INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles

Addressing nutritional issues and eating behaviours among university students: a narrative review

University life is a critical period for establishing healthy eating habits and attitudes. However, university students are at risk of developing poor eating habits due to various factors, including economic conditions, academic stress and lack of information about nutritional concepts. Poor diet quality leads to malnutrition or overnutrition, increasing the risk of preventable diseases. Food environments on university campuses also play a significant role in shaping the dietary habits of students, with the availability of and accessibility to healthy food options being important factors influencing food choices and overall diet quality. Disordered eating habits and body dissatisfaction are prevalent among university students and can lead to eating disorders. Income and living arrangements also influence dietary habits, with low household income and living alone being associated with unhealthy eating habits. This study is a narrative review that aimed to address nutritional issues and eating behaviours, specifically among university students. We investigated the eating behaviours of university students, including their dietary patterns, food choices and food environments. The objective of this review was to provide insights into the nutritional issues and eating behaviours of university students, with the aim of identifying target areas for intervention to improve the overall health and wellbeing among college students. University food environments need to be restructured to promote healthy eating, including the availability, accessibility, affordability and labelling of healthy foods, and policies to limit the availability of unhealthy foods and drinks on campus.

Is a voluntary healthy food policy effective? evaluating effects on foods and drinks for sale in hospitals and resulting policy changes

BACKGROUND

Healthy food and drink guidelines for public sector settings can improve the healthiness of food environments. This study aimed to assess the implementation and impact of the voluntary National Healthy Food and Drink Policy (the Policy) introduced in New Zealand in 2016 to encourage provision of healthier food and drink options for staff and visitors at healthcare facilities.

METHODS

A customised digital audit tool was used to collate data on foods and drinks available for sale in healthcare organisations and to systematically classify items as green ('healthy'), amber ('less healthy'), or red ('unhealthy') according to Policy criteria. On-site audits were undertaken between March 2021 and June 2022 at 19 District Health Boards (organisations responsible for providing public health services) and one central government agency. Forty-three sites were audited, encompassing 229 retail settings (serviced food outlets and vending machines). In total, 8485 foods/drinks were classified according to Policy criteria. The primary outcome was alignment with Policy guidance on the availability of green, amber, and red category food/drink items (≥ 55% green and 0% red items). Secondary outcomes were proportions of green, amber, and red category items, promotional practices, and price. Chi-square tests were used to compare results between categorical variables.

RESULTS

No organisation met the criteria for alignment with the Policy. Across all sites, 38.9% of food/drink items were rated red (not permitted), 39.0% were amber, and 22.1% were green. Organisations that adopted the voluntary Policy offered more healthy foods/drinks than those with their own organisational policy, but the proportion of red items remained high: 32.3% versus 47.5% (p < 0.0001). About one-fifth (21.3%) of all items were promoted, with red (24.6%) and amber (22.2%) items significantly more likely to be promoted than green items (14.0%) (p < 0.001). Green items were also significantly more costly on average (NZ$6.00) than either red (NZ$4.00) or amber (NZ$4.70) items (p < 0.0001).

CONCLUSIONS

Comprehensive and systematic evaluation showed that a voluntary Policy was not effective in ensuring provision of healthier food/drink options in New Zealand hospitals. The adoption of a single, mandatory Policy, accompanied by dedicated support and regular evaluations, could better support Policy implementation.

Understanding the underlying systems dynamics contributing to the continued predominance of the unhealthy motorway food environment in the Netherlands: identifying leverage points and actions for change

BACKGROUND

Motorway food environments are dominated by roadside restaurants and petrol station stores offering predominantly unhealthy quick-service meals and foods for on-the-go consumption. Improving these environments to promote healthier diets is necessary, but how to achieve this is not fully understood. Therefore, this study aims to identify the complex underlying systems dynamics contributing to the continued predominance of the unhealthy motorway food environment as well as to identify potential leverage points and corresponding actions for change to improve the healthiness of the motorway food environment.

METHODS

Two Group Model Building workshops were held in October 2023 with motorway food environment stakeholders (e.g. food providers, producers, national policymakers, truck drivers). In the first workshop, a Causal Loop Diagram (CLD) was created to identify the system that contributes to the continued predominance of the unhealthy motorway food environment. The research team then identified leverage points for change based on the CLD. During the second workshop, stakeholders formulated actions to improve the motorway food environment for each identified leverage point. Leverage points and actions were classified based on the Action Scales Model (ASM).

RESULTS

The resulting CLD comprised six interconnected subsystems (food providers, supply chain collaboration, government, social culture, road users, global trends) with six reinforcing feedback loops, underlying the continued predominance of the unhealthy motorway food environment. Additionally, 14 potential leverage points and 31 corresponding actions for change were identified at different levels of the system based on the ASM (i.e. events, structures, goals and beliefs).

CONCLUSIONS

The findings show many interrelated factors and mechanisms underlying the continued predominance of the unhealthy motorway food environment. Actions for change were proposed together with stakeholders aimed at leverage points at different system levels. The results show that the motorway food environment is shaped by broader societal goals and beliefs (e.g. the profitability of unhealthy products) and social-cultural beliefs particularly evident to the on-the-go setting, including the motorway food environment. Together they present the strongest potential for leveraging systems change. There is a need for a coherent multidimensional action plan targeting these leverage points, which is broadly supported by various stakeholders, to induce systemic change.

The Food Environment Toolbox: Developing and Piloting a Suite of Tools to Measure Food Environments in Low- and Middle-Income Countries

Background

Measuring food environments in low- and middle-income countries (LMICs) can inform and support the design of interventions aimed at improving diets and reducing malnutrition in all its forms. Most food environment measurement tools have been developed for high-income countries, however, and do not sufficiently capture the diverse and dynamic food environments in LMICs.

Objectives

The objective of this study was to develop, modify, implement, and refine a suite of tools to measure the different dimensions of diverse food environments in LMICs.

Methods

Through an iterative process, we: 1) identified the food environment dimensions to be measured; 2) identified existing tools using literature searches; 3) modified and developed tools based on feedback from team members of study settings, an expert advisory board, and workshops with key food environment experts in India and Cambodia; 4) implemented the tools by piloting the suite in rural, peri-urban, and urban settings in India and Cambodia; and 5) finalized tools based on feedback from experts and our tool piloting implementation and analysis experience.

Results

Overall, we included 7 tools in the finalized Toolbox (Participatory Mapping, Seasonal Food Availability Calendar, Food Environment Perceptions Survey, Community Food Environment Mapping, Market Mapping, In-depth Vendor Assessment, and a Cost of a Healthy Diet data collection protocol), all of which were rated positively by workshop participants. On the basis of piloting experiences, the tools were relatively easy to implement in the field. Apart from the Seasonal Food Availability Calendar being better suited to rural or peri-urban settings and the In-depth Vendor Assessment being less suitable for large formal supermarkets, we found that the tools were feasible and useful across pilot settings in India and Cambodia.

Conclusions

The suite of tools included in the Food Environment Toolbox can be used to measure diverse food environments in LMICs, with minimal anticipated adaptations across contexts.

Voicing residents' perception of (commercial) food cues in outdoor public spaces: a photovoice study

BACKGROUND

(Commercial) food cues in outdoor public spaces are environmental drivers of unhealthy diets. This study aimed to explore residents' perceptions of food cues in outdoor public spaces in relation to their perceived food environment, eating behaviour, and their opinion on governmental outdoor food cue regulations.

METHODS

A photovoice study, consisting of a photography assignment followed by semi-structured interviews, was conducted among 15 adult residents of the municipality of Wageningen, the Netherlands. Participants had one week to take photographs of outdoor food cues they encountered in their municipality, using a mobile app "myfoodenvironment", that were central to the interview afterwards.

RESULTS

Participants mainly noticed unhealthy food cues, which they viewed as constant 'reminders' that unhealthy food was easily accessible and affordable. Their views varied on the extent to which food cues affected their own eating behaviour, but generally believed that food cues affected that of others. Participants identified several factors that amplify outdoor food cues' influence on eating behaviour, including hunger, fatigue and attractiveness of the cues. The findings revealed support for government regulation of food cues, while acknowledging the complexity of this issue and the diverse perspectives on how such regulations should be designed (e.g., where, for whom), with one notable counterargument being concerns about feeling patronized by such policies.

CONCLUSIONS

Current findings may inform health professionals and (local) policy makers about the unhealthy food cues encountered by residents in outdoor public spaces, which unconsciously influence their eating behaviour, while also providing insights into designing food cue regulations that attract policy support by balancing public health goals with considerations of consumer autonomy and citizen preferences.

Perception of the Food Environment and Food Security Levels of Residents of the City of Rio de Janeiro

The way individuals perceive and interact with the food environment can contribute to a higher prevalence of food insecurity (FI).

OBJECTIVE

To evaluate the perception of the food environment and its association with FI in households in the city of Rio de Janeiro, Brazil.

METHODS

Cross-sectional study. The survey was conducted with a sample of 2000 households, a representative stratified sample, with a margin of error of 4.9 percentage points and a 95% confidence interval (CI95%) in the city of Rio de Janeiro. The studies were evaluated using the Brazilian Food Insecurity Scale (EBIA). Perceptions of the food environment were measured by assessing the perceived availability, price, and quality of fruits and vegetables (FVs) and ultra-processed foods (UPFs) sold in the neighborhood. To analyze the association between stage variations and the perceived food environment, we conducted multinomial logistic regression, considering a 95%CI.

RESULTS

Household heads in Rio de Janeiro perceive that both FVs and UPFs are available in their neighborhoods. However, UPFs are perceived as cheaper and more diverse than FVs, regardless of the level of food safety. In the association analysis, a greater relative risk ratio was found for heads of households who perceive an unfavorable scenario in the food environment for FVs, in terms of availability (RRR = 5.6; 95%IC: 3.0-10.4), quality (RRR = 4.5; 95%IC: 2.6-7.9), and price (RRR = 2.5; 95%IC: 1.7-3.6), to experience a situation of moderate/severe FI.

CONCLUSIONS

The way individuals interact with and perceive their territories can reflect on access to adequate and healthy food, especially in households in a situation of FI.

Changes in the healthfulness of food and beverage purchases from 2006 to 2022 by outlet type in Mexico

BACKGROUND

To better inform retail food environment policies in the global south, it is necessary to further understand the healthfulness of food and beverages purchased by type of food outlet over time.

METHODS

Using repeated cross-sectional data from the National Income and Expenditure Survey (ENIGH) in Mexico (2006 to 2022), we estimate the percentage of food and beverage purchases by processing level for each food outlet for the overall population and stratify by education (proxy of socioeconomic status) and urbanicity levels.

RESULTS

In 2006, the food outlets with the largest proportions of ultra-processed foods purchases were chain convenience stores (49%), small neighborhood stores (37%), and supermarkets (35%). In contrast, the outlets with the highest proportions of minimally processed food purchases were street markets (83%), public markets (81%), and specialty stores (75%). Over time, households increased the proportion of expenditure in minimally processed foods in supermarkets and slightly in small neighborhood stores (49 to 54% and 46 to 47%, respectively). Conversely, the proportion of expenditures in minimally processed foods decreased from 70 to 62% in street vendors. Households without formal education and residing in rural areas increased their minimally processed food purchases in specialty stores, but decreased in street vendors, acquaintances, and public markets. Households with higher education and residing in more urbanized areas increased their purchases of minimally processed foods in supermarkets and small neighborhood stores and decreased in street vendors. These households also increased their purchases in ultra-processed foods in chain convenience stores.

CONCLUSIONS

There is a wide range of food outlets in Mexico, each with varying levels of healthfulness. While purchases in supermarkets have become healthier, particularly among higher socioeconomic households and in larger cities, small neighborhood stores have also shown improvements, especially in lower-income households and smaller cities. Since no outlet exclusively sells healthy or unhealthy foods, policies should focus on where people make the majority of their purchases and address healthfulness variations based on education level education and urbanization.

Food purchasing places classification system based on the Dietary Guidelines for the Brazilian Population: Locais-Nova

OBJECTIVE

To propose a new classification system for food purchasing places (Locais-Nova) based on the Dietary Guidelines for the Brazilian Population.

METHODS

We used 2017-2018 Brazilian Household Budgets Survey data on household food purchasing. Foods were categorized, according to the Nova classification, into unprocessed or minimally processed food, processed culinary ingredients, processed foods and ultra-processed foods. We estimated the average share of each Nova classification group in the total of grams acquired in Brazil. This estimate was compared with the average share of each Nova classification group in each of the 16 purchasing places assessed. Places were classified as "purchasing sources" for a specific Nova classification group whenever that group's share a given place was equal to or greater than the national average.

RESULTS

Locais-Nova identified three categories of purchasing places: sources of unprocessed or minimally processed food and processed culinary ingredients, sources of processed foods and sources of ultra-processed foods. Fruits, vegetables, and farm products and butcher shops stood out as the main sources of unprocessed or minimally processed food; minimarkets and grocery stores were the main sources of ultra-processed foods; and bakeries and confectionaries, stood out as sources of processed and ultra-processed foods. Supermarkets were classified as sources of unprocessed or minimally processed food and ultra-processed foods.

CONCLUSION

This study presented an innovative classification of food purchasing places. This reflected the recommendations of the Dietary Guidelines for the Brazilian Population and made it possible to understand food purchasing patterns in different types of purchasing places.

A best practice guide for conducting healthy food retail research: A resource for researchers and health promotion practitioners

Retail food environments play a pivotal role in influencing dietary behaviors, and therefore have huge potential as settings for promoting good nutrition and preventing obesity. Conducting research in retail settings can be challenging due to the varied motivations of the parties involved and the complex nature of retail environments. To improve the quality and consistency of research in this field, we have identified 16 thematic topics aimed at guiding researchers and public health practitioners on how to conduct healthy food retail research. A summary for each topic, encompassing existing methodologies, best practice examples, and knowledge gaps, was developed based on available literature and the collective experience and expertise of 32 multidisciplinary researchers from a high-income perspective engaged in healthy food retail research in a diverse range of retail settings. A summary checklist describing key considerations at each stage of conducting healthy food retail research was also developed.

The role of the workplace food environment in eating behaviours of employees at small and medium-sized enterprises: a qualitative study in the Netherlands

BACKGROUND

Workplace food environments play a pivotal role in encouraging healthy and sustainable food choices. However, research on food environments in small and medium-sized enterprises (SMEs) without a workplace cafeteria is scarce, with much of the existing research concentrating on larger or specific types of companies. This qualitative study primarily aims to explore how employers and employees perceive the workplace food environment across different types of SMEs in the Netherlands, including desk-based, mobile workforce, and on-site manual labour settings. Second, it aims to gain insight into the perceived opportunities and barriers in SMEs to promote a healthy and sustainable diet.

METHODS

This qualitative study involved 27 interviews conducted between May 2021 and February 2022, engaging both employers and employees across different types of SMEs: 10 desk-based, 8 on-site manual labour, and 9 mobile workforce SMEs. The data was analysed via a hybrid coding process, including deductive coding based on themes included in the interview guide and allowing for further codes to emerge from the data inductively.

RESULTS

The results showed noticeable differences in the perceived workplace food environment between the three SME types. Although structural food offerings (such as those offered through a workplace cafeteria) were mostly lacking among all SMEs, most desk-based SMEs offered a daily facilitated lunch, whilst employees of mobile workforce SMEs typically received a daily allowance. However, similarities were also observed across the three SME types as there was a noticeable absence of financial incentives, or food policies regarding healthy and sustainable food. Barriers to promoting a healthy and sustainable diet among employees were that SMEs did not identify healthy and sustainable consumption at the workplace as their responsibility, or as a 'problem' that needed to be solved. Both employers and employees found it difficult to identify opportunities to promote healthy and sustainable diets in the workplace.

CONCLUSIONS

Across all three types of SMEs, both employers and employees described a food environment that was limited in actively encouraging healthy and sustainable food choices at the workplace. Future research should focus on developing tailored workplace policies and interventions addressing the unique food environment characteristics of different types of SMEs to improve employee eating behaviour.

Social determinants of health and type 2 diabetes in Asia

Type 2 diabetes mellitus (T2DM) is a major global public health challenge driven by a complex interplay of genetic, environmental, and social factors. This review highlights the effects of social determinants of health (SDOH) on T2DM in Asia, where rapid urbanization, worsening air pollution, and distinct socioeconomic structures uniquely influence disease outcomes. Key SDOH domains, socioeconomic status (education, income, and occupation), physical environment, food environment, healthcare access, and social context, were analyzed for their associations with T2DM prevalence, progression, and management. Among these, environmental and lifestyle shifts have emerged as particularly influential factors in Asia. Air pollution, particularly fine particulate matter, has been increasingly linked to insulin resistance and diabetes risk in Asian populations. Additionally, rapid urbanization and changing food environments contribute to rising T2DM incidence through shifts in lifestyle and dietary patterns. Across the diverse healthcare systems of Asian countries, primary care remains a universally critical component in addressing T2DM issues. Additionally, social capital and cohesion serve as protective factors, whereas social isolation heightens vulnerabilities. These insights underscore the importance of addressing SDOH in public health strategies to combat T2DM in Asia. Future research should prioritize longitudinal studies and culturally tailored interventions to reduce the region's diabetes burden.

The rural food environment and its association with diet, nutrition status, and health outcomes in low-income and middle-income countries (LMICs): a systematic review

BACKGROUND

The food environment consists of external and personal domains that shape food purchasing decisions. While research on food environments has grown rapidly within high-income countries (HICs) in response to increasing rates of overweight, obesity, and non-communicable diseases (NCDs), critical research gaps remain. The role of food environment on diet, health and nutrition has been understudied in LMICs. To date, there has not been a systematic review specifically focusing on rural LMICs. This systematic review aims to synthesize findings from studies examining the association between rural food environment domains and diet, nutrition and health in LMICs or effects of food environment interventions on these outcomes.

METHODS

Searches were conducted from 9 databases: Medline (PubMed), Embase (Ovid), Global Health (Ovid), PsycINFO (Ovid), EconLit (EBSCOhost), Web of Science (Social Science Citation Index), Scopus, CINAHL (EBSCOhost), and Applied Social Sciences Index and Abstracts (ProQuest) to identify studies published between 2000 and 2023 that reported associations between this/these dimensions with diets, nutrition or health outcomes. Both quantitative and qualitative studies that were published in English were included. Data extraction and quality appraisal was conducted independently by two authors, before the study findings were collated and summarized through a narrative data synthesis.

RESULTS

Nineteen eligible studies were identified from 9 databases covering 11 LMICs. The included studies employed quantitative (n = 12), mixed method (n = 6) and qualitative (n = 1) designs in the neighbourhood food environment. In this review, availability dimension of the external food environment featured most prominently, followed by accessibility, affordability, desirability, and convenience dimensions of the personal food environment. Food availability was positively associated with diet (n = 10), nutrition (n = 7) and health (n = 1). There was good evidence regarding associations between food accessibility, diet (n = 7) and nutrition (n = 3). We identified some evidence that food price and affordability (n = 8) were considered key barriers to achieving healthy diets. Desirability (n = 4) and convenience (n = 2) dimensions were also associated with dietary outcomes, although we found only a few studies. Only one South African qualitative study was identified which highlighted limited availability and accessibility to local supermarkets and surrounding informal fruit and vegetable vendors to be a barrier to expensive, healthy foods consumption. Finally, evidence regarding health outcomes, sustainability dimension, impacts of food environment interventions on relevant outcomes and interactions between food environment dimensions was missing. Overall, seven out of nineteen studies were rated as good quality, six were rated as fair and six were rated as poor.

CONCLUSIONS

Future interventions should consider improving availability and accessibility of nutritious foods to improve public health nutrition in rural LMICs. Evidence from studies assessing the workplace, home, and school food environments, food environment interventions, sustainability dimension and other key dimensions of the external food environment such as prices, vendor and product properties and marketing and regulation is needed to identify effective interventions to address malnutrition in all its forms characterized by the coexistence of undernutrition, overnutrition, undernutrition and diet-related non-communicable diseases (NCDs).

Product reformulation in non-alcoholic beverages and foods after the implementation of front-of-pack warning labels in Mexico

BACKGROUND

In late March 2020, the Mexican government announced an updated norm to include front-of-pack warning labels for packaged foods and non-alcoholic beverages. Warning labels came into effect in October 2020. To avoid displaying warning labels, producers can reformulate their products by reducing the content of calories or critical nutrients targeted by the policy (added sugars, saturated fat, and sodium) or removing non-caloric sweeteners or added caffeine. The objective of this study is to assess changes in the percentage of products above warning-label cutoffs for calories and critical nutrients and changes in the content of calories and critical nutrients associated with warning labels in Mexico.

METHODS AND FINDINGS

We used nutritional panel data collected by the Mexican National Institute of Public Health from ≈1,000 top-purchased products, which represented ≥60% of the market share for each of the included food groups according to household purchases in the Nielsen Consumer Panel commercial dataset for Mexico in 2016. Nutritional panel data is available for three periods: 2016-2017, T0 (pre-policy); Jul-Sep 2020, T1 (post-warning-label announcement); and Feb-Apr 2021, T2 (post-warning-label implementation). We assessed changes in T1 versus T0 (potential anticipatory reformulation before the warning-label implementation) and T2 versus T0 (reformulation after the warning-label implementation) by food group using generalized estimating equations for the percentage of products above warning-label cutoffs or containing non-caloric sweeteners or added caffeine, and fixed-effects linear models and quantile regressions for the content of calories and critical nutrients. Included food groups were cereal-based desserts, bread and other cereals, salty snacks, sweetened beverages, solid dairy, liquid dairy, instant food, and candies. At T0, the food group level with the lowest percentage of products with at least one calorie/nutrient content above warning-label cutoffs was instant food (77.8%); at T2, this fell to 52.6%. Based on our statistical models, we found that all food groups showed reductions in at least one type of warning label. The most common reductions in the percentage of products exceeding warning-label cutoffs were for sodium (up to -63.1 percentage points for bread and other cereals; 95% CI: -77.5, -48.6; p-value < 0.001), saturated fat (up to -26.3 percentage points for salty snacks; 95% CI: -35.8, -16.8; p-value < 0.001), and products containing non-caloric sweeteners (up to -29.0 percentage points for solid dairy; 95% CI: -40.7, -17.2; p-value < 0.001). The reductions in products above warning-label cutoffs were coupled with reductions in products' content of calories and critical nutrients. According to quantile regressions, these reductions mostly occurred at the 50th-75th percentiles. Product reformulation mainly occurred in T2.

CONCLUSION

Our findings show product reformulation due to reductions in critical nutrients/calories after the warning-label policy implementation, which entails improving the nutritional profile of the packaged food and beverage supply in Mexico.

Dietary Salt-Related Knowledge, Attitudes, and Behaviors of New Zealand Adults Aged 18-65 Years

OBJECTIVE

To explore dietary salt-related knowledge, attitudes, and behaviors of New Zealand (NZ) adults aged 18-65 years and assess differences by demographic subgroups.

DESIGN

Cross-sectional online survey conducted between June 1, 2018 and August 31, 2018.

SETTING

Participants were recruited in shopping malls, via social media, and a market research panel.

PARTICIPANTS

English-speaking adults residing in NZ.

VARIABLES MEASURED

An amended version of The Pan American and World Health Organization Knowledge, Attitudes, and Behaviors standardized survey tool was used. Demographic data (age, sex, ethnicity, and educational attainment) were also collected.

ANALYSIS

Descriptive statistics reported. Chi-square test for independence to assess differences by demographics.

RESULTS

The survey was completed by 1,131 adults (mean age 36 ± 15 years; n = 876 [78%] female; n = 661 [78%] NZ European/other; n = 210 [19%] Asian; n =164 [15%] Māori). In addition, 865 participants (83%) knew the primary dietary source of salt; 406 (40%) knew the recommended salt intake; 946 (95%) believed food manufacturers are responsible for sodium reduction; 563 (55%) supported government regulations; and 259 (26%) used food labels. Females and NZ European/other participants reported more favorable salt-reducing behaviors, such as avoiding fast-food and packaged, ready-to-eat foods (P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Improving salt-related knowledge, attitudes, and behaviors in NZ is particularly important for men, underserved populations, and adults aged 45-65 years. A multicomponent, national NZ salt reduction program based on research addressing engagement and effectiveness for at-risk groups is warranted.

Anaemia, overweight and abdominal obesity in mothers and children are associated with the food environment in socially vulnerable areas of a northeastern Brazilian capital

This study aimed to assess the association between community and consumer food environment (FE) measures and anaemia, overweight and abdominal obesity in mother-child dyads living in situations of social vulnerability. A cross-sectional study was carried out in 40 favelas in a capital city in the northeast of Brazil. The sample consisted of 1882 women and 665 children aged under 5 years. The community FE was assessed using a scale of perception of the availability of healthy food in the neighbourhood. Consumer FE was assessed by auditing 624 retail food stores using the AUDITNOVA instrument. This investigated various aspects of the food environment and evaluated the availability of 18 ultra-processed foods (UPF) most consumed by the Brazilian population available in these stores. The presence of overweight was assessed by measuring the weight and height of the mother and the child, and abdominal obesity was assessed by measuring the mother's waist circumference. The presence of anaemia in the mother and the child was assessed by measuring haemoglobin. Adjusted multilevel regression models were used to verify associations between the FE and malnutrition in mother-child dyads. Low perception of community FE was associated with higher risk of women being overweight (OR: 1.35; 95% CI: 1.05-1.73) and abdominally obese (OR: 1.38; 95% CI: 1.04-1.84); low health scores in food shops were associated with higher risk of abdominal obesity (OR: 1.35; 95% CI: 1.01-1.79) and anaemia (OR: 1.16; 95% CI: 1.02-1.98) in women and overweight in children (OR: 1.69; 95% CI: 1.05-2.73); and the high availability of UPF in retail shops was associated with increased odds of overweight (OR: 2.64; 95% CI: 1.61-4.33) and anaemia (OR: 2.11; 95% CI: 1.38-3.02) in children by 164% and 111%, respectively. It was observed that less healthy food environments are associated with greater chances of anaemia, overweight and abdominal obesity in mothers and children under 5 years in situations of social vulnerability in Brazil.

Examining differences in exposure to digital marketing of unhealthy foods reported by Canadian children and adolescents in two policy environments

BACKGROUND

There has been relatively little research on youth's exposure to food marketing on digital media, which is important as new digital platforms emerge and youth spend more time online. Evidence evaluating different policy approaches to restricting digital food marketing to children is also limited. This study examined differences in self-reported exposure to digital food marketing between children and adolescents in different policy environments: Ontario (where food marketing is self-regulated) and Quebec (where advertising is government regulated).

METHODS

An observational cross-sectional online survey was conducted in April 2023 among children (aged 10-12 years) and adolescents (13-17 years) from Ontario and Quebec, recruited by Leger Marketing. Participants self-reported their frequency of exposure to food marketing via various digital platforms and marketing techniques. Logistic regression and proportional odds models examined differences in exposure by province and age group, adjusting for sociodemographic characteristics and digital device usage.

RESULTS

The odds of reporting more frequent exposure to marketing of sugary drinks (OR: 0.48; 95% CI: 0.33, 0.69), sugary cereals (OR: 0.59; 95% CI: 0.41, 0.86), salty/savoury snacks (OR: 0.67; 95% CI: 0.47, 0.96), fast food (OR: 0.65; 95% CI: 0.45, 0.92), and desserts/sweet treats (OR: 0.54; 95% CI: 0.37, 0.78) were lower among Quebec children than Ontario children. Quebec children were less likely than Ontario children (OR: 0.56; 95% CI: 0.38, 0.84), but more likely than Quebec adolescents (OR: 1.58; 95% CI: 1.04, 2.42), to report exposure to unhealthy food marketing on one or more gaming/TV/music streaming platform/website(s). Compared with Ontario children, Quebec children were less likely to report exposure to marketing featuring characters or child/teenage actors (OR: 0.51; 95% CI: 0.34, 0.76), child-appealing subjects, themes and language (OR: 0.59; 95% CI: 0.40, 0.89), and visual design, audio and special effects (OR: 0.64; 95% CI: 0.41, 0.99), and to report exposure to a greater number of marketing techniques (OR: 0.60; 95% CI: 0.43, 0.84).

CONCLUSIONS

Exposure to unhealthy food marketing on digital media is high for youth from Ontario and Quebec, particularly for Ontario children. These findings reinforce the need for federal regulations to protect Canadian youth from unhealthy food marketing on digital media.

Cultural influences on dietary choices

Food choices and dietary behaviors are inherently complex and influenced by numerous interconnected factors including individual preferences such as taste, meal timing, and social interactions, alongside external elements like affordability, cultural norms, marketing, and policy environments. The physical contexts of food consumption - homes, schools, workplaces, and neighborhoods- further shape these behaviors, as do societal expectations and generational food literacy. Underpinning these dynamics are food systems, which are influenced by health, ethical, and sustainability considerations throughout the food production and consumption continuum. Cultural influences, encompassing traditions, rituals, and shared beliefs, play a pivotal role in shaping dietary practices. Distinctions between "cultural food" and "food culture" illustrate the deep integration of cuisine within identity and daily life. Historical events, globalization, and modernization have reshaped food traditions, leading to the adoption of new eating patterns and the erosion of others. Religion, socioeconomic status, and social networks also critically impact dietary behaviors, while contemporary challenges such as the nutrition transition and fast-food culture contribute to rising chronic disease burdens. Addressing these issues requires culturally tailored interventions and a focus on food environments, integrating modern tools like social media to promote healthier, community-oriented behaviors while recognizing the social and emotional roles of food.

Identifying mechanisms that shape the food environment in long-term healthcare facilities in the Netherlands: a participatory system dynamics approach

BACKGROUND

Creating healthy and sustainable food environments within long-term healthcare facilities asks for a systemic approach. This study aimed to: (1) identify system dynamics underlying the food environment of long-term healthcare facilities, (2) formulate actions for changing the system to promote a healthy and sustainable food environment and (3) evaluate stakeholder perspectives about the process and progress towards action implementation up to one-year follow-up.

METHODS

A group model building (GMB) approach was used during two workshops with stakeholders of five different long-term healthcare facilities in the Netherlands. Stakeholders created a causal loop diagram (CLD) and formulated actions for change. Interviews were conducted at six- and twelve months to evaluate perspectives on the GMB process and progress towards action implementation.

RESULTS

The developed CLD consisted of 30 factors influencing the food environment in long-term healthcare facilities and four interrelated subsystems (patient; healthcare organization; national governance and policy; purchasing, procurement and budget). Stakeholders formulated 40 corresponding actions. After one year follow-up, small steps towards action implementation were observed (e.g., agenda setting, raising internal awareness, formulating plans), with several barriers hindering implementation being noted (e.g., lack of time, budget, priority).

CONCLUSIONS

This study gained a comprehensive, collectively acknowledged understanding of the system dynamics underlying the food environment in Dutch long-term healthcare institutions. The results underscore the importance of crafting a coherent set of actions that addresses various factors and underlying mechanisms to initiate systemic change. However, achieving actual system changes in long-term healthcare facilities requires prolonged efforts and overcoming barriers towards implementation.

Affordability of family foods is associated with Nutritional Status of women with pre-school children in Addis Ababa, Ethiopia

Malnutrition among women of reproductive age is a critical public health issue in LMICs, where undernutrition coexists with rising overweight and obesity rates. In Ethiopia, particularly among urban women, maternal and child undernutrition remains high despite efforts to combat poverty and food insecurity. This study examined the relationship between food affordability and the nutritional status of 4797 women in Addis Ababa. Using repeated cross-sectional surveys, body mass index was calculated, and women's nutritional status was categorized. Data on the affordability of 11 healthy family food groups were collected and categorized into terciles. Multinomial logistic regression models analyzed the association between food affordability and nutritional status, adjusting for confounding factors. The prevalence of underweight among women was 7.3%, while 39.1% were overweight or obese. On average, families could afford 6.1 out of the 11 food groups. Women with higher food affordability had increased odds of being overweight (AOR: 1.32; 95% CI 1.09, 1.60) or obese (AOR: 1.50; 95% CI 1.14, 1.97). The findings highlight that two out of five women are either overweight or obese, with obesity more likely in those with greater perceived food affordability. Addressing food choices as food affordability improves is crucial, as better food affordability is associated with an increased risk of becoming overweight and obese.

Temptation at every corner: exploring public perceptions of food cues and policy support for governmental food cue regulation in outdoor public spaces

BACKGROUND

Unhealthy visual food cues in outdoor public spaces are external drivers of unhealthy diets. Food cues are visible situations associated with food-related memories. This study aimed to gain insight into the (un)healthy food cues residents notice in outdoor public spaces in Dutch municipalities. It also aimed to explore residents' perceptions of food cues' influence on eating behaviour to gain insight into the acceptability of food cues and support for governmental food cue regulation.

METHODS

An exploratory study was conducted among 101 adults who photographed outdoor visual food cues in their municipality and answered survey questions about the food cues using a bespoke app ('myfoodenvironment'). Participant and food cue characteristics were analysed. Associations between those characteristics, perceived influence on eating behaviour, acceptability of food cues and support for regulation were analysed.

RESULTS

Participants took 461 photographs of food cues. Most food cues visualised food (73.8%), 54.4% of which showed only unhealthy food. Food cues photographed by participants with a high level of education and those located near a food service outlet were more often perceived as stimulating others to eat compared to those photographed by participants with a middle education level and located near a food store or along the road (Fisher's exact test: p < 0.001 and p = 0.001, respectively). For most photographs, participants found the presence of food cues acceptable and were opposed to governmental cue regulation. However, when food cues visualised healthy food, they were more likely to be found acceptable than when visualising unhealthy food (χ2 (4; N = 333) = 16.955; p = 0.002). Besides, when food cues visualised unhealthy food, participants were less likely to oppose governmental regulation of those types of cues, than when visualising healthy food (Fisher's exact test: p = 0.002).

CONCLUSIONS

Unhealthy food cues in outdoor public spaces were predominantly photographed by the participants. Yet, for most photographs, participants found the food cues acceptable and opposed governmental food cue regulation, although acceptance was higher for healthy food cues and opposition was lower for unhealthy food cues. These findings can serve as input for policymakers to develop governmental food cue regulations that may gain public support.

Extent and Nature of Television Food and Nonalcoholic Beverage Marketing in 9 Asian Countries: Cross-Sectional Study Using a Harmonized Approach

BACKGROUND

Rising childhood obesity rates in Asia are adding risk for the future adult burden of obesity and noncommunicable diseases. Weak policies across most Asian countries enable unrestricted marketing of obesogenic foods and beverages to children. Television is the common medium for food marketing to reach this audience.

OBJECTIVE

This study aimed to assess the extent and nature of television food and nonalcoholic beverage marketing in 9 Asian countries (Bangladesh, China, India, Malaysia, Mongolia, Nepal, the Philippines, Sri Lanka, and Vietnam) with capacity building support from the International Network for Food and Obesity/Non-Communicable Disease Research, Monitoring and Action Support, who enabled harmonization of data collection method and content analyses.

METHODS

Advertised foods were categorized as permitted or not permitted based on the nutrient profile models established by the World Health Organization regional offices for South-East Asia (SEARO) and the World Health Organization regional offices for Western Pacific (WPRO). Overall rates of food advertisements (advertisements per hour per channel) and persuasive strategy use were analyzed along with comparisons between children's peak viewing time (PVT) and non-PVT.

RESULTS

Cross-country comparisons, irrespective of country income level, indicated that not permitted food advertising dominated children's popular television channels, especially during PVT with rates as per WPRO or SEARO criteria ranging from 2.40/2.29 (Malaysia) to 9.70/9.41 advertisements per hour per channel (the Philippines). Persuasive strategy rates were also comparatively higher during PVT. Sugar-sweetened beverages, sugar-containing solid foods, and high salt- and fat-containing snacks and fast foods were frequently advertised. Evaluation of the application of WPRO and SEARO nutrient profile models identified inconsistencies due to regional taste and cuisine variations across Asia.

CONCLUSIONS

This study clearly showed that unhealthy food marketing through popular children's television channels is widely occurring in Asia and is a clear breach of child rights. Evidence outcomes will benefit advocacy toward stronger policy regulations to control unhealthy food marketing and strengthen strategies to promote a healthier food environment for Asia's children.

Addressing the global obesity burden: a gender-responsive approach to changing food environments is needed

Obesity is a leading cause of death and disability globally. There is a higher proportion of women living with obesity than men, with differences in prevalence rates between women and men particularly staggering in low- and middle-income countries. The food environments that most people live in have been defined as 'obesogenic', characterised by easy access to energy dense, highly palatable foods with poor nutritional value. There is an established need to intervene to change food environments to prevent obesity. However, minimal successes are evident with no country set to meet the WHO goal of reducing obesity prevalence to 2010 numbers by 2025. In this review, we provide a narrative around the sex (biological)- and gender (sociocultural)-related considerations for the relationship between nutrition, interactions with the food environment and obesity risk. We provide an argument that there are gendered responses to food environments that place women at a higher risk of obesity particularly in relation to food industry influences, due to gendered roles and responsibilities in relation to paid and unpaid labour, and due to specific food security threats. This review concludes with hypotheses for addressing the obesity burden in a gender-responsive manner, with a call for gender equity to be a key component of the development, implementation and monitoring of obesity prevention focused policies going forward.

Changes in Availability and Affordability on the University Food Environment: The Potential Influence of the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has had an impact on the eating habits of the general population, among other reasons, because it has affected access to commercial establishments since some of them closed. This study aimed to describe potential changes that occurred between 2019 and 2022 in the availability and affordability of food and beverages in the food environment of a Brazilian public university.

METHODS

Cross-sectional and descriptive study conducted at a public university located in Rio de Janeiro, Brazil. Audits were carried out in all establishments selling food and beverages at the university's main campus in 2019 and 2022. Descriptive analysis with frequencies and means was carried out and the 95% confidence intervals were compared.

RESULTS

Over the period, there was a decrease in the on-campus number of establishments, dropping from 20 to 14, and ultra-processed foods became more prevalent. In general, the decrease in the number of establishments led to a reduction in the supply of fresh or minimally processed foods and beverages, and higher average prices were noted.

CONCLUSIONS

The pandemic seems to have deteriorated the availability and the prices of healthy food in the university food environment, making healthy choices harder for students and the university community.

Offline to online: a systematic mapping review of evidence to inform nutrition-related policies applicable to online food delivery platforms

BACKGROUND

Online food delivery (OFD) platforms offer easy access to an abundance of energy-dense and nutrient-poor takeaway foods and may exacerbate existing unhealthy food environments. Efforts to improve population diets include a range of policy recommendations focused on improving the healthiness of food environments; however, the way in which such policies may apply to OFD platforms is not clear. This paper aimed to synthesise the existing evidence to inform nutrition-related policies applicable to OFD platforms for population health and well-being. A secondary aim was to scan existing nutrition-related policies in Australia and internationally, which have the potential to be applicable to OFD platforms.

METHODS

Seven electronic databases including Medline, Embase, CINAHL, Business Source Ultimate, Scopus, Web of Science, and Proquest were searched from January 2010 to October 2023. Evidence from studies was mapped to five existing policy domains outlined by the Healthy Food Environment Policy Index (Food-EPI) including (i) food labelling; (ii) food promotion; (iii) food composition and nutritional quality; (iv) food retail; and (v) food pricing. Relevant data sources were searched for currently implemented nutrition-related government policies that may have relevance to OFD platforms.

RESULTS

A total of 2012 records were screened, and 43 studies were included. There were 70 relevant study outcomes across the included studies, which addressed one or more of the 5 domains. Of these, 21 were relevant to 'Food Promotion' (30%), 18 to 'Food Retail' (26%), 15 to 'Food Composition (21%), 11 to 'Food Prices' (16%), and six to 'Food Labelling' (9%). Three existing policies from international jurisdictions (England, Singapore, EU) included OFD platforms, of which one was a voluntary measure. Several existing policies under food labelling have the potential to be amended to include OFD platforms under regulatory definitions.

CONCLUSION

OFD platforms have emerged as a disruptor to how people acquire their food and have yet to be widely included in existing nutrition-related policies. Advancing the evidence base to support the design of effective policy actions and mitigate the potential negative health impacts of OFD platforms will support efforts to improve population diets.

Association Between the Food Environment Around Schools and Food Consumption of Adolescents in Large and Small Municipalities in Southern Brazil

This cross-sectional study aimed to evaluate the association between the consumption of healthy and unhealthy food markers among adolescents enrolled in the ninth grade of elementary school in municipal public schools and the food environment around the schools in two municipalities of different sizes, located in Southern Brazil. The data were collected between 2022 and 2023, with 449 adolescent participants. Of these, 347 were students from the municipality of Florianópolis, and 102 were students from the municipality of Governador Celso Ramos, all aged between 13 and 17 years. The establishments located around the schools were evaluated using AUDITNOVA, an instrument that investigates the environmental dimension and food dimension. The consumption of healthy eating markers (beans, vegetables, and fresh fruits) and unhealthy eating markers (ultra-processed foods, soft drinks, sweets, and fried snacks) among students was assessed using a food frequency questionnaire. Statistically significant associations were observed between the food environment around the school and the consumption of unhealthy food markers (OR = 0.63; 95% CI = 0.41-0.98 p = 0.041) but only in the large municipality. No significant associations were found in the students' food consumption in the small municipality. A significant association between the school food environment and adolescents' consumption of unhealthy foods was observed in Florianópolis. Healthy food consumption was low among students in the small municipality, Governador Celso Ramos.

Conceptual Model on Access to Food in the Favela Food Environment

The inequalities of Brazilian society are amplified in favelas, affecting access to basic sanitation, health, education services, and food. More research is needed to better understand the favela food environment and propose appropriate public food and nutrition policies to increase the availability of and access to healthy food. In this context, this study aimed to develop a conceptual model of the relationship between access to food and the favela food environment and its determinants. In developing the conceptual model, this study undertook a bibliographical survey of the food environment, and a preliminary version was submitted to an expert panel. The model represents a set of dimensions (individual, micro-environment, macro-environment, and decision-making) and elements that interact in a complex manner and help understand access to food in areas subject to multiple social vulnerabilities. This model can guide future research and aid policymakers in designing effective strategies to improve the food security and health of populations in areas of high socio-spatial vulnerability.

Places to purchase food in urban and rural areas of Brazil

OBJECTIVE

To describe the locations of food and beverage acquisition in Brazil, according to the level of food processing and household location (urban/rural).

METHODS

Data from 49,489 households from the Household Budget Survey 2017-2018 were used. Information regarding food and beverages was collected through a collective acquisition booklet over 7 consecutive days. Locations were classified into 10 groups on the basis of similarities in sales structure and mode of food offering, and food and beverages were categorized according to the NOVA classification. The frequency of households acquiring food in each location was estimated, as well as the acquisition frequency according to processing level, considering significance through non-overlapping 95% confidence intervals.

RESULTS

Half of the households (51.9%) acquired food in supermarkets, contributing to both the acquisition of fresh and minimally processed foods (92.2% in urban; 90.2% in rural) and ultra-processed foods (78.6% in urban; 74.1% in rural). For the urban area, the Supermarket (55.0%), Bakery (46.5%) and Small markets (43.1%) are among the places with the highest frequency of food acquisition, while for rural areas, it is found that Small Markets (53%), Supermarkets (32.3%) and Home production (31.0%) presented the highest frequencies.

CONCLUSION

The acquisition of food and beverages for household consumption in Brazil differs according to household location (urban/rural), indicating the importance of the community food environment in the consumption patterns of ultra-processed foods.

The Retail Food Environment Index and its association with dietary patterns, body mass index, and socioeconomic position: A multilevel assessment in Mexico

In Mexico, 75% of the population are affected by overweight or obesity, and the availability and affordability of high-calorie-dense foods and beverages are high. This study tested the association between the retail food environment index (RFEI), dietary patterns, body mass index (BMI), and socioeconomic position (SEP) in Mexico. Cross-sectional diet, health, and sociodemographic population-based secondary data analyses were conducted. The RFEI was calculated by dividing the total number of fast-food outlets and convenience stores by the total number of supermarkets and fruit and vegetable stores per census tract area. Associations between BMI, dietary patterns, SEP and the RFEI were tested using multilevel linear regression, including interactions of the RFEI with SEP, gender, and age. Living in neighbourhoods with a higher RFEI was associated with a 0.01kg/m2 higher BMI (β = 0.01, 95%CI: 0.0005, 0.02, p = 0.04), equivalent to a mean 0.046 weight gain for a 1.60m tall person per 10% higher RFEI. Unhealthy dietary patterns were more likely in neighbourhoods with a higher RFEI (β = 0.100, 95%CI: 0.03, 0.12, p = 0.001). Multilevel linear regression showed that lower SEP households had a higher RFEI compared to higher SEP households (β = 0.020, 95% CI: -0.006 to 0.04, p = 0.10). Generalised structural equation models revealed a graded relationship between RFEI and SEP, showing that lower SEP households were exposed to a higher RFEI (β = 0.060, 95% CI: 0.05 to 0.07, p < 0.001.) The study identified significant associations between higher proportions of fast-food outlets and convenience stores, higher BMI, and unhealthy dietary patterns. It was particularly evident that low-income populations are more likely to be exposed to obesogenic food environments.

Normalizing junk food: The frequency and reach of posts related to food and beverage brands on social media

Food and beverage marketing on social media contributes to poor diet quality and health outcomes for youth, given their vulnerability to marketing's effects and frequent use of social media. This study benchmarked the reach and frequency of earned and paid media posts, an understudied social media marketing strategy, of food brands frequently targeting Canadian youth. The 40 food brands with the highest brand shares in Canada between 2015 and 2020 from frequently marketed food categories were determined using Euromonitor data. Digital media engagement data from 2020 were licensed from Brandwatch, a social intelligence platform, to analyze the frequency and reach of brand-related posts on Twitter, Reddit, Tumblr, and YouTube. The 40 food brands were mentioned on Twitter, Reddit, Tumblr, and YouTube a total of 16.85M times, reaching an estimated 42.24B users in 2020. The food categories with the most posts and reach were fast food restaurants (60.5% of posts, 58.1% of total reach) and sugar sweetened beverages (29.3% of posts, 37.9% of total reach). More men mentioned (2.77M posts) and were reached (6.88B users) by the food brands compared to women (2.47M posts, 5.51B users reached). The food and beverage brands (anonymized), with the most posts were fast food restaurant 2 (26.5% of the total posts), soft drink 2 (10.4% of the total posts), and fast food restaurant 6 (10.1% of the total posts). In terms of reach, the top brands were fast food restaurant 2 (33.1% of the total reach), soft drink 1 (18.1% of the total reach), and fast food restaurant 6 (12.2% of the total reach). There is a high number of posts on social media related to food and beverage brands that are popular among children and adolescents, primarily for unhealthy food categories and certain brands. The conversations online surrounding these brands contribute to the normalization of unhealthy food and beverage intake. Given the popularity of social media use amongst of children and adolescents, policies aiming to protect these vulnerable groups need to include the digital food environment.

Young people's perspectives on policies to create healthier food environments in England

Food environments are important determinants of healthy diets among young people. This study explored young people's perspectives on their food environment, their recommendations to policymakers and views on youth engagement in policy processes. There is limited research on young people's perspectives on their involvement in developing food environment policies. Youth engagement in policymaking processes can lead to greater policy integrity and inclusivity. Four focus group discussions were conducted with 39 young people (12-21 years) from a town in North West England and a metropolitan area in the English Midlands. Participants were recruited through youth organizations. Data were analysed using inductive thematic analysis. Young people reported concerns about the density of fast food outlets in their local area, the unaffordability of healthier food, and fast food advertisement. These issues were not believed to be prioritized in local and national policymaking. Accordingly, policy recommendations were mainly for structural food environment policies, including restrictions on fast food outlet density and incentives for menu reformulation. Young people did not feel involved in local decisions about the food environment. They expressed a need for more meaningful engagement beyond consultation. Young people have repeatedly shown to have a deep understanding of the social, commercial and political factors that influence diet and health. It is essential that policymakers aiming to improve young people's diets take their unique views and concerns into account to create effective policies that resonate with young people.

Nutritional quality and diversity in Ghana's school feeding programme: a mixed-methods exploration through caterer interviews in the Greater Accra Region

BACKGROUND

The Ghana School Feeding Programme (GSFP) provides public primary school pupils with a free daily meal. Each meal is expected to follow set menus, providing 30% of children's' (6-12 years) energy requirements. This study assessed the nutritional quality and diversity of planned and provided GSFP meals, engaging school caterers to identify how meal quality in the Greater Accra Region could be enhanced.

METHODS

A cross-sectional mixed methods study design was used. Multistage sampling was used to select 129 schools implementing the GSFP in six districts of the Greater Accra Region. GSFP district menus were collected as well as a one-week school caterer recall of provided school meals. The meal served on the day of data collection was recorded and photographed. Nutritional quality was evaluated based on nutrient profiling methods: energy density (low<125kcal/100g; medium 125-225kcal/100g; high>225kcal/100g) and nutrient density (low<5%; medium 5-10%; high>10%). Meal diversity was assessed by a simple count composed of 5 food groups: cereals, pulses/nuts/seeds, animal-source, vegetables and fruits. Caterers' views on programme facilitators and barriers were also explored.

RESULTS

Planned menus included 14-20 weekly options, composed of eight minimally processed traditional dishes. All meals, except white rice, had a high nutrient density/100g. Energy density was varied (low, n=2; medium, n=2; high, n=4). Meals included only 2/5 or 3/5 food groups, mainly starchy staples, pulses/nuts/seeds, and sometimes vegetables. Fruit was never reported. About half of caterers (51.1%) reported deviating from the planned menus: 11.7% served alternative meals, with some including animal-sourced food (17.0%), and 39.4% repeated meals provided during the week, often based on starchy staples, influencing overall nutritional quality. Most caterers reported food item cost and lack of food purchase guidelines as barriers to providing school meals, while food safety training and guidelines for food preparation were facilitators.

CONCLUSIONS

While school meals are composed of minimally processed, nutrient dense, local foods, there are notable gaps in meal diversity and compliance, as reflected in provided meals. Caterer compliance to planned menus varied greatly, reflecting recent food price inflation. Upwardly adjusting the current meal allocation of 1.2 cedis (0.22USD) per child per day could enhance access to more affordable, nutritious and diverse foods in school meals.

Healthiness of food products promoted through placement strategies in Australian online supermarkets: a cross-sectional study

BACKGROUND

Prominent product placement is a core promotional tactic in retail food environments. How this practice has been adapted for online supermarkets, and the extent to which it is applied to healthier and less healthy food products in this setting, is largely unknown. We aimed to investigate placement-type promotions of food products in Australian online supermarkets.

METHODS

We developed a new method to assess placement promotions and applied it to the online stores of the two largest supermarket retailers in Australia. Each online store was audited across six 'locations' (input prior to data collection), including a randomly selected high socio-economic position area and low socio-economic position area from each of the three largest Australian cities. The names, page locations and type of placement strategy of promoted food products were captured, with product healthiness assessed using the Health Star Rating (HSR) nutrient profiling system. Descriptive statistics summarised the page locations of promoted products and the placement strategies used to promote them, and chi-squared tests applied to compare product healthiness by retailer and socio-economic position.

RESULTS

We recorded 12,152 food products promoted through placement strategies, 99% of which were eligible for a HSR. Overall, 44% of products promoted through placement strategies were unhealthy. Cross-promotions and recommendations was the most common strategy recorded overall (55.9% of all strategies), and advertisements and site content was the strategy most likely to promote unhealthy products (53.7% of products unhealthy). One retailer was more likely to promote unhealthy products (46% v 43%, p = 0.004) and unhealthy products were more likely to be promoted in more disadvantaged than less disadvantaged locations (45% vs 43%, p = 0.05), though the magnitudes of difference were small.

CONCLUSIONS

A considerable number of unhealthy products are likely presented to online grocery shoppers in Australia. Public health policies targeting unhealthy food promotions may need to be updated, including with consideration of the different ways that products can be prominently displayed online, to avoid exacerbating risks of diet-related disease and health inequalities. Our novel methodology could be used for ongoing monitoring of online supermarkets in Australia and elsewhere to inform such policies.

Systems thinking for local food environments: a participatory approach identifying leverage points and actions for healthy and sustainable transformations

BACKGROUND

Current local food environments encourage poor diets, posing a significant threat to public and planetary health. Acknowledging and addressing its inherent complexity is vital to making meaningful improvements to the food environment. Using a participatory approach with local stakeholders, this study aims to gain insight into the factors and mechanisms underlying the local food environment and to identify leverage points and system-based actions to foster healthy and sustainable local food environments.

METHODS

A systems-thinking approach was used in a Dutch municipality in 2022. Two group model building (GMB) workshops were held with community stakeholders (e.g. local policymakers, retailers and residents). During the first workshop (June 2022), factors and mechanisms influencing the local food environment were identified and visualized through a causal loop diagram (CLD). During the second workshop, leverage points and system-based actions to improve food environments were identified by the stakeholders. Four months after (October 2022), an action-implementation meeting was organized to stimulate the implementation of selected actions. Progress was monitored through brief telephone interviews 6 and 12 months after the second workshop.

RESULTS

The CLD visualises the factors and mechanisms influencing the local food environment from the point of view of the community stakeholders. The CLD consists of 46 factors shaping the local food environment, which were categorized into four identified subsystems: societal factors, individual, socio-economic factors, commercial factors and political factors. Eight leverage points were identified within the CLD, for example, 'lobby from food industry', 'governmental food policies' and 'e-commerce and platform economy'. Stakeholders formulated 20 actions targeting the identified leverage points. During the action-implementation meeting, long-term plans were created for five actions. After 1 year, only one participant (policy advisory role) remained actively engaged in three of these actions.

CONCLUSIONS

This study yields insight into the numerous factors and mechanisms underlying the local food environment and identified system-based actions as perceived by local stakeholders to improve this food environment locally. The CLD offers stakeholders valuable insights on employing a systems approach when enhancing food environments. More research is necessary, especially into the long-term processes and effects of implementing system-oriented actions to improve local food environments.

Unveiling viewpoints on national food environment policies in the Dutch newspaper discourse: an interpretative media content analysis

BACKGROUND

National food environment policies can contribute to the reduction of diet-related non-communicable diseases. Yet, their implementation in the Netherlands remains low. It has been hypothesized that the media can play a pivotal role in inducing spikes in policy attention, thereby shaping political action. The aim of this study was to examine the discourse on food policies in Dutch newspaper articles between 2000-2022, by analyzing arguments used by various actors.

METHODS

A systematic search in Nexis Uni was used to identify newspaper articles that covered national-level Dutch food environment policies published in seven Dutch national newspapers between 2000-2022. Covered policies were classified into six domains including food composition, labeling, promotion, prices, provision and retail and into the four stages of the policy cycle; policy formulation, decision-making, implementation, and evaluation. A grey literature search was used to identify food policies implemented during 2000-2022. Descriptive statistics were used to summarize coverage of policies over time, policy type and policy stage. An interpretive content analysis was performed on a random subsample of the newspaper articles to determine the actors, viewpoints and arguments of the food policies.

RESULTS

We identified 896 relevant newspaper articles. The coverage of food policies in newspapers was initially low but peaked in 2018/2021/2022. Through grey literature search we identified 6 food policies which were implemented or adjusted between 2000-2022. The majority of the newspaper articles reported on food pricing policies and were discussed in the policy formulation stage. Academics (mainly supportive) were the most and food industry (mostly opposing) the least cited actors. Supportive arguments highlighted health consequences, health inequalities and collective responsibility, whereas opposing arguments focused on unwanted governmental interference and ineffectiveness of policies.

CONCLUSIONS

Dutch newspaper articles covering food policies represented a variety of actors and arguments, with individual versus collective responsibility for food choices playing a central role in the arguments. These insights may serve as a basis for further research into why certain arguments are used and their effect on policy attention and implementation.

Food environment in Burkina Faso: priority actions recommended to the government using Food-EPI tool

Introduction

The food environment is an important factor in the efforts of countries worldwide to achieve a transition to sustainable food systems. The objective of this study is to formulate and prioritize actions to be addressed to the government of Burkina Faso for the creation of a healthy food environment, which will contribute to reducing malnutrition in all its forms and non-communicable diseases.

Methods

National experts were brought together to identify and prioritize actions to fill the gaps identified through a multi-step assessment process following the methodology of the Healthy Food and Environment Policy Index (Food-EPI).

Results

Up to 20 priority policy actions were recommended to the Burkina Faso government. Actions in the policy component focused mainly on regulation of food promotion and marketing, particularly to children, and others in the infrastructure support component focused largely on political leadership, i.e., strong and visible political support from the government to improve the food environment, population nutrition, diet-related non-communicable diseases and their inequalities.

Conclusion

The priority actions to be recommended to the government will strengthen advocacy for government decisions to create a healthier food environment in the country.

Differences in the cost and environmental impact between the current diet in Brazil and healthy and sustainable diets: a modeling study

BACKGROUND

While healthy and sustainable diets benefit human and planetary health, their monetary cost has a direct impact on consumer food choices. This study aimed to identify the cost and environmental impact of the current Brazilian diet (CBD) and compare it with healthy and sustainable diets.

METHODS

Data from the Brazilian Household Budget Survey 2017/18 and the Footprints of Foods and Culinary Preparations Consumed in Brazil database were used for a modeling study comparing the cost of healthy and sustainable diets (based on the Brazilian Dietary Guidelines (BDG) diet and the EAT-Lancet diet) versus the CBD. The DIETCOST program generated multiple food baskets for each scenario (Montecarlo simulations). Nutritional quality, cost, and environmental impact measures (carbon footprint (CF) and water footprint (WF)) were estimated for all diets and compared by ANOVA. Simple linear regressions used standardized environmental impacts measures to estimate differentials in costs and environmental impacts among diets scenarios.

RESULTS

We observed significant differences in costs/1000 kcal. The BDG diet was cheaper (BRL$4.9 (95%IC:4.8;4.9) ≈ USD$1.5) than the CBD (BRL$5.6 (95%IC:5.6;5.7) ≈ USD$1.8) and the EAT-Lancet diet (BRL$6.1 (95%IC:6.0;6.1) ≈ USD$1.9). Ultra-processed foods (UPF) and red meat contributed the most to the CBD cost/1000 kcal, while fruits and vegetables made the lowest contribution to CBD. Red meat, sugary drinks, and UPF were the main contributors to the environmental impacts of the CBD. The environmental impact/1000 kcal of the CBD was nearly double (CF:3.1 kg(95%IC: 3.0;3.1); WF:2,705 L 95%IC:2,671;2,739)) the cost of the BDG diet (CF:1.4 kg (95%IC:1.4;1.4); WF:1,542 L (95%IC:1,524;1,561)) and EAT-Lancet diet (CF:1.1 kg (95%IC:1.0;1.1); WF:1,448 L (95%IC:1,428;1,469)). A one standard deviation increase in standardized CF corresponded to an increase of BRL$0.48 in the cost of the CBD, similar to standardized WF (BRL$0.56). A similar relationship between the environmental impact and the cost of the BDG (CF: BRL$0.20; WF: BRL$0.33) and EAT-Lancet (CF: BRL$0.04; WF: BRL$0.18) was found, but with a less pronounced effect.

CONCLUSIONS

The BDG diet was cost-effective, while the EAT-Lancet diet was slightly pricier than the CBD. The CBD presented almost double the CF and WF compared to the BDG and EAT-Lancet diets. The lower cost in each diet was associated with lower environmental impact, particularly for the BDG and EAT-Lancet diets. Multisectoral public policies must be applied to guide individuals and societies towards healthier and more sustainable eating patterns.

Improving student diet and food security in higher education using participatory and co-creation approaches: a systematic review

BACKGROUND

Higher education students are an important target group for public health nutrition interventions. When designing tailored and contextually relevant interventions, participatory and co-creation approaches are increasingly recognized as promising but their use and effectiveness has not been assessed in this type of population. We systematically reviewed interventions aiming to improve dietary quality and/or food security in higher education settings with the aims 1) to identify and describe their participatory and co-creation approaches and 2) to compare the effectiveness of interventions using or not using participatory and co-creation approaches.

METHODS

Our search in PubMed, Google Scholar, Web of Science, EMBASE was performed in January 2023 and yielded 3658 unique records, out of which 42 articles (66 interventions) were included. Effectiveness of interventions was assessed at the individual level (longitudinal evaluations) or at the group level (repeated cross-sectional evaluations). A five-level classification was used to describe a continuum of engagement from students and other partners in the intervention design and implementation: no participation (level one), consultation, co-production, co-design and co-creation (levels two to five). To synthetize effectiveness, comparisons were made between studies without participation (level one) or with participation (levels two-five).

RESULTS

Ten (24%) out of 42 studies used a participatory and co-creation approach (levels two-five). Studies using a participatory and co-creation approach reported a positive finding on individual-level outcome (i.e. overall diet quality or food group intake or food security) in 5/13 (38%) intervention arms (vs 13/31 or 42% for those without participation). Studies using a participatory and co-creation approach reported a positive finding on group-level outcomes (i.e. food choices in campus food outlets) in 4/7 (57%) (vs 8/23 or 35% in those without participation).

CONCLUSIONS

Participatory and co-creation approaches may improve the effectiveness of nutrition interventions in higher education settings but the level of evidence remains very limited. More research is warranted to identify best co-creation practices when designing, implementing and evaluating nutritional interventions in the higher education setting.

TRIAL REGISTRATION

PROSPERO registration number CRD42023393004.

Benchmarking for healthy food stores: protocol for a randomised controlled trial with remote Aboriginal and Torres Strait Islander communities in Australia to enhance adoption of health-enabling store policy and practice

BACKGROUND

Aboriginal and Torres Strait Islander communities in remote Australia have initiated bold policies for health-enabling stores. Benchmarking, a data-driven and facilitated 'audit and feedback' with action planning process, provides a potential strategy to strengthen and scale health-enabling best-practice adoption by remote community store directors/owners. We aim to co-design a benchmarking model with five partner organisations and test its effectiveness with Aboriginal and Torres Strait Islander community stores in remote Australia.

METHODS

Study design is a pragmatic randomised controlled trial with consenting eligible stores (located in very remote Northern Territory (NT) of Australia, primary grocery store for an Aboriginal community, and serviced by a Nutrition Practitioner with a study partner organisation). The Benchmarking model is informed by research evidence, purpose-built best-practice audit and feedback tools, and co-designed with partner organisation and community representatives. The intervention comprises two full benchmarking cycles (one per year, 2022/23 and 2023/24) of assessment, feedback, action planning and action implementation. Assessment of stores includes i adoption status of 21 evidence-and industry-informed health-enabling policies for remote stores, ii implementation of health-enabling best-practice using a purpose-built Store Scout App, iii price of a standardised healthy diet using the Aboriginal and Torres Strait Islander Healthy Diets ASAP protocol; and, iv healthiness of food purchasing using sales data indicators. Partner organisations feedback reports and co-design action plans with stores. Control stores receive assessments and continue with usual retail practice. All stores provide weekly electronic sales data to assess the primary outcome, change in free sugars (g) to energy (MJ) from all food and drinks purchased, baseline (July-December 2021) vs July-December 2023.

DISCUSSION

We hypothesise that the benchmarking intervention can improve the adoption of health-enabling store policy and practice and reduce sales of unhealthy foods and drinks in remote community stores of Australia. This innovative research with remote Aboriginal and Torres Strait Islander communities can inform effective implementation strategies for healthy food retail more broadly.

TRIAL REGISTRATION

ACTRN12622000596707, Protocol version 1.

Policy implementation and recommended actions to create healthy food environments using the Healthy Food Environment Policy Index (Food-EPI): a comparative analysis in South Asia

Background

The increasing prevalence of diet-related non-communicable diseases (NCDs) in South Asia is concerning, with type 2 diabetes projected to rise to 68%, compared to the global increase of 44%. Encouraging healthy diets requires stronger policies for healthier food environments.

Methods

This study reviewed and assessed food environment policies in Bangladesh, India, Pakistan, and Sri Lanka from 2020 to 2022 using the Healthy Food Environment Policy Index (Food-EPI) and compared them with global best practices. Seven policy domains and six infrastructure support domains were considered, employing 47 good practice indicators to prevent NCDs. Stakeholders from government and non-governmental sectors in South Asia (n = 148) were invited to assess policy and infrastructure support implementation using the Delphi method.

Findings

Implementation of food environment policies and infrastructure support in these countries was predominantly weak. Labelling, monitoring, and leadership policies received a moderate rating, with a focus on food safety, hygiene, and quality rather than obesity prevention. Key policy gaps prioritized for attention included front-of-pack labelling, healthy food subsidies, unhealthy food taxation, restrictions on unhealthy food promotion, and improvements in school nutrition standards to combat NCDs.

Interpretation

Urgent action is required to expand food policies beyond hygiene and food security measures. Comprehensive strategies targeting NCD prevention are crucial to combat the escalating burden of NCDs in the region.

Funding

This research was funded by the NIHR (16/136/68 and 132960) with aid from the UK Government for global health research. Petya Atanasova also acknowledges funding from the Economic and Social Research Council (ESRC) (ES/P000703/1). The views expressed are those of the authors and not necessarily of the NIHR, the UK government or the ESRC.

The role of corruption in global food systems: a systematic scoping review

BACKGROUND

Corruption exists at all levels of our global society and is a potential threat to food security, food safety, equity, and social justice. However, there is a knowledge gap in the role and impact of corruption within the context of the global food system. We aimed to systematically review empirical literature focused on corruption in the global food system to examine how it is characterized, the actors involved, its potential impacts, and the solutions that have been proposed to address corruption in the food system.

METHODS

We used a systematic scoping review methodology. Terms combining corruption and the food system were searched in Scopus, PubMed, Web of Science, PsycInfo and Econlit, in October 2021. Two screeners applied a priori selection criteria to screen the articles at the title and abstract and full-text levels. Data was extracted into a charting form and thematically synthesized to describe the types of corruption in the food system, the actors involved, how corruption impacts the food system, and potential solutions. Sankey diagrams and narrative summaries were developed to summarize the included studies and findings.

RESULTS

From the 238 included records, five main types of corruption were identified in the global food system: bureaucratic corruption, fraud, bribery, organized crime, and corporate political activity. These different types of corruption spanned across various food system areas, from policy and governance structures to food environments, and involved a wide range of actors. More powerful actors like those in public and private sectors tended to instigate corruption in the food system, while community members and primary producers tended to be impacted by it. The impacts of corruption were mostly negative and corruption was found to undermine food system governance and regulatory structures; threaten health, safety, and food security; and lead or contribute to environmental degradation, economic loss, erosion of trust, social inequities, and decreased agricultural productivity. While solution-oriented literature was limited, the essential role of strong governance,  use of technology and predictive modelling methods to improve detection of corruption, and organizational approaches to problem solving were identified.

CONCLUSION

Our review findings provide researchers and policymakers with a comprehensive overview of corruption in the global food system, providing insights to inform a more holistic approach to addressing the issue. Addressing corruption in the food system is an essential element of supporting the transition to a more healthy, equitable and sustainable global food system.

Food Environment in Burkina Faso: Review of Public Policies and Government Actions Using the Food-EPI Tool

BACKGROUND

Governments have a central role to play in creating a food environment that will enable people to have and maintain healthy eating practices.

OBJECTIVES

This study analyzes public policies and government actions related to creating healthy food environments in Burkina Faso.

METHODS

The Healthy Food Environment Policy Index tool used for this study has 2 components, 13 domains, and 56 indicators of good practice adapted to the Burkina Faso context. Official policy documents collected from data sources such as government and nongovernment websites, and through interviews with government and nongovernment resource persons, provided evidence of considerations of food environment in public policy documents in Burkina Faso.

RESULTS

Policies documents show a lack of revision of old texts and administrative processes for new policies and government practices are very slow. Added to this is the absence of a regulatory document for some implemented actions. The analysis of the documents collected in relation to the indicators of Food-EPI tool shows that there is no evidence of consideration of food environments for the indicators concerning the regulation of nutrition and health claims, labeling, taxes on healthy and unhealthy foods, support systems for training for private structures on healthy diets, implementation of food guidelines, and food trade and investment.

CONCLUSION

This study permits a review of public policies that take into account food environments through the various indicators and constitutes a starting point from which improvements can be made by the government.

PLAIN LANGUAGE TITLE

Overview of Nutrition Policies, Taking Into Account All the Dimensions That Can Influence People's Food Choices Across Government, the Food Industry and Society.

Covert marketing of quick-service restaurants via news media in Australia: A content analysis

OBJECTIVE

To determine the extent and nature of news media coverage generated from press releases made by top-selling quick-service restaurants in Australia.

METHODS

We conducted a content analysis of press releases made between July 2021 and June 2022 by the five largest quick-service restaurant brands in Australia by brand share, including coding their main subject. We then conducted a content analysis of news media coverage related to the press releases, including coding its slant towards the brand.

RESULTS

Among 52 press releases, new food products (27% of press releases; all unhealthy foods) and corporate social responsibility activities (25%) were the most promoted subjects. For 62% of press releases, at least one news media item was identified. Among the 86 identified news media items, most related to press releases promoting new food products (45% of news media items) or corporate social responsibility activities (21%). News media items overwhelmingly had a slant favourable to the relevant brand (93%).

CONCLUSIONS

Press releases by top-selling quick-service restaurant brands in Australia commonly generate news media coverage that promotes such brands and their predominantly unhealthy products.

IMPLICATIONS FOR PUBLIC HEALTH

Policies restricting unhealthy food marketing should consider brand-generated news media coverage.

Local retail food environment exposure and diet quality in rural and urban adults: A longitudinal analysis of the ORISCAV-LUX cohort study

Despite growing interest in understanding how food environments shape dietary behaviors, European longitudinal evidence is scarce. We aimed to investigate the associations of 9-year average and change in exposure to local retail food environments with the diet quality of residents in Luxembourg. We used data from 566 adults enrolled in both waves of the nationwide ORISCAV-LUX study (2007-2017). Dietary quality was assessed by the Diet Quality Index-International (DQI-I). Exposure to "healthy" and "less healthy" food outlets was assessed by both absolute and relative GIS-based measurements. The results showed a 56.3% increase in less healthy food outlets over the period. In adjusted linear mixed models, high (vs. low) 9-year average exposure to less healthy food outlets was associated with lower DQI-I, when examining spatial access (β = -1.25, 95% CI: -2.29, -0.22) and proportions (β = -1.24, 95% CI: -2.15, -0.33). Stratified analyses showed these associations to be significant only among urban residents. There was no association between change in exposure to less healthy food outlets and DQI-I. Increased exposure to healthy outlets in rural areas, using absolute measurements, was associated with worsened DQI-I. Neighborhood socioeconomic status did not moderate the above associations. Findings suggest that the proliferation of less healthy food outlets may have contributed to the deterioration of the diet quality of urban residents, and support the use of relative measurements to fully capture the healthiness of food environments.

More than the worksite cafeteria: the workplace food environment of small and medium-sized enterprises in the Netherlands

OBJECTIVE

To characterise the food environment of Dutch small and medium-sized enterprises (SMEs), encompassing physical, sociocultural, economic and policy features and to explore variations within SMEs according to company characteristics (number of employees, location of work and presence of worksite cafeteria).

DESIGN

Online cross-sectional survey study of a representative Dutch SME sample by a panel agency.

SETTING

Dutch SMEs.

PARTICIPANTS

Three hundred and fifteen employees of Dutch SMEs responsible for food and drink in their company.

RESULTS

Most SMEs did not have a worksite cafeteria, no provision of fruits or vegetables, and did not offer discounts on food or drinks. The food environment of these SMEs varied significantly based on company characteristics. For example, SMEs with a worksite cafeteria were significantly more likely to have fruits (OR = 8·76, 95 % CI (4·50, 17·06)), vegetables (OR = 10·29, 95 % CI (5·49, 19·31)) and company food policies (OR = 5·04, 95 % CI (2·08, 12·20)) than SMEs without. Additionally, SMEs with ≥ 50 employees were more likely to have fruits (OR = 2·39, 95 % CI (1·42, 4·03)), vegetables (OR = 1·89, 95 % CI (1·04, 3·46)) and company food policies (OR = 2·82, 95 % CI (1·09, 7·29) than SMEs with < 50 employees. Moreover, having a worksite cafeteria (B = 0·23, 95 % CI (0·08, 0·38)) and employees working mostly on-site (B = 0·14, 95 % CI (0·01, 0·28)) were associated with stronger social norms of healthy and sustainable eating at work compared to SMEs without a worksite cafeteria and working mostly off-site.

CONCLUSIONS

In SMEs, an overall comprehensive picture of the food environment points to its limited active encouragement of healthy food choices, particularly so in small SMEs without a worksite cafeteria. Company characteristics strongly influence SME food environments and should be considered when developing interventions improving SME workplace food environments.

Characteristics of commercial determinants of health research on corporate activities: A scoping review

INTRODUCTION

Business practices have influenced human health for centuries, yet an overarching concept to study these activities across nations, time periods, and industries (called 'the commercial determinants of health' (CDH)) has emerged only recently. The purpose of this review was to assess the descriptive characteristics of CDH research and to identify remaining research gaps.

METHODS

We systematically searched four databases (Scopus, OVID Medline, Ovid Embase, and Ovid Global Health) on Sept 13, 2022 for literature using CDH terms that described corporate activities that have the potential to influence population health and/or health equity (n = 116). We evaluated the following characteristics of the literature: methods employed, industries studied, regions investigated, funders, reported conflicts of interest, and publication in open-access formats.

RESULTS

The characteristics of the articles included that many were conceptual (50/116 articles; 43%) or used qualitative methods (37; 32%). Only eight articles (7%) used quantitative or mixed methods. The articles most often discussed corporate activities in relation to the food and beverage (51/116; 44%), tobacco (20; 17%), and alcohol industries (19; 16%), with limited research on activities occurring in other industries. Most articles (42/58 articles reporting a regional focus; 72%) focused on corporate activities occurring in high-income regions of the world.

CONCLUSIONS

Our findings indicate that literature that has used CDH terms and described corporate practices that influence human health has primarily focused on three major industries in higher-income regions of the world. Qualitative methods were the most common empirical method for investigating these activities. CDH-focused investigations of corporate practices conducted by less-studied industries (e.g., social media) and in lower-income regions are recommended. Longitudinal quantitative studies assessing the associations between corporate practices and a range of health outcomes is also a necessary next step for this field.

Food environment and obesity: a systematic review and meta-analysis

Background

Obesity is influenced by a complex, multifaceted system of determinants, including the food environment. Governments need evidence to act on improving the food environment. The aim of this study was to review the evidence from spatial environmental analyses and to conduct the first series of meta-analyses to assess the impact of the retail food environment on obesity.

Methods

We performed a systematic review and random-effects meta-analyses, focusing on geographical-statistical methods to assess the associations between food outlet availability and obesity. We searched OvidSP-Medline, Scielo, Scopus and Google Scholar databases up to January 2022. The search terms included spatial analysis, obesity and the retail food environment. Effect sizes were pooled by random-effects meta-analyses separately according to food outlet type and geographical and statistical measures.

Findings

Of the 4118 retrieved papers, we included 103 studies. Density (n=52, 50%) and linear and logistic regressions (n=68, 66%) were the main measures used to assess the association of the food environment with obesity. Multilevel or autocorrelation analyses were used in 35 (34%) studies. Fast-food outlet proximity was positively and significantly associated with obesity (OR: 1.15, 95% CI: 1.02 to 1.30, p=0.02). Fresh fruit and vegetable outlet density and supermarket proximity were inversely associated with obesity (OR: 0.93, 95% CI: 0.90 to 0.96, p<0.001; OR: 0.90, 95% CI: 0.82 to 0.98, p=0.02). No significant associations were found for restaurants, convenience stores or any of the body mass index measures.

Conclusions

Food outlets which sell mostly unhealthy and ultra-processed foods were associated with higher levels of obesity, while fruit and vegetable availability and supermarket accessibility, which enable healthier food access, were related to lower levels of obesity. The regulation of food outlets through zoning laws may not be enough to tackle the burden of obesity. Regulations that focus on increasing the availability of healthy food within stores and ensure overall healthy food environments require further attention.

PROSPERO registration number

CRD42018111652.

Adapting food environment frameworks to recognize a wild-cultivated continuum

Food environments, or interfaces between consumers and their food systems, are a useful lens for assessing global dietary change. Growing inclusivity of nature-dependent societies in lower-and middle-income countries is driving recent developments in food environment frameworks. Downs et al. (2020) propose a food environment typology that includes: wild, cultivated, informal and formal market environments, where wild and cultivated are "natural food environments." Drawing from transdisciplinary perspectives, this paper argues that wild and cultivated food environments are not dichotomous, but rather exist across diverse landscapes under varying levels of human management and alteration. The adapted typology is applied to a case study of Indigenous Pgaz K'Nyau food environments in San Din Daeng village, Thailand, using the Gallup Poll's Thailand-adapted Diet Quality Questionnaire with additional food source questions. Wild-cultivated food environments, as classified by local participants, were the source of more food items than any other type of food environment (37% of reported food items). The case of Indigenous Pgaz K'Nyau food environments demonstrates the importance of understanding natural food environments along a continuum from wild to cultivated.

Association of county-level food deserts and food swamps on postoperative outcomes among patients undergoing colorectal surgery

BACKGROUND

Although malnutrition has been linked to worse healthcare outcomes, the broader context of food environments has not been examined relative to surgical outcomes. We sought to define the impact of food environment on postoperative outcomes of patients undergoing resection for colorectal cancer (CRC).

METHODS

Patients who underwent surgery for CRC between 2014 and 2020 were identified from the Medicare database. Patient-level data were linked to the United States Department of Agriculture data on food environment. Multivariable regression was used to examine the association between food environment and the likelihood of achieving a textbook outcome (TO). TO was defined as the absence of an extended length of stay (≥75th percentile), postoperative complications, readmission, and mortality within 90 days.

RESULTS

A total of 260,813 patients from 3017 counties were included in the study. Patients from unhealthy food environments were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with higher social vulnerability (all P < .01). Patients residing in unhealthy food environments were less likely to achieve a TO than that of patients residing in the healthiest food environments (food swamp: 48.8% vs 52.4%; food desert: 47.9% vs 53.7%; P < .05). On multivariable analysis, individuals residing in the unhealthy food environments had lower odds of achieving a TO than those of patients living in the healthiest food environments (food swamp: OR, 0.86; 95% CI, 0.83-0.90; food desert: OR, 0.79; 95% CI, 0.76-0.82); P < .05).

CONCLUSION

The surrounding food environment of patients may serve as a modifiable sociodemographic risk factor that contributes to disparities in postoperative CRC outcomes.

The INFORMAS healthy food environment policy index in Brazil: Benchmarking, current policies, and determining priorities for the future

INTRODUCTION

Obesity and non-communicable diseases are the most important cause of death and inability in Brazil and worldwide. Public policies are an important strategy to prevent obesity. This study analysed the scope of Brazilian public policies for preventing and controlling obesity using the INFORMAS/Food-EPI protocol.

METHODS

The public policies evaluation was conducted based on the INFORMAS/Food-EPI protocol. Experts from academia, civil society, and government assessed the level of implementation of food policies compared with international best practices and proposed new actions to be developed nationally. The protocol consisted of five phases: (1) A comprehensive review of the implementation of food environment-related public policies; (2) validation with experts; (3) comparison of the national actions with the international best practice and due to the level of implementation; (4) list a set of actions to improve the current policies; and (5) evaluation of the actions due to their importance and achievability.

RESULTS

Brazilian actions were focused on monitoring, leadership, governance, and resources and financing domains.

CONCLUSION

The results will provide elements to support and improve the national policies that aim at the promotion of a healthy food environment and obesity prevention.