Association between full service and fast food restaurant density, dietary intake and overweight/obesity among adults in Delhi, India

Understanding the Food Environment and Its Impact on Diet and Health in Asia: A Scoping Review

Food environment (FE), an interface where people interact with a broader food system, is critical to health. Understanding the Asian FE may help to tackle the "triple burden of malnutrition" through informed research and policy. This review identifies FE domains assessed in the Asian context and collates the tools/measures used in these evaluations. We further synthesized the reported associations of FE with diet and health outcomes and identified knowledge gaps. Forty-two articles were reviewed (East Asia, n = 25, 60%; South Asia, n = 8, 19%; and Southeast Asia, n = 9, 21%). The results showed that FE was frequently examined in children, adolescents, or adults, but data were scarce in older adults. Food availability (n = 30) and accessibility (n = 19) were popularly studied domains. Furthermore, FE was measured using geographic information systems (n = 18), market (n = 7), or stakeholder (n = 21) surveys. Twenty-eight (67%) articles assessed associations of FE exposures with diet (n = 12) and health (n = 21). Increased food availability and accessibility were associated with poorer dietary and health outcomes despite nonexisting validity and reliability reporting in 62% of articles. Limited high-quality studies emphasize the need for harmonized definitions, better study designs, and validated FE measures/tools in Asia. Improving the quality of FE research is critical to designing effective interventions to improve public health nutrition in Asia.

The hidden imbalance in neighbourhood nutrition environment: a perspective from lower-middle-income country setting

Neighbourhood environment plays a pivotal role in determining the individual's nutrition through availability and accessibility of healthy food options. This community-based cross-sectional descriptive study examined neighbourhood spatial attributes using Geographical Information System (GIS) and describe perceived nutrition environment among adult residents in urban Puducherry, India. The density of grocery shops, fruits and vegetable shops, food outlets and restaurants were 64.4, 74.8 and 88.7 per km2, respectively. Out of 200 participants, 191 (95.5%) and 190 (95%) reported easy accessibility to fruits and vegetables shops and restaurants, respectively, while 192 (96%) agreed on availability of unhealthy food options in shops. Current study provides framework for assessment of objective and perceived neighbourhood nutrition environment in lower-middle-income countries with a user-friendly and easily administrable tool.

Demographic Dynamics and the Changing Faces of Nutrition Literacy in India: A Tryst with the Transition among Communities Over Two Decades

Aims and Objective

The development of a nation depends on well-nourished individuals. A country's economic independence also depends on adequate food supply for all sections of its population and the proper selection of the right kinds of food, called nutritional literacy. This review will show the transition of dietary selection and practices across India over the last two decades and its impact on health.

Materials and Methods

We conducted a literature search to review the evidence of the last two decades. The literature search was done using the PubMed search engine and the MeSH words "Nutrition Literacy, Dietary Practices, Diet Transition, Nutrition transition, India and Food pattern." Evidence from the last two decades was collectively reviewed, and observations on the transition in nutrition literacy were summated.

Results

The literature search revealed 18 articles, out of which 13 articles were included in this review based on inclusion-exclusion criteria. Nine were review articles, and five were cross-sectional studies. The studies done over the last two decades on nutrition culture revealed that most of the studies related to transition have been done during the second decade of the twenty-first century. Most have found that the shift has been happening more among the urban poor and rural rich people. Indian diets have diversified and shifted away from cereals towards processed food.

Conclusion

It was found that there is a shift in feeding preferences in diet-deprived sections in India. The findings are similar in rural and urban areas where the poor fall prey to the food fads, make poor nutrition choices, and gradually develop chronic ailments. Such a transition over the years clearly shows that a malnourished child, having faulty feeding practices, becomes prey to the triple burden of hidden hunger, lack of nutrition, and repercussions of chronic non-communicable diseases, including dental ailments.

Non-traditional data sources in obesity research: a systematic review of their use in the study of obesogenic environments

BACKGROUND

The complex nature of obesity increasingly requires a comprehensive approach that includes the role of environmental factors. For understanding contextual determinants, the resources provided by technological advances could become a key factor in obesogenic environment research. This study aims to identify different sources of non-traditional data and their applications, considering the domains of obesogenic environments: physical, sociocultural, political and economic.

METHODS

We conducted a systematic search in PubMed, Scopus and LILACS databases by two independent groups of reviewers, from September to December 2021. We included those studies oriented to adult obesity research using non-traditional data sources, published in the last 5 years in English, Spanish or Portuguese. The overall reporting followed the PRISMA guidelines.

RESULTS

The initial search yielded 1583 articles, 94 articles were kept for full-text screening, and 53 studies met the eligibility criteria and were included. We extracted information about countries of origin, study design, observation units, obesity-related outcomes, environment variables, and non-traditional data sources used. Our results revealed that most of the studies originated from high-income countries (86.54%) and used geospatial data within a GIS (76.67%), social networks (16.67%), and digital devices (11.66%) as data sources. Geospatial data were the most utilised data source and mainly contributed to the study of the physical domains of obesogenic environments, followed by social networks providing data to the analysis of the sociocultural domain. A gap in the literature exploring the political domain of environments was also evident.

CONCLUSION

The disparities between countries are noticeable. Geospatial and social network data sources contributed to studying the physical and sociocultural environments, which could be a valuable complement to those traditionally used in obesity research. We propose the use of information available on the Internet, addressed by artificial intelligence-based tools, to increase the knowledge on political and economic dimensions of the obesogenic environment.

Perceived neighborhood environment walkability and health-related quality of life among predominantly Black and Latino adults in New York City

BACKGROUND

Measures of the built environment such as neighborhood walkability have been associated with health behaviors such as physical activity, the lack of which in turn may contribute to the development of diseases such as obesity, diabetes, cardiovascular disease, and cancer. However, limited research has examined these measures in association with health-related quality of life (HR-QoL), particularly in minoritized populations. We examined the relationship between perceived neighborhood environment and HR-QoL in a sample of mostly Black and Latino residents in New York City (NYC).

METHODS

This study utilized the baseline survey data from the Physical Activity and Redesigned Community Spaces (PARCS) Study among 1252 residents [34.6% Black, 54.1% Latino, 80.1% female, mean(±SD) age = 38.8 ± 12.5) in 54 park neighborhoods in NYC. Perceived built environment was measured using Neighborhood Environment and Walkability Survey, and mental and physical HR-QoL was estimated using Short Form (SF)-12. Using factor analysis, we identified two subscales of neighborhood walkability: enablers (e.g., trails, sidewalks, esthetics) vs. barriers (e.g., high crime and traffic). In addition, we included a third subscale on neighborhood satisfaction. Generalized Estimating Equation models adjusted for demographics and BMI and accounted for the clustering effect within neighborhood. Multiple imputation was used to account for missing data.

RESULTS

Mental HR-QoL was associated with barriers of walkability (β ± SE = - 1.63 ± 0.55, p < 0.01) and neighborhood satisfaction (β ± SE = 1.55 ± 0.66, p = 0.02), after adjusting for covariates. Physical HR-QoL was associated with only barriers of walkability (β ± SE = - 1.13 ± 0.57, p < 0.05).

CONCLUSIONS

Among NYC residents living in minoritized neighborhoods, mitigating negative aspects of the neighborhood environment may be more crucial than adding positive features in terms of HR-QoL. Our study points to the need to investigate further the role of the built environment in urban, minoritized communities.

Type, density, and healthiness of food-outlets in a university foodscape: a geographical mapping and characterisation of food resources in a Ghanaian university campus

Introduction

Food environments are viewed as the interface where individuals interact with the wider food system to procure and/or consume food. Institutional food environment characteristics have been associated with health outcomes including obesity and nutrition-related non-communicable diseases (NR-NCDs) in studies from high-income countries. The objectives of this study were (1) to map and characterise the food-outlets within a Ghanaian university campus; and (2) to assess the healthiness of the food outlets.

Methods

Data collection was undertaken based on geospatial open-source technologies and the collaborative mapping platform OpenStreetMap using a systematic approach involving three phases: remote mapping, ground-truthing, and food-outlet survey. Spatial analyses were performed using Quantum Geographical Information System (QGIS) and comprised kernel density, buffer, and average nearest neighbour analyses to assess outlet distribution, density, and proximity. A classification system was developed to assess the healthiness of food-outlets within the University foodscape.

Results

Food-outlets were unevenly distributed over the University foodscape, with many outlets clustered closer to student residencies. Informal food-outlets were the most frequent food-outlet type. Compared to NCD-healthy food-outlets, NCD-unhealthy food-outlets dominated the foodscape (50.7% vs 39.9%) with 9.4% being NCD-intermediate, suggesting a less-healthy university foodscape. More NCD-unhealthy food outlets than NCD-healthy food outlets clustered around student residences. This difference was statistically significant for food outlets within a 100-m buffer (p < 0.001) of student residence and those within 100 and 500 m from departmental buildings/lecture halls (at 5% level of significance).

Conclusion

Further action, including research to ascertain how the features of the University’s food environment have or are influencing students’ dietary behaviours are needed to inform interventions aimed at creating healthier foodscapes in the study University and other campuses and to lead the way towards the creation of healthy food environments at the home, work, and community levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14266-7.

Association between neighborhood food environment and dietary diversity score among older people in Beijing, China: A cross-sectional study

Objective

To examine the association between the neighborhood food environment and dietary diversity score (DDS) among elderly people in China.

Methods

Participants were recruited from 12 communities in Beijing, China, in 2019, using a multi-stage stratified random sampling method. Participants (n = 1,764, 730 men) in this study were elderly people aged 65 to 80. A questionnaire survey was used to investigate the intake of various foods in the past 3 days, and their dietary diversity score (DDS) was calculated. Baidu Map Application Programming Interface was used to measure the neighborhood food environments, including the density of and proximity to different food outlets. Adjusted multiple linear regression was performed to estimate the association between the neighborhood food environment and DDS.

Results

A total of 1,800 questionnaires were distributed, and 1,775 questionnaires were returned. The questionnaire response rate was 98.6%. Among them, the number of valid questionnaires was 1,764, and the valid rate was 99.4%. The mean age of the participants was 69.7 ± 4.3, and the average DDS was 7.2 ± 1.4. Among the three types of stores, convenience stores had the best access, followed by greengrocers, and finally supermarkets. Sit-down restaurants had the nearest walking distance, Chinese fast-food restaurants had the largest number, and western fast-food restaurants were the most difficult to access. Better access to supermarkets tended to be associated with higher DDS score within all the buffer zones (250 m buffer zone: β = 0.495, P < 0.001; 500 m buffer zone: β = 0.341, P < 0.001; 800 m buffer zone: β = 0.163, P < 0.001; 1,000 m buffer zone: β = 0.243, P < 0.001). However, greengrocers were negatively associated with DDS score within all the buffer zones (250 m buffer zone: β = −0.475, P < 0.001; 500 m buffer zone: β = −0.161, P < 0.001; 800 m buffer zone: β = −0.090, P < 0.001; 1000 m buffer zone: β = −0.112, P < 0.001). As for convenience stores, we only found significant results within the 250 m buffer zone (β = 0.075, P = 0.002). Among the three types of restaurants, the results were inconsistent within different buffer zones. Sit-down restaurants were negatively associated with DDS score within 250 m buffer zone (β = −0.257, P < 0.001), and positively associated with DDS score within 1,000 m buffer zone (β = 0.018, P < 0.001). Living in areas with more Chinese fast-food restaurants tended to have higher DDS within 250 m buffer zone (β = 0.357, P < 0.001); however, there was a opposite result within 1,000 m buffer zone (β = −0.044, P < 0.001). Better access to western fast-food restaurants tended to be associated with lower DDS score within 500 m buffer zone (β = −0.235, P < 0.001) and higher DDS score within 1,000 m buffer zone (β = 0.189, P < 0.001). There was a negative correlation between the nearest distance to the supermarket and the DDS score (β = −0.002, P < 0.001), and the nearest distance to the greengrocer was directly positively correlated with the DDS score (β = 0.004, P < 0.001).

Conclusion

This study suggests that supermarkets may increase the DDS score among older adults in Beijing, while greengrocers may reduce the DDS score. However, the current results are not strong enough to draw specific conclusions. Policymakers need to rely on more evidence to make specific policy recommendations.

Restaurant managers' readiness to maintain people's healthy weight and minimise food waste in Japan

BACKGROUND

People who consume high amounts of ready-to-eat meals have a higher body mass index than those who do not. However, if customers adhere to eating proper amounts without restaurants reducing the portions, plate waste may occur. It is therefore incumbent upon restaurants to serve suitable meal portions to customers in the interests of their health and the environment. This study examined whether restaurants support Japan's national goals of minimising food loss and waste and maintaining healthy body weight. Additionally, the characteristics of restaurant managers who display a willingness to meet these goals, were identified.

METHODS

An internet-based nationwide cross-sectional survey was conducted among restaurant managers in Japan in May 2019. The main outcome measured was readiness to take action toward maintaining healthy weight and minimising food loss and waste. Chi-square tests were performed to examine the characteristics of three groups, divided on the basis of their readiness to take action toward achieving these two goals. The group that displayed a higher readiness toward attaining both goals was examined using logistic regression analyses.

RESULTS

Of the 412 restaurant managers who responded, 387 (93.9%) were analysed. Few managers reported taking action toward maintaining healthy weight (n = 13, 3.4%) and minimising food loss and waste (n = 45, 11.6%). Two variables, 'medium- or big-sized company' and 'referring to the United Nations' Sustainable Development Goals for running their business', were related to both higher readiness for maintaining healthy weight and minimising food loss and waste (odds ratio [OR] = 2.27, confidence interval [CI]: 1.11-4.62; OR = 4.06, CI: 2.39-6.88, respectively).

CONCLUSIONS

Increasing recognition of the Sustainable Development Goals among restaurant managers is needed to increase their cooperation toward meeting Japan's national goals.

Perceived neighbourhood food access is associated with consumption of animal-flesh food, fruits and vegetables among mothers and young children in peri-urban Cambodia

OBJECTIVE

To examine whether mothers' perceived neighbourhood food access is associated with their own and their young children's consumption of animal-flesh food, fruits and vegetables in peri-urban areas of Cambodia.

DESIGN

A cross-sectional survey measured food consumption frequency and perceived neighbourhood food access, the latter including six dimensions of food availability, affordability, convenience, quality, safety and desirability. Multivariate logistic regression was used to assess the association between perceived food access and food consumption.

SETTING

Peri-urban districts of Phnom Penh and Siem Reap, Cambodia.

PARTICIPANTS

198 mothers of children between 6 and 24 months old.

RESULTS

Over 25 % of the mothers and 40 % of the children had low consumption (< once a day) of either animal-flesh food or fruits and vegetables. Compared with perceived high food access, perceived low food access was associated with an adjusted 5·6-fold and 4·3-fold greater odds of low animal-flesh food consumption among mothers (95 % CI 2·54, 12·46) and children (95 % CI 2·20, 8·60), respectively. Similarly, relative to perceived high food access, perceived low food access was associated with 7·6-times and 5·1-times higher adjusted odds of low fruits and vegetables consumption among mothers (95 % CI 3·22, 18·02) and children (95 % CI 2·69, 9·83), respectively.

CONCLUSIONS

Mothers' perceived neighbourhood food access was an important predictor of their own and their young children's nutrient-rich food consumption in peri-urban Cambodia. Future work is needed to confirm our findings in other urban settings and examine the role of neighbourhood food environment in the consumption of both nutrient-rich and nutrient-poor food.

The usage of different types of food outlets was not significantly associated with body mass index during the third COVID‐19 national lockdown in the United Kingdom

Background

The United Kingdom (UK) implemented several national lockdowns during the coronavirus pandemic during which restaurants were closed and people were advised to stay at home if possible. These restrictions were eased and reapplied multiple times between March 2020 and May 2021. The change in restaurant access and prolonged restriction of activity may have an impact on body weight.

Aim

The aim of this study was to examine the impact of multiple lockdowns on body mass index (BMI) change from pre‐pandemic till during the third lockdown and on the use of different types of food outlets and their association with BMI change.

Materials and Method

Surveys of usage of different types of food outlets were distributed online before the lockdown between 06 January and 12 December 2019 and during the third national lockdown between 29 March and 25 April 2021. The food outlet usage surveys were filled out for seven consecutive days. Self‐reported BMI was reported before the pandemic and during the third phase of the lockdown. The total number of individuals who started the study before the pandemic was 681, and 60 participants completed the surveys during the third phase of lockdown.

Results

For the 60 participants in both surveys mean BMI was significantly higher during the third lockdown (28.6 ± 5.9 kg.m²) in comparison with the mean BMI before the pandemic 2019 (28.0 ± 5.5 kg.m²) (paired T = 3.09, p < 0.003). There was a significant positive association between BMI change, total number of days spent in lockdown (β = 0.05, p < 0.01, R² = 9.99), and age (β = 0.06, p < 0.007, R² = 11.8). There was no significant association between change in BMI and change in the frequency of using fast food restaurants (FFRs), full‐service restaurants (FSRs), and delivery and takeaways.

Conclusion

BMI was increased significantly during the lockdown in comparison with prior to the pandemic. Individuals gained more weight the longer they stayed at home during lockdowns, and physical activity was reduced to approximately half. However, the BMI change was not related to the change in use of different types of food outlets. This pattern does not support the widespread belief that visiting restaurants or using delivery and takeaway services has a significant impact on body weight.

A Direct Assessment of the External Domain of Food Environments in the National Capital Region of India

Data on food environments in India and other low- and middle-income countries are scarce. The objective of this study was to assess the four dimensions of the external domain of food environments (availability, price, vendor and product properties, and marketing) in food establishments in the National Capital Region of India. The assessment focused on fruits, vegetables, and ultra-processed foods. The 60 food establishments surveyed were categorized as stores, restaurants, or mobile food vendors. Only 13.3% of food establishments sold fruits and vegetables. Stores were more likely to sell vegetables than mobile food vendors (14.8 vs. 6.2%, respectively) and sold a greater variety of both fruits and vegetables as compared to mobile food vendors [mean (SD) of 8.6 (3.2) fruits and 18.6 (9.2) vegetables available at stores vs. 5.5 (5.7) fruits and 25 vegetables available at the one mobile food vendor who sold vegetables]. However, these healthy food items were more expensive at stores. The availability (100% of stores, 12.5% of mobile food vendors, and 12.5% of restaurants) and variety (156 types) of ultra-processed foods across food establishments were higher than fruits and vegetables. A greater percentage of food establishments displayed advertisements for ultra-processed foods as compared to unprocessed or minimally processed foods such as fruits and vegetables. The National Capital Region of India has an unhealthy food environment. Regulations that limit the availability of ultra-processed foods and improve the availability and affordability of fruits and vegetables are needed to reverse the rising tide of chronic non-communicable diseases in this setting.

The influence of the urban food environment on diet, nutrition and health outcomes in low-income and middle-income countries: a systematic review

INTRODUCTION

Diet and nutrition are leading causes of global morbidity and mortality. Our study aimed to identify and synthesise evidence on the association between food environment characteristics and diet, nutrition and health outcomes in low-income and middle-income countries (LMICs), relevant to urban settings, to support development and implementation of appropriate interventions.

METHODS

We conducted a comprehensive search of 9 databases from 1 January 2000 to 16 September 2020 with no language restrictions. We included original peer-reviewed observational studies, intervention studies or natural experiments conducted in at least one urban LMIC setting and reporting a quantitative association between a characteristic of the food environment and a diet, nutrition or health outcome. Study selection was done independently in duplicate. Data extraction and quality appraisal using the National Heart Lung and Blood Institute checklists were completed based on published reports using a prepiloted form on Covidence. Data were synthesised narratively.

RESULTS

74 studies met eligibility criteria. Consistent evidence reported an association between availability characteristics in the neighbourhood food environment and dietary behaviour (14 studies, 10 rated as good quality), while the balance of evidence suggested an association with health or nutrition outcomes (17 of 24 relevant studies). We also found a balance of evidence that accessibility to food in the neighbourhood environment was associated with diet (10 of 11 studies) although evidence of an association with health outcomes was contradictory. Evidence on other neighbourhood food environment characteristics was sparse and mixed. Availability in the school food environment was also found to be associated with relevant outcomes. Studies investigating our other primary outcomes in observational studies of the school food environment were sparse, but most interventional studies were situated in schools. We found very little evidence on how workplace and home food environments are associated with relevant outcomes. This is a substantial evidence gap.

CONCLUSION

'Zoning' or 'healthy food cart' interventions to alter food availability may be appropriate in urban LMIC.

PROSPERO REGISTRATION NUMBER

CRD42020207475.

Prevalence and Correlates of Cardio-Metabolic Risk Factors Among Regular Street Food Consumers in Dar es Salaam, Tanzania

BACKGROUND

Regular street food consumers (RSFCs) in Africa are at an increased risk of unhealthy eating practices, which have been associated with intermediate risk factors of cardio-metabolic diseases. However, knowledge of the magnitude and correlates of these risk factors is limited in Tanzania. This study aimed to fill this gap using data collected from RSFCs in Dar es Salaam, the largest city in Tanzania.

METHODOLOGY

A cross-sectional study was carried out among 560 RSFCs in three districts of Dar es Salaam between July and September 2018. Information on socio-economic factors and demographics, behavioral risks, anthropometric and biochemical indicators was collected. Adjusted odds ratios (OR) and prevalence ratio (PR) with corresponding 95% confidence intervals (CI) were estimated using multivariable binary logistic and modified Poisson regression models, respectively.

RESULTS

On average, participants consumed 11 street food meals/week. The prevalence (95% CI) of cardio-metabolic risk factors was 63.9% (60.6-69.9%) for overweight/obesity, 42.5% (38.3-46.9%) for raised blood pressure, 13.5% (10.9-16.8%) for raised triglycerides and 6.6% (4.9-9.3%) for raised glucose levels. The correlates of overweight/obesity were female vs male sex (APR=1.3; 95% CI 1.2-1.5), age of 41-64 vs 25-40 years (APR=1.4; 95% CI 1.2-1.6), high vs low income (APR=1.2; 95% CI 1.04-1.3), being married/cohabiting vs other (APR=1.2; 95% CI 1.01-1.4) and family history of diabetes vs no family history (APR=1.2; 95% CI 1.01-1.3). Age 41-64 vs 25-40 years, was the only significant factor associated with raised blood pressure APR (95% CI) 2.2 (1.7-2.9) and raised glucose AOR (95% CI) 3.9 (1.5-10.5).

CONCLUSION

Our study revealed that RSFCs are at risk of cardio-metabolic health problems, especially women, middle-aged people and those with higher incomes. Transdisciplinary studies to understand the drivers of street food consumption are needed in order to inform interventions to mitigate the risk of developing cardio-metabolic diseases. These interventions should target both street food vendors and their consumers.

Do Changes in the Local Food Environment Within New Residential Developments Influence the Diets of Residents? Longitudinal Results from RESIDE

Background: There is limited longitudinal evidence supporting a link between food outlet locations and dietary outcomes to inform policy and urban planning. This study examined how longitudinal changes in the local food environment within new residential developments influenced changes in adult dietary intake. Methods: Adult participant data (n = 3223 person-observations) were sourced from the RESIDential Environments (RESIDE) project across three time points between 2004 to 2012 in Perth, Western Australia. Fixed effects regression estimated the relationship between change in spatial exposure to the local food environment, individual behaviours and perceptions of the local food environment with dietary outcome variables (healthy diet score, unhealthy diet score, diet quality score and fruit/vegetable intake). Results: An increase over time in the percentage of healthy food outlets around the home was significantly (p ≤ 0.05) associated with an increase in healthy diet scores and an increase in the distance from home to the nearest café restaurant was significantly (p ≤ 0.05) associated with an increase in diet quality scores. Conclusions: Modifying the local food environment by increasing the relative proportion of healthy food outlets around the home may support healthier dietary intake.

A Dream Deferred: African American Women's Diminished Socioeconomic Returns of Postponing Childbearing from Teenage to Adulthood

Background

Brookings Institution has identified postponing childbirth from teenage to adulthood as a major strategy that is needed for upward social mobility of women. However, according to the Minorities' Diminished Returns (MDRs), the associations between aspirations, investments, behaviors, and socioeconomic position (SEP) may be diminished for marginalized groups such as African Americans.

Objective

To extend the existing knowledge on the MDRs, the current study had two aims: First to compare White and African American women for the association between postponing childbearing to adulthood and SEP in a national sample of American women. Second, to test correlates of postponing childbearing to adulthood and SEP at birth with long term outcomes 15 years later when the child was 15 years old.

Methods

For this longitudinal study, data came from the Fragile Families and Child Well-being Study (FFCWS), a national longitudinal prospective study in the United States (US) that followed an ethnically diverse sample of women from childbirth for 15 years from 1998 to 2016. For the first aim, this study included 2679 women composed of 723 Whites and 1956 African Americans. For the second aim, among 1842 individuals who had available data 15 years later, we measured various economic, behavioral, and mental health outcomes when the child was 15 years old. For aim 1 we ran linear regression. Postponing childbearing to adulthood was the independent variable. The dependent variable, SEP (poverty) was treated as a continuous measure with higher score indicating more poverty. Confounders included marital status and delivery characteristics. For the aim 2, we ran Pearson correlation test (exploratory analysis) to test if baseline SEP correlates with future outcomes.

Results

Postponing childbearing from adolescence to adulthood was associated with higher SEP in adulthood, net of all confounders including marital status and education. We found a significant interaction between postponing childbearing from adolescence to adulthood and race on SEP, suggesting that the economic reward of postponing childbearing may be weaker for African American women than for White women.

Conclusions

Although postponing the age at childbirth is a recommended strategy for women who wish to maximize their chance of upward social mobility, this strategy may be associated with smaller economic returns for African American women than White women. The results can also be interpreted as MDRs in investments in terms of a postponing childbearing. In a fair society, the same investment should be similarly rewarded across diverse racial groups. In the reality, however, the US society differently rewards White and African American women who postpone childbearing. Research should explore the roles of social stratification, blocked opportunities, and concentrated poverty in explaining the unequal return of such an investment for African American and White women.

Overweight and obesity of school-age children in El Salvador according to two international systems: a population-based multilevel and spatial analysis

BACKGROUND

The World Health Organization (WHO-2007) and the International Obesity Task Force (IOTF-Cole) systems assess child weight status. However, derived estimations often differ. We aimed to a) compare the prevalence of overweight and obesity, b) analyze individual and contextual factors associated with child weight using multilevel analysis and c) explore the spatial distribution of overweight and obesity using both classification systems.

METHODS

We used data from the 2015/2016 National School Height and Weight Census in El Salvador. Information on 111,991 children aged 6.0-9.9 years attending the first grade was analyzed. Body mass index Z-score (BMIZ), overweight and obesity were defined with both classification systems. Weighted kappa was used to measure agreement. Child, school and municipal potential determinants of BMIZ were examined by multilevel analysis. Municipal spatial clustering of overweight and obesity was tested using Moran's Index and Getis-ord Gi* statistics.

RESULTS

The combined prevalence of overweight and obesity was higher according to the WHO system than the IOTF (30.4% vs 23.1%). The weighted kappa was 0.83. Boys, children attending urban schools, children attending private schools, and children residing in municipalities with high human development index had higher BMIZ than their counterparts. The Moran's indexes were positives and significant. Clusters of high prevalence (above the national prevalence) of overweight and obesity were found in 29 municipalities using the WHO and IOTF systems. For obesity, 28 and 23 municipalities in clusters of high prevalence were detected using the WHO and IOTF criteria, respectively.

CONCLUSIONS

Overweight and obesity is high among school-age children in El Salvador. The prevalence of overweight and obesity was higher when using the WHO system, as compared to the IOTF system. Irrespective of the classification system, the multilevel and spatial analysis derived similar interpretations. These results support the need for national preventive interventions with targeting strategies to reduce overweight and obesity in school-age children.

Place-Based Diminished Returns of Parental Educational Attainment on School Performance of Non-Hispanic White Youth

BACKGROUND

Youth educational outcomes are a function of a wide range of factors including parental education level. This effect, however, is shown to be smaller for African American, Hispanic, and Asian American youth, a pattern called Marginalization-related Diminished Returns (MDRs). It is, however, unknown if it is race/ethnicity or other conditions associated with race/ethnicity (e.g., poor neighborhood quality) which reduces the marginal returns of parental education for youth.

AIM

To explore whether MDRs are only due to race/ethnicity or if they also remain for non-Hispanic Whites in poor neighborhoods, we compared the association between parental education level and adolescents' school performance based on neighborhood quality in a nationally representative sample of non-Hispanic Whites in the United States.

METHODS

This cross-sectional study used wave 1 of the Add Health study, an ongoing nationally representative cohort, 1994-2019. Participants included 849 non-Hispanic White adolescents between the ages of 12 and 21 years and their parents. The independent variable was parental education level, which was treated as a continuous measure. Age, grade, gender, and parental marital status were the covariates. The dependent variable was school performance (sum of school grades in Math, English, History, and Science). Linear regression models were used for data analysis.

RESULTS

Overall, worse neighborhood quality was associated with worse school performance. Parental education level, however, was not directly associated with youth school performance. We found a statistically significant interaction between parental education level and neighborhood quality suggesting that the strength of the association between parental education and youth school performance weakens as neighborhood quality declines.

CONCLUSION

Parental education level is a more salient determinant of youth educational outcomes in better neighborhoods. The result suggests that MDRs may not be solely due to race/ethnicity but contextual factors that commonly covary with marginalization and poverty. These contextual factors may include segregation, concentration of poverty, and social and physical neighborhood disorder.

Food Environment Research in Low- and Middle-Income Countries: A Systematic Scoping Review

Food environment research is increasingly gaining prominence in low- and middle-income countries (LMICs). However, in the absence of a systematic review of the literature, little is known about the emerging body of evidence from these settings. This systematic scoping review aims to address this gap. A systematic search of 6 databases was conducted in December 2017 and retrieved 920 records. In total, 70 peer-reviewed articles met the eligibility criteria and were included. Collectively, articles spanned 22 LMICs, including upper-middle-income countries (n = 49, 70%) and lower-middle-income countries (n = 18, 26%). No articles included low-income countries. Articles featured quantitative (n = 45, 64%), qualitative (n = 17, 24%), and mixed-method designs (n = 11, 8%). Studies analyzed the food environment at national, community, school, and household scales. Twenty-three articles (55%) assessed associations between food environment exposures and outcomes of interest, including diets (n = 14), nutrition status (n = 13), and health (n = 1). Food availability was associated with dietary outcomes at the community and school scales across multiple LMICs, although associations varied by vendor type. Evidence regarding associations between the food environment and nutrition and health outcomes was inconclusive. The paucity of evidence from high-quality studies is a severe limitation, highlighting the critical need for improved study designs and standardized methods and metrics. Future food environment research must address low-income and lower-middle-income countries, and include the full spectrum of dietary, nutrition, and health outcomes. Improving the quality of food environment research will be critical to the design of feasible, appropriate, and effective interventions to improve public health nutrition in LMICs.

Is the local food environment associated with excess body weight in adolescents in São Paulo, Brazil?

The obesogenic environment stimulates an inadequate diet by hampering healthy choices. This cross-sectional study evaluated the association between the local food environment and the prevalence of overweight and obesity in a representative sample population of adolescents living in the city of São Paulo, Brazil, using multilevel logistic regression models. Among the adolescents, 29.6% were overweight/obese. There were no significant differences between food environment and adolescents’ weight status. However, the presence of fast food restaurants near their home increased the chances of being overweight or obese (OR = 2.53; 95%CI: 1.02-6.27). Results suggest the need to intensify food and nutrition policies, development of culinary skills, and the reduction in prices of healthy foods to facilitate access to these foods, so that adolescents have options in locations to socialize with friends and family.

Neighborhood physical food environment and cardiovascular risk factors in India: Cross-sectional evidence from APCAPS

There has been increasing interest in associations between neighborhood food environments and cardiovascular risk factors. However, results from high-income countries remain inconsistent, and there has been limited research from low- and middle-income countries. We conducted a cross-sectional analysis of the third wave follow-up of the Andhra Pradesh children and parents study (APCAPS) (n = 5764, median age 28.8 years) in south India. We examined associations between the neighborhood availability (vendor density per km2 within 400 m and 1600 m buffers of households) and accessibility (distance from the household to the nearest vendor) of fruit/vegetable and highly processed/take-away food vendors with 11 cardiovascular risk factors, including adiposity measures, glucose-insulin, blood pressure, and lipid profile. In fully adjusted models, higher density of fruit/vegetable vendors within 400 m of participant households was associated with lower systolic blood pressure [-0.09 mmHg, 95% confidence interval (CI): -0.17, -0.02] and diastolic blood pressure (-0.10 mmHg, 95% CI: -0.17, -0.04). Higher density of highly processed/take-away food vendors within 400 m of participant households was associated with higher Body Mass Index (0.01 Kg/m2, 95% CI: 0.00, 0.01), waist circumference (0.22 mm, 95% CI: 0.05, 0.39), systolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.06), and diastolic blood pressure (0.03 mmHg, 95% CI: 0.01, 0.05). However, within 1600 m buffer, only association with blood pressure remained robust. No associations were found for between neighborhood accessibility and cardiovascular risk factors. Lower density of fruit/vegetable vendors, and higher density of highly processed/take-away food vendors were associated with adverse cardiovascular risk profiles. Public health policies regarding neighborhood food environments should be encouraged in south India and other rural communities in south Asia.

Unequal Protective Effects of Parental Educational Attainment on the Body Mass Index of Black and White Youth

BACKGROUND

Parental educational attainment is shown to be protective against health problems; the Minorities' Diminished Returns theory, however, posits that these protective effects tend to be smaller for socially marginalized groups particularly blacks than whites.

AIMS

To explore racial differences in the effect of parental educational attainment on body mass index (BMI) in a national sample of US adolescents.

METHODS

In this cross-sectional study, we used baseline data of 10,701 (8678 white and 2023 black) 12-17 years old adolescents in the Population Assessment of Tobacco and Health (PATH; 2013). Parental educational attainment was the predictor. Youth BMI (based on self-reported weight and height) was the dependent variable. Age, gender, ethnicity, and family structure were covariates. Race was the focal moderator.

RESULTS

Overall, higher parental educational attainment was associated with lower youth BMI. Race, however, moderated the effect of parental educational attainment on BMI, suggesting that the protective effect of parental educational attainment on BMI is significantly smaller for black than white youth.

CONCLUSIONS

In the United States, race alters the health gains that are expected to follow parental educational attainment. While white youth who are from highly educated families are fit, black youth have high BMI at all levels of parental educational attainment. This means, while the most socially privileged group, whites, gain the most health from their parental education, blacks, the least privileged group, gain the least. Economic, social, public, and health policymakers should be aware that health disparities are not all due to lower socioeconomic status (SES) of the disadvantaged group but also diminished returns of SES resources for them. Black-white health disparities exist across all high socioeconomic status (SES) levels.

Parental Educational Attainment and Chronic Medical Conditions among American Youth; Minorities' Diminished Returns

Background: Parental educational attainment is protective against chronic medical conditions (CMCs). According to the minorities’ diminished returns (MDRs) theory, however, the health effects of socioeconomic status (SES) indicators are smaller for socially marginalized groups such as racial and ethnic minorities rather than Whites. Aims: To explore racial and ethnic differences in the effect of parental educational attainment on CMCs in a nationally representative sample of American youth. Methods: In this cross-sectional study, we used baseline data of 10,701 12–17 years old youth in the Population Assessment of Tobacco and Health (PATH; 2013). Parental educational attainment was the independent variable. The dependent variable was the number of CMCs in youth. Age, gender, and family structure were covariates. Race and ethnicity were the focal moderators. Linear and multinomial regression were applied to analyze the data. Results: Overall, higher parental educational attainment was associated with a lower number of CMCs. Race and ethnicity, however, showed significant interactions with parental educational attainment on a number of CMCs as well as 2+ CMCs, suggesting that the effect of parenting educational attainment on CMCs is significantly smaller for Black and Hispanic than White youth. Conclusions: In the United States, race and ethnicity alter the health gains that are expected to follow parental educational attainment. While White youth who are from highly educated families are most healthy, Black and Hispanic youth from highly educated families remain at higher risk for CMCs. That means, while the most socially privileged group, Whites, gain the most health from their parental education, Blacks and Hispanics, the least privileged groups, gain the least. The result is a disproportionately high number of CMCs in middle-class Blacks and Hispanics. Economic, social, public, and health policy makers should be aware that health disparities are not all due to lower SES of the disadvantaged group but also diminished returns of SES resources for them. Youth physical health disparities due to race and ethnicity exist across all SES levels.

Progress Evaluation for Transnational Restaurant Chains to Reformulate Products and Standardize Portions to Meet Healthy Dietary Guidelines and Reduce Obesity and Non-Communicable Disease Risks, 2000-2018: A Scoping and Systematic Review to Inform Policy

Transnational restaurant chains sell food and beverage products in 75 to 139 countries worldwide linked to obesity and non-communicable diseases (NCDs). This study examined whether transnational restaurant chains reformulated products and standardized portions aligned with healthy dietary guidelines and criteria. Firstly, we describe the transnational restaurant industry structure and eating trends. Secondly, we summarize results from a scoping review of healthy dietary guidelines for restaurants. Thirdly, we describe a systematic review of five electronic databases (2000-2018) to identify studies on nutrient profile and portion size changes made by transnational restaurants over 18 years. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, identified 179 records, and included 50 studies conducted in 30 countries across six regions. The scoping review found a few expert-recommended targets for restaurants to improve offerings, but no internationally accepted standard for portions or serving sizes. The systematic review results showed no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve menu offerings. There was wide variation within and across countries, regions, firms, and chains to reduce energy, saturated and trans fats, sodium, and standardized portions. These results may inform future research and encourage transnational chain restaurants to offer healthy product profiles and standardized portions to reduce obesity and NCD risks worldwide.

Obesity in South Asia: Phenotype, Morbidities, and Mitigation

PURPOSE OF REVIEW

Obesity has increased in South Asian countries that are still grappling with undernutrition. In this review, we highlight the characteristics of obesity, its relation to morbidities, and its management in South Asians. A literature search was conducted using relevant search engines and based on key words focusing on obesity in South Asians.

RECENT FINDINGS

The increasing trend in obesity prevalence is caused by imbalanced diets and physical inactivity. South Asians, in general, have higher body fat and lower skeletal muscle mass at the same or lower BMIs compared to white people ("high body fat-normal BMI-low muscle mass" phenotype). In addition, excess abdominal adiposity, typically seen in South Asians, and increased hepatic fat (non-alcoholic fatty liver disease) are associated with an increased risk for type 2 diabetes and cardiovascular disease. Challenges in treatment include lack of awareness regarding correct diets and non-compliance to diet and exercise regimens. Social and cultural issues limit physical activity in South Asian women. Finally, there is a lack of expert health professionals to deal with increased cases of obesity. Aggressive management of obesity is required in South Asians, with more intensive and earlier diet and exercise interventions (i.e., at lower BMI levels than internationally accepted). At a population level, there is no clear policy for tackling obesity in any South Asian country. Prevention strategies focusing on obesity in childhood and the creation of food and activity environments that encourage healthy lifestyles should be firmly applied. Obesity in South Asians should be evaluated with ethnic-specific guidelines and prevention and management strategies should be applied early and aggressively.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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