster inflammation emphasize a lifecourse approach: social disadvantages enable chronic or repeated exposure to stressors, unhealthy behaviors, and environmental risks that accumulate across the lifecourse to increase low-grade inflammation. However, single samples rarely include multiple racial and socioeconomic groups that each span a wide age range, precluding examination of this proposition. To address this issue, the current study combined seven studies that measured C-reactive protein and interleukin-6, producing a pooled sample of 1650 individuals aged 11-60 years. We examined (a) whether race and socioeconomic disparities in inflammatory biomarkers vary across the lifecourse, (b) whether adiposity operates as a pathway leading to these disparities, and (c) whether any indirect pathways through adiposity also vary across the lifecourse. Relative to White individuals, Black individuals exhibited higher, whereas Asian individuals exhibited lower, levels of inflammatory biomarkers, and adiposity accounted for these racial differences. Similarly, lower socioeconomic status was associated with higher inflammatory biomarkers via elevated adiposity. Importantly, both racial and socioeconomic disparities, as well as their pathways via adiposity, widened across the lifecourse. This pattern suggests that the impact of social disadvantages compound with age, leading to progressively larger disparities in low-grade inflammation. More broadly, these findings highlight the importance of considering age when examining health disparities and formulating conceptual models that specify how and why disparities may vary across the lifecourse.

Availability and placement of healthy and discretionary food in Australian supermarkets by chain and level of socio-economic disadvantage

OBJECTIVE

The current study aimed to investigate availability and placement of healthy and discretionary (less healthy) food in supermarkets in Victoria, Australia, and examine variation by supermarket chain and area-level socio-economic disadvantage.

DESIGN

Cross-sectional supermarket audit. Measures included: (i) proportion of shelf space (in square metres) allocated to selected healthy and discretionary food and beverages; (ii) proportion of end-of-aisle, checkout and island bin displays containing discretionary food and beverages and (iii) proportion of space within end-of-aisle, checkout and island bin displays devoted to discretionary food and beverages.

SETTING

Metropolitan areas of Melbourne and Geelong, Australia. Assessment: June-July 2019.

PARTICIPANTS

Random sample of 104 stores, with equal numbers from each supermarket group (Coles, Woolworths, Aldi and Independent stores) within strata of area-level socio-economic position.

RESULTS

Proportion of shelf space devoted to selected discretionary foods was greater for Independent stores (72·7 %) compared with Woolworths (65·7 %), Coles (64·8 %) and Aldi (63·2 %) (all P < 0·001). Proportion of shelf space devoted to selected discretionary food for all Coles, Woolworths and Aldi stores was 9·7 % higher in the most compared with the least disadvantaged areas (P = 0·002). Across all stores, 90 % of staff-assisted checkout displays and 50 % of end-of-aisle displays included discretionary food. Aldi was less likely to feature discretionary food in end-of-aisle and checkout displays compared with other supermarket groups.

CONCLUSIONS

Extensive marketing of discretionary food in all Australian supermarket chains was observed, which is likely to strongly influence purchasing patterns and population diets. Findings should be used to inform private and public sector policies to reduce marketing of discretionary food in supermarkets.

Development and pilot of a tool to measure the healthiness of the in-store food environment

Objective:

To rigorously develop a tool which enables rapid yet comprehensive appraisal of the consumer food retail environment and provision of real-time feedback to store managers and owners, based on the ‘4Ps’ principles of marketing.

Design:

Multi-stage iterative approach including (1) Systematic literature review; (2) Stakeholder consultation; (3) Assessment of existing tools against identified needs; (4) Tool development; (5) Pilot testing and (6) Transition of tool to mobile application (the Store Scout app).

Setting:

Northern Territory, Australia.

Participants:

Nine remote Aboriginal community food stores; public health nutritionists, retailers, store board directors, Aboriginal community members, government representatives.

Results:

Forty-seven existing tools and thirty-four stakeholder interviews informed the development of the current instrument, which comprised: (1) seven product categories (Fruit & Vegetables, Drinks, Snack Foods, Meals & Convenience Foods, Meat & Seafood, Dairy & Eggs, Breads & Cereals) across the ‘4Ps’ (Product, Placement, Price, Promotion); (2) Store manager questions about context and perceived importance of key principles about the store environment and (3) a scoring and feedback component. The tool was considered feasible and acceptable by all testers.

Conclusions:

The developed tool addresses an unmet need to measure the consumer food retail environment across all 4Ps whilst also incorporating manager perspectives and immediate feedback. Our objectives of developing a comprehensive, feasible and acceptable instrument were achieved during pilot testing. The tool will support implementation of best practice within stores to encourage healthy food choices and has potential for broad application in retail settings locally and internationally, as well as for research purposes.

Work-related physical activity and psychological distress among women in different occupations: a cross-sectional study

BACKGROUND

Recent evidence suggests that work-related physical activity may not have the same mental health benefits as leisure-time physical activity. Further, work-related physical activity is likely to include a variety of different behaviours for people with different occupations. As such, the aim of this study was to determine if occupation type moderated the association between work-related physical activity and psychological distress.

METHODS

A randomly selected sample of 1080 women from Melbourne, Australia completed the International Physical Activity Questionnaire (IPAQ) and General Health Questionnaire (GHQ-30), and reported their current occupation.

RESULTS

Linear regression analyses indicated that occupation significantly moderated the association between work-related walking and psychological distress (F [8, 55] = 2.26, p = .036). Given evidence of moderation, we fitted linear regression models to test the associations between work-related physical activity and psychological distress for three separate groups; professionals, sales and services workers, and tradespersons. Female tradespersons who engaged in a low (B = - 3.81, p = .006) or high amount of work-related walking (B = - 3.23, p = .029), had significantly lower psychological distress symptoms than those who engaged in no work-related walking. There were no significant associations between work-related physical activity of any intensity and psychological distress for professionals, or sales and service workers.

CONCLUSIONS

Given the relationship does not exist across all occupations, work-related physical activity should not be promoted above and beyond leisure-time physical activity. However, walking at work may be important in reducing psychological distress for some people and should therefore, not be discounted.

A tale of two cities: the cost, price-differential and affordability of current and healthy diets in Sydney and Canberra, Australia

BACKGROUND

The perception that healthy foods are more expensive than unhealthy foods has been reported widely to be a key barrier to healthy eating. However, assessment of the relative cost of healthy and unhealthy foods and diets is fraught methodologically. Standardised approaches to produce reliable data on the cost of total diets and different dietary patterns, rather than selected foods, are lacking globally to inform policy and practice.

METHODS

This paper reports the first application, in randomly selected statistical areas stratified by socio-economic status in two Australian cities, of the Healthy Diets Australian Standardized Affordability and Pricing (ASAP) method protocols: diet pricing tools based on national nutrition survey data and dietary guidelines; store sampling and location; determination of household incomes; food price data collection; and analysis and reporting. The methods were developed by the International Network on Food and Obesity/NCD Research, Monitoring and Action Support (INFORMAS) as a prototype of an optimum approach to assess, compare and monitor the cost and affordability of diets across different geographical and socio-economic settings and times.

RESULTS

Under current tax policy in Australia, healthy diets would be 15-17% less expensive than current (unhealthy) diets in all locations assessed. Nevertheless, healthy diets are likely to be unaffordable for low income households, costing more than 30% of disposable income in both cities surveyed. Households spent around 58% of their food budget on unhealthy food and drinks. Food costs were on average 4% higher in Canberra than Sydney, and tended to be higher in high socioeconomic locations.

CONCLUSIONS

Health and fiscal policy actions to increase affordability of healthy diets for low income households are required urgently. Also, there is a need to counter perceptions that current, unhealthy diets must be less expensive than healthy diets. The Healthy Diets ASAP methods could be adapted to assess the cost and affordability of healthy and unhealthy diets elsewhere.

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.

A systematic review of the Australian food retail environment: Characteristics, variation by geographic area, socioeconomic position and associations with diet and obesity

There is strong support across multiple sectors for the implementation of policies to create healthier food environments as part of comprehensive strategies to address obesity and improve population diets. The existing evidence base describing food retail environments and their relationship with health outcomes is limited in several respects. This systematic review examines the current evidence regarding food retail environments in Australia, including associations with diet and people with obesity, and socioeconomic and geographic disparities. Three databases were searched and independently screened. Studies were included if they were undertaken in Australia and objectively measured the food retail environment. Sixty papers were included. The broad range of methodological approaches used across studies limited the ability to synthesize the evidence and draw conclusions. Results indicated that there is some evidence that disparities exist in food retail environments across measures of socioeconomic position and geographic area in parts of Australia. Overall, there were inconsistent findings regarding the association between the healthiness of food retail environments and diet or people with obesity. Findings support previous calls for standardized tools and measures for monitoring the healthiness of food retail environments. This is imperative to inform evidence-based policy and evaluation in this critical component of recommended obesity prevention strategies.

Obesity and the Built Environment: A Reappraisal

The built environment (BE) has been viewed as an important determinant of health. Numerous studies have linked BE exposure, captured using a variety of methods, to diet quality and to area prevalence of obesity, diabetes, and cardiovascular disease. First-generation studies defined the neighborhood BE as the area around the home. Second-generation studies turned from home-centric to person-centric BE measures, capturing an individual's movements in space and time. Those studies made effective uses of global positioning system tracking devices and mobile phones, sometimes coupled with accelerometers and remote sensors. Activity space metrics explored travel paths, modes, and destinations to assess BE exposure that was both person and context specific. However, as measures of the contextual exposome have become ever more fine-grained and increasingly complex, connections to long-term chronic diseases with complex etiologies, such as obesity, are in danger of being lost. Furthermore, few studies on obesity and the BE have included intermediate energy balance behaviors, such as diet and physical activity, or explored the potential roles of social interactions or psychosocial pathways. Emerging survey-based applications that identify habitual destinations and associated travel patterns may become the third generation of tools to capture health-relevant BE exposures in the long term.

Disparities in food consumption between economically segregated urban neighbourhoods

OBJECTIVE

To examine associations between economic residential segregation and prevalence of healthy and unhealthy eating markers.

DESIGN

Cross-sectional. A stratified sample was selected in a three-stage process. Prevalence of eating markers and their 95 % CI were estimated according to economic residential segregation: high (most segregated); medium (integrated) and low (less segregated or integrated). Segregation was measured at the census tract and assessed using the Getis-Ord local $G_i^{\rm{\ast}}$ statistic based on the proportion of heads of household in a neighbourhood earning a monthly income of 0-3 minimum wages. Binary logistic regression using generalized estimating equations were used to model the associations.

SETTING

Belo Horizonte, Brazil.

PARTICIPANTS

Adults (n 1301) residing in the geographical environment (178 census tracts) of ten units of the Brazilian primary-care service known as the Health Academy Program.

RESULTS

Of the 1301 participants, 27·7 % lived in highly segregated neighbourhoods, where prevalence of regular consumption of fruit was lower compared with more affluent areas (34·6 v. 53·2 %, respectively). Likewise, regular consumption of vegetables (70·1 v. 87·6 %), fish (23·6 v. 42·3 %) and replacement of lunch or dinner with snacks (0·8 v. 4·7 %) were lower in comparison to more affluent areas. In contrast, regular consumption of beans was higher (91·0 v. 79·5 %). The associations of high-segregated neighbourhood with consumption of vegetables (OR = 0·62; 95 % CI 0·39, 0·98) and beans (OR = 1·85; 95 % CI 1·07, 3·19) remained significant after adjustments.

CONCLUSIONS

Economic residential segregation was associated with healthy eating markers even after adjustments for individual-level factors and perceived food environment.

Low proportions of folic acid deficiency after introduction of mandatory folic acid fortification in remote areas of northern Queensland, Australia: a secondary health data analysis

Background: Australia implemented mandatory folic acid fortification of bread-making flour in 2009. Objective: To assess the impact of folic acid fortification in remote vs. regional urban areas and Indigenous vs. non-Indigenous populations in northern Queensland. Methods: Routinely collected data on folic acid measurements in remote areas and two regional urban centres in northern Queensland between 2004 and 2015 were analysed (n = 13,929) dichotomously (folic deficient vs. non-deficient). Results: Overall prevalence of folic acid deficiency was 3.2% (235/7282) in urban centres compared with 7.2% (480/6647) in remote areas (p < 0.001), and 9.3% (393/4240) in the Indigenous population compared with 3.2% (273/8451) in the non-Indigenous population (p < 0.001). Prevalence of folic acid deficiency dropped from 12.2% (n = 481) in 2004-2008 to 1.5% (n = 126) in 2010-2015 (p < 0.001). This translates into a relative risk reduction (RRR) of 88%. RRR was 79% (7.2% vs. 1.5%) in urban centres, 91% (17.3% vs. 1.5%) in remote areas, 92% (20.5% vs. 1.6%) in the Indigenous population and 80% (7.4% vs. 1.5%) in the non-Indigenous population (p < 0.001 for all). Conclusions: Substantial declines of folic acid deficiency to low and comparable proportions in former high-risk populations indicate that mandatory folic acid fortification of flour has had a population-wide benefit in northern Queensland.

Impact of social disadvantages in the presence of diabetes at old age

Background

Social disadvantages that start during childhood and continue into the later stages in life may be linked to the presence of diabetes during adulthood. Objective. To analyze whether the presence of social disadvantages in childhood and in the present affects the presence of diabetes in older adults.

Methods

The present study was based on longitudinal data from the third and fourth Mexican Health and Aging Study (MHAS) waves (2012 and 2015). Data on diabetes diagnosis, past (e.g. “no shoes during childhood”) and present (e.g. self-perception of economic status) social disparities, and other covariables were analyzed.

Results

From 8,848 older adults, 21.5% (n = 1903) were classified as prevalent cases (PG), 5.2% (n = 459) as incident cases (IG) and 77.4% (n = 6,486) were free of disease (NDG). The predictor variable “no shoes during childhood” was statistically significant in the model incident versus no diabetes group. Hypertension and body mass index (BMI) were the most relevant covariates as they were statistically significant in the three groups (PG, IG and NDG).

Conclusions

Not having shoes during childhood, an indicator of social disadvantages, is associated with the incidence and prevalence of diabetes in older adults. This suggests that social disadvantages can be a determinant for the presence of chronic diseases in adulthood.

Socioeconomic Inequalities in the Retail Food Environment around Schools in a Southern European Context

Across Europe, excess body weight rates are particularly high among children and adolescents living in Southern European contexts. In Spain, current food policies appeal to voluntary self-regulation of the food industry and parents’ responsibility. However, there is no research (within Spain) assessing the food environment surrounding schools. We examined the association between neighborhood-level socioeconomic status (NSES) and the spatial access to an unhealthy food environment around schools using both counts and distance measures, across the city of Madrid. We conducted a cross-sectional study citywide (n = 2443 census tracts). In 2017, we identified all schools (n = 1321) and all food retailers offering unhealthy food and beverages surrounding them (n = 6530) using publicly available data. We examined both the counts of retailers (within 400 m) and the distance (in meters) from the schools to the closest retailer. We used multilevel regressions to model the association of neighborhood-level socioeconomic status (NSES) with both measures, adjusting both models for population density. Almost all schools (95%) were surrounded by unhealthy retailers within 400 m (median = 17 retailers; interquartile range = 8–34). After adjusting for population density, NSES remained inversely associated with unhealthy food availability. Schools located in low-NSES areas (two lowest quintiles) showed, on average, 29% (IRR (Incidence Rate Ratio) = 1.29; 95% CI (Confidence Interval) = 1.12, 1.50) and 62% (IRR = 1.62; 95% CI = 1.35, 1.95) more counts of unhealthy retailers compared with schools in middle-NSES areas (ref.). Schools in high-NSES areas were farther from unhealthy food sources than those schools located in middle-NSES areas (β = 0.35; 95% CI = 0.14, 0.47). Regulating the school food environment (within and beyond school boundaries) may be a promising direction to prevent and reduce childhood obesity.

A multilevel study of neighborhood disadvantage, individual socioeconomic position, and body mass index: Exploring cross-level interaction effects

This study examined associations between neighborhood disadvantage and body mass index (BMI), and tested whether this differed by level of individual socioeconomic position (SEP). Data were from 9953 residents living in 200 neighborhoods in Brisbane, Australia in 2007. Multilevel linear regression analyses were undertaken by gender to determine associations between neighborhood disadvantage, individual SEP (education, occupation and household income) and BMI (from self-reported height and weight); with cross-level interactions testing whether the relationship between neighborhood disadvantage and BMI differed by level of individual SEP. Both men (Quintile 4, where Quintile 5 is the most disadvantaged β = 0.66 95%CI 0.20, 1.12) and women (Quintile 5 β = 1.32 95%CI 0.76, 1.87) from more disadvantaged neighborhoods had a higher BMI. BMI was significantly higher for those with lower educational attainment (men β = 0.71 95%CI 0.36, 1.07 and women β = 1.66 95%CI 0.78, 1.54), and significantly lower for those in blue collar occupations (men β = -0.67 95%CI -1.09, -0.25 and women β = -0.71 95%CI -1.40, -0.01). Among men, those with a lower income had a significantly lower BMI, while the opposite was found among women. None of the interaction models had a significantly better fit than the random intercept models. The relationship between neighborhood disadvantage and BMI did not differ by level of education, occupation, or household income. This suggests that individual SEP is unlikely to be an effector modifier of the relationship between neighborhood disadvantage and BMI. Further research is required to assist policy-makers to make more informed decisions about where to intervene to counteract BMI-inequalities.

Development of an intervention program to prevent childhood obesity targeted to Mexican mothers of school-aged children using intervention mapping and social cognitive theory

In Mexico, data from the last National Health and Nutrition Survey (2016) described the increase in the prevalence of overweight and obesity in school-aged children (33.2%). Obesity prevention strategies have not been effective, and currently, Mexico has one of the highest prevalence of childhood obesity. Thus, there is an urgent need to develop strategies that can prevent childhood obesity and also to avoid these children to remain overweight/obese through adulthood. The objective of this study was to provide a step-by-step description of the design, implementation and evaluation of an intervention plan for Mexican mothers of school aged children to promote healthy eating and to prevent childhood obesity. The program Niño Sano Adulto Sano was developed using the Intervention Mapping Approach and the Social Cognitive Theory frameworks to provide Mexican mothers with knowledge and skills to positively modify their children's food behavior, thus preventing future weight gain. The program was developed, piloted and delivered to the target population with positive results on the mothers' nutrition knowledge and children's BMI. Intervention Mapping and Social Cognitive Theory are useful models to design and deliver an intervention that provides a holistic approach to promote healthy eating.

The evolution of local food environments within established neighbourhoods and new developments in Perth, Western Australia

Temporal changes in the location of food outlets can result in disparities in the availability and access of food across geographic areas, contributing to health inequalities. This study used mixed linear models to investigate how the location of food outlets around the home evolved over time with respect to area-level socio-economic status (SES) and urban design within established neighbourhoods and new residential developments. Food outlet data (supermarket/greengrocers, convenience stores, café restaurants and takeaway/fast food) were sourced from commercial database listings (SENSIS Pty. Ltd.) in 2004, 2006, 2007, and 2011. Using 2468 addresses from the RESIDential Environments Project (RESIDE), in Perth, Western Australia (WA), a count of each food outlet type and percentage of healthy food outlets within a 1.6 km road network buffer around the home, along with the road network distance to nearest food outlet were generated relative to each address at each time point. Proximity to and count of all food outlets increased over time in both new developments and established neighbourhoods. However, unhealthy food outlets were always in greater numbers and proximity to the home. The percentage of healthy food outlets was significantly greater in established neighbourhoods compared to new developments at all four time points. There were significantly more food outlets, and within closer proximity to the home, in established neighbourhoods compared to new developments at each time point. In established neighbourhoods, there were more convenience stores, takeaway/fast food and café restaurants, a lower percentage of healthy food outlets, and closer proximity to convenience stores in lower compared to high SES areas. In new developments there were significantly less supermarket/greengrocers, a lower percentage of healthy food outlets and greater proximity to takeaway/fast food and café restaurants in low compared to high SES areas. New developments designed according to the WA government's "Liveable Neighbourhoods Community Design Guidelines" policy had significantly more of all food outlets compared to other new developments. As such, people living in new developments, and low SES areas of Perth, may be disadvantaged with poorer access to healthy food outlets and greater exposure to unhealthy food outlets. Future urban planning and policy should focus on providing incentives that support the early development of supermarkets and healthy food outlets within new developments and low SES areas of Perth.

Data Collection Instruments for Obesogenic Environments in Adults: A Scoping Review

The rise in obesity prevalence has increased research interest in the obesogenic environment and its influence on excess weight. The aim of the present study was to review and map data collection instruments for obesogenic environments in adults in order to provide an overview of the existing evidence and enable comparisons. Through the scoping review method, different databases and webpages were searched between January 1997 and May 2018. Instruments were included if they targeted adults. The documents were categorised as food environment or built environment. In terms of results, 92 instruments were found: 46 instruments measuring the food environment, 42 measuring the built environment, and 4 that characterised both environments. Numerous diverse instruments have been developed to characterise the obesogenic environment, and some of them have been developed based on existing ones; however, most of them have not been validated and there is very little similarity between them, hindering comparison of the results obtained. In addition, most of them were developed and used in the United States and were written in English. In conclusion, there is a need for a robust instrument, improving or combining existing ones, for use within and across countries, and more sophisticated study designs where the environment is contemplated in an interdisciplinary approach.

Assessing Support for Advantaged and Disadvantaged Groups: A Comparison of Urban Food Environments

Individuals from lower-socio-economic status (SES) communities have increased risk of developing obesity in developed countries such as Australia. Given the influence of the environment on dietary behaviour, this paper seeks to examine food environments in areas of differing social advantage. An established measurement tool (the NEMS-Nutrition Environment Measurement Survey), that captures aspects of support for healthy eating within restaurants (NEMS-R) and grocery/convenience stores (NEMS-S), was applied to both a high-SES and a low-SES suburb within Brisbane, Australia. The study found a significantly more supportive restaurant food environment in the high-SES suburb, with greater access to and availability of healthful foods, as well as facilitators for, reduced barriers to, and substantially more nutrition information for healthful eating. A higher number of outlets were found in the high-SES suburb, and later opening times were also observed. Overall, the results from stores (NEMS-S) suggest poor support for healthful eating across both suburbs. This study highlights how food environments in low-SES regions continue to be less supportive of healthful eating. Public health strategies must move beyond individual-focused strategies to ensure that our most disadvantaged, low-SES communities have an equal opportunity to access healthful foods.

A qualitative study of the drivers of socioeconomic inequalities in men's eating behaviours

Background

Men of low socioeconomic position (SEP) are less likely than those of higher SEP to consume fruits and vegetables, and more likely to eat processed discretionary foods. Education level is a widely used marker of SEP. Few studies have explored determinants of socioeconomic inequalities in men’s eating behaviours. The present study aimed to explore intrapersonal, social and environmental factors potentially contributing to educational inequalities in men’s eating behaviour.

Methods

Thirty Australian men aged 18–60 years (15 each with tertiary or non-tertiary education) from two large metropolitan sites (Melbourne, Victoria; and Newcastle, New South Wales) participated in qualitative, semi-structured, one-on-one telephone interviews about their perceptions of influences on their and other men’s eating behaviours. The social ecological model informed interview question development, and data were examined using abductive thematic analysis.

Results

Themes equally salient across tertiary and non-tertiary educated groups included attitudes about masculinity; nutrition knowledge and awareness; ‘moralising’ consumption of certain foods; the influence of children on eating; availability of healthy foods; convenience; and the interplay between cost, convenience, taste and healthfulness when choosing foods. More prominent influences among tertiary educated men included using advanced cooking skills but having relatively infrequent involvement in other food-related tasks; the influence of partner/spouse support on eating; access to healthy food; and cost. More predominant influences among non-tertiary educated men included having fewer cooking skills but frequent involvement in food-related tasks; identifying that ‘no-one’ influenced their diet; having mobile worksites; and adhering to food budgets.

Conclusions

This study identified key similarities and differences in perceived influences on eating behaviours among men with lower and higher education levels. Further research is needed to determine the extent to which such influences explain socioeconomic variations in men’s dietary intakes, and to identify feasible strategies that might support healthy eating among men in different socioeconomic groups.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6162-6) contains supplementary material, which is available to authorized users.

Extending the paradigm: a policy framework for healthy and equitable eating (HE2)

OBJECTIVE

The current short communication aimed to provide a new conceptualisation of the policy drivers of inequities in healthy eating and to make a call to action to begin populating this framework with evidence of actions that can be taken to reduce the inequities in healthy eating.

DESIGN

The Healthy and Equitable Eating (HE2) Framework derives from a systems-based analytical approach involving expert workshops.

SETTING

Australia.

SUBJECTS

Academics, government officials and non-government organisations in Australia.

RESULTS

The HE2 Framework extends previous conceptualisations of policy responses to healthy eating to include the social determinants of healthy eating and its social distribution, encompassing policy areas including housing, social protection, employment, education, transport, urban planning, plus the food system and environment.

CONCLUSIONS

As the burden of non-communicable diseases continues to grow globally, it is important that governments, practitioners and researchers focus attention on the development and implementation of policies beyond the food system and environment that can address the social determinants of inequities in healthy eating.

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.

What is known about consumer nutrition environments in Australia? A scoping review of the literature

OBJECTIVE

Food environments can influence food selection and hold the potential to reduce obesity, non-communicable diseases and their inequalities. 'Consumer nutrition environments' describe what consumers encounter within a food retail outlet, including products, price, promotion and placement. This study aimed to summarize the attributes that have been examined in existing peer-reviewed studies of Australian consumer nutrition environments, identify knowledge gaps and provide recommendations for future research.

METHODS

A systematic search of peer-reviewed literature was conducted. Sixty-six studies that assessed an aspect of within-store consumer nutrition environments were included.

RESULTS

Most studies were published from 2011 onwards and were conducted in capital cities and in supermarkets. Studies assessed the domains of product (40/66), price (26/66), promotion (16/66) and placement (6/66). The most common research themes identified were assessment of the impact of area socioeconomic status (13/66), remoteness (9/66) and food outlet type (7/66) on healthy food prices; change in price of healthy foods (6/66); variety of healthy foods (5/66); and prevalence of unhealthy child-orientated products (5/66).

CONCLUSIONS

This scoping review identified a large number of knowledge gaps. Recommended priorities for researchers are as follows: (1) develop consistent observational methodology, (2) consider consumer nutrition environments in rural and remote communities, (3) develop an understanding of food service outlets, (4) build on existing evidence in all four domains of product, price, placement and promotion and (5) determine effective policy and store-based interventions to increase healthy food selection.

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.

Food environments and dietary intakes among adults: does the type of spatial exposure measurement matter? A systematic review

BACKGROUND

The relationships between food environments and dietary intake have been assessed via a range of methodologically diverse measures of spatial exposure to food outlets, resulting in a largely inconclusive body of evidence, limiting informed policy intervention.

OBJECTIVE

This systematic review aims to evaluate the influence of methodological choice on study outcomes by examining the within-study effect of availability (e.g., counts) versus accessibility (e.g., proximity) spatial exposure measures on associations with diet.

METHODS

(PROSPERO registration: CRD42018085250). PubMed, Web of Science, Scopus and ScienceDirect databases were searched for empirical studies from 1980 to 2017, in the English language, involving adults and reporting on the statistical association between a dietary outcome and spatial exposure measures of both availability and accessibility. Studies were appraised using an eight-point quality criteria with a narrative synthesis of results.

RESULTS

A total of 205 associations and 44 relationships (i.e., multiple measures of spatial exposure relating to a particular food outlet type and dietary outcome) were extracted from 14 eligible articles. Comparative measures were dominated by counts (availability) and proximity (accessibility). Few studies compared more complex measures and all counts were derived from place-based measures of exposure. Sixteen of the 44 relationships had a significant effect involving an availability measure whilst only 8 had a significant effect from an accessibility measure. The largest effect sizes in relationships were mostly for availability measures. After stratification by scale, availability measure had the greatest effect size in 139 of the 176 pairwise comparisons. Of the 33% (68/205) of associations that reached significance, 53/68 (78%) were from availability measures. There was no relationship between study quality and reported study outcomes.

CONCLUSIONS

The limited evidence suggests that availability measures may produce significant and greater effect sizes than accessibility measures. However, both availability and accessibility measures may be important concepts of spatial exposure depending on the food outlet type and dietary outcome examined. More studies reporting on multi-method effects are required to differentiate findings by the type of spatial exposure assessment and build an evidence base regarding the appropriateness and robustness of measures under different circumstances.

Associations of Food Addiction in a Sample Recruited to Be Nationally Representative of the United States

The current study investigated the prevalence of food addiction and its associations with obesity and demographic factors in a sample recruited to be more nationally representative of the United States than previous research. Individuals (n = 1050) were recruited through Qualtrics' qBus, which sets demographic quotas developed using the United States census reference population. Participants (n = 986) self-reported food addiction, measured by the modified Yale Food Addiction Scale 2.0, height, weight, age, gender, race and income. Food addiction was observed in 15% of participants, with greater prevalence in individuals who were younger, Hispanic and/or reported higher annual income. Food addiction prevalence was higher in persons who were underweight or obese, relative to normal weight or overweight. Food addiction was associated with higher body mass index in women and persons who were older, White and/or reported lower income. Identifying the scope of food addiction and individual risk groups may inform public policy initiatives and early intervention efforts. Copyright © 2017 John Wiley & Sons, Ltd and Eating Disorders Association.

Does the edge effect impact on the measure of spatial accessibility to healthcare providers?

BACKGROUND

Spatial accessibility indices are increasingly applied when investigating inequalities in health. Although most studies are making mentions of potential errors caused by the edge effect, many acknowledge having neglected to consider this concern by establishing spatial analyses within a finite region, settling for hypothesizing that accessibility to facilities will be under-reported. Our study seeks to assess the effect of edge on the accuracy of defining healthcare provider access by comparing healthcare provider accessibility accounting or not for the edge effect, in a real-world application.

METHODS

This study was carried out in the department of Nord, France. The statistical unit we use is the French census block known as 'IRIS' (Ilot Regroupé pour l'Information Statistique), defined by the National Institute of Statistics and Economic Studies. The geographical accessibility indicator used is the "Index of Spatial Accessibility" (ISA), based on the E2SFCA algorithm. We calculated ISA for the pregnant women population by selecting three types of healthcare providers: general practitioners, gynecologists and midwives. We compared ISA variation when accounting or not edge effect in urban and rural zones. The GIS method was then employed to determine global and local autocorrelation. Lastly, we compared the relationship between socioeconomic distress index and ISA, when accounting or not for the edge effect, to fully evaluate its impact.

RESULTS

The results revealed that on average ISA when offer and demand beyond the boundary were included is slightly below ISA when not accounting for the edge effect, and we found that the IRIS value was more likely to deteriorate than improve. Moreover, edge effect impact can vary widely by health provider type. There is greater variability within the rural IRIS group than within the urban IRIS group. We found a positive correlation between socioeconomic distress variables and composite ISA. Spatial analysis results (such as Moran's spatial autocorrelation index and local indicators of spatial autocorrelation) are not really impacted.

CONCLUSION

Our research has revealed minor accessibility variation when edge effect has been considered in a French context. No general statement can be set up because intensity of impact varies according to healthcare provider type, territorial organization and methodology used to measure the accessibility to healthcare. Additional researches are required in order to distinguish what findings are specific to a territory and others common to different countries. It constitute a promising direction to determine more precisely healthcare shortage areas and then to fight against social health inequalities.

Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position: A Retrospective Cohort Study

BACKGROUND

Inequality in health outcomes in relation to Americans' socioeconomic position is rising.

OBJECTIVE

First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)-related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates.

DESIGN

Observational cohort analysis of geocoded longitudinal electronic health records.

SETTING

A single academic health center and surrounding neighborhoods in northeastern Ohio.

PATIENTS

109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline.

MEASUREMENTS

Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward).

RESULTS

The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract-level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM.

LIMITATIONS

Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood.

CONCLUSION

Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.

PRIMARY FUNDING SOURCE

The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.

Supermarket access, transport mode and BMI: the potential for urban design and planning policy across socio-economic areas

OBJECTIVE

To investigate dietary intake, BMI and supermarket access at varying geographic scales and transport modes across areas of socio-economic disadvantage, and to evaluate the implementation of an urban planning policy that provides guidance on spatial access to supermarkets.

DESIGN

Cross-sectional study used generalised estimating equations to investigate associations between supermarket density and proximity, vegetable and fruit intake and BMI at five geographic scales representing distances people travel to purchase food by varying transport modes. A stratified analysis by area-level disadvantage was conducted to detect optimal distances to supermarkets across socio-economic areas. Spatial distribution of supermarket and transport access was analysed using a geographic information system.

SETTING

Melbourne, Australia.

SUBJECTS

Adults (n 3128) from twelve local government areas (LGA) across Melbourne.

RESULTS

Supermarket access was protective of BMI for participants in high disadvantaged areas within 800 m (P=0·040) and 1000 m (P=0·032) road network buffers around the household but not for participants in less disadvantaged areas. In urban growth area LGA, only 26 % of dwellings were within 1 km of a supermarket, far less than 80-90 % of dwellings suggested in the local urban planning policy. Low public transport access compounded disadvantage.

CONCLUSIONS

Rapid urbanisation is a global health challenge linked to increases in dietary risk factors and BMI. Our findings highlight the importance of identifying the most appropriate geographic scale to inform urban planning policy for optimal health outcomes across socio-economic strata. Urban planning policy implementation in disadvantaged areas within cities has potential for reducing health inequities.

Investigating the Spatial Dimension of Food Access

The purpose of this article is to investigate the sensitivity of food access models to a dataset’s spatial distribution and the empirical definition of food access, which contributes to understanding the mixed findings of previous studies. Data was collected in the Dan River Region in the United States using a telephone survey for individual-level variables (n = 784) and a store audit for the location of food retailers and grocery store quality. Spatial scanning statistics assessed the spatial distribution of obesity and detected a cluster of grocery stores overlapping with a cluster of obesity centered on a grocery store suggesting that living closer to a grocery store increased the likelihood of obesity. Logistic regression further examined this relationship while controlling for demographic and other food environment variables. Similar to the cluster analysis results, increased distance to a grocery store significantly decreased the likelihood of obesity in the urban subsample (average marginal effects, AME = −0.09, p-value = 0.02). However, controlling for grocery store quality nullified these results (AME = −0.12, p-value = 0.354). Our findings suggest that measuring grocery store accessibility as the distance to the nearest grocery store captures variability in the spatial distribution of the health outcome of interest that may not reflect a causal relationship between the food environment and health.

Socioeconomic differences in the cost, availability and quality of healthy food in Sydney

OBJECTIVE

To compare the cost of a basket of staple foods, together with the availability and quality of fresh fruit and vegetables, by supermarket store type in high and low socioeconomic suburbs of Sydney.

METHODS

A food basket survey was undertaken in 100 supermarkets in the 20 highest and 20 lowest socioeconomic suburbs of Sydney. We assessed the cost of 46 foods, the range of 30 fresh fruit and vegetables and the quality of ten fresh fruit and vegetables. Two major supermarket retailers, a discount supermarket chain and independent grocery stores were surveyed.

RESULTS

The food basket was significantly cheaper in low compared to high socioeconomic suburbs ($177 vs $189, p<0.01). Discount supermarkets were at least 30% cheaper than other supermarket stores. There were fewer varieties and poorer quality fruit and vegetables in stores in low socioeconomic suburbs.

CONCLUSIONS

Food basket prices and the availability and quality of fruit and vegetables varied significantly by store type and socioeconomic status of suburb. Implications for public health: A nationwide food and nutrition surveillance system is required to inform public health policy and practice initiatives. In addition to the food retail environment, these initiatives must address the underlying contributors to inequity and food insecurity for disadvantaged groups.

Longitudinal Associations Between Observed and Perceived Neighborhood Food Availability and Body Mass Index in a Multiethnic Urban Sample

INTRODUCTION

Blacks, Hispanics, and women of lower socioeconomic status tend to have a higher risk of obesity. Numerous studies over the past decade examined the role of the neighborhood food environment in body weight. However, few were longitudinal.

PURPOSE

This longitudinal study examined whether multiple measures of neighborhood food availability were associated with body mass index (BMI) in a predominately Black and Hispanic adult sample living in low- to moderate-income urban neighborhoods.

METHOD

This longitudinal study used two waves of data (2002, 2008), including interviewer-measured height and weight, from a community survey of adults ( n = 219). In both 2002 and 2008, multiple measures characterized neighborhood food availability: GIS-derived availability of retail food outlets (large grocery store, small grocery store, convenience store, liquor stores), observed fruit and vegetable availability (count of stores selling 10 or more fresh fruit or vegetable varieties), and perceived fruit and vegetable access. Random intercept models estimated multivariable associations, controlling for individual-level demographics and neighborhood median household income.

RESULTS

Small grocery store availability was associated with 1.22-unit increase in BMI ( p = .047), while each unit increase in perceived fruit and vegetable access was associated with a 0.69-unit decrease in BMI ( p = .055). BMI was not associated with large grocery store, convenience store, or liquor store availability, or with observed fruit and vegetable availability.

CONCLUSIONS

Findings suggest that improving the neighborhood food environment, particularly at small grocery stores, may help urban residents living in low- to moderate-income neighborhoods achieve healthier body weights over time.

Measures of the food environment: A systematic review of the field, 2007-2015

BACKGROUND

Many studies have examined the relationship between the food environment and health-related outcomes, but fewer consider the integrity of measures used to assess the food environment. The present review builds on and makes comparisons with a previous review examining food environment measures and expands the previous review to include a more in depth examination of reliability and validity of measures and study designs employed.

METHODS

We conducted a systematic review of studies measuring the food environment published between 2007 and 2015. We identified these articles through: PubMed, Embase, Web of Science, PsycINFO, and Global Health databases; tables of contents of relevant journals; and the National Cancer Institute's Measures of the Food Environment website. This search yielded 11,928 citations. We retained and abstracted data from 432 studies.

RESULTS

The most common methodology used to study the food environment was geographic analysis (65% of articles) and the domination of this methodology has persisted since the last review. Only 25.9% of studies in this review reported the reliability of measures and 28.2% reported validity, but this was an improvement as compared to the earlier review. Very few of the studies reported construct validity. Studies reporting measures of the school or worksite environment have decreased since the previous review. Only 13.9% of the studies used a longitudinal design.

CONCLUSIONS

To strengthen research examining the relationship between the food environment and population health, there is a need for robust and psychometrically-sound measures and more sophisticated study designs.