'Obesogenic' School Food Environments? An Urban Case Study in The Netherlands

Time-varying exposure to food retailers and cardiovascular disease hospitalization and mortality in the netherlands: a nationwide prospective cohort study

BACKGROUND

Very few studies to date investigated the prospective association of changes in exposure to the food environment with cardiovascular disease (CVD) risk. We aim to explore if time-varying exposure to the food environment was associated with hospitalization and mortality due to total and specific types of CVD in The Netherlands.

METHODS

In this prospective cohort study, 4,641,435 Dutch adults aged 35 + years who did not change residence in 2002-2018 were identified through registry data. Exposure to the food environment was defined as time-varying Food Environment Healthiness Index (FEHI) scores (range: - 5 to 5) and time-varying kernel density of specific food retailers (e.g., fast food outlets, supermarkets) around the home location between 2004 and 2018. The main outcome measures were hospitalization and mortality due to overall CVD, stroke, HF, and CHD occurring between 2004 and 2020, based on hospital and death registries.

RESULTS

In Cox regression models, each unit increase in the FEHI was associated with a lower hospitalization and mortality of CVD (hospitalization hazard ratio (HRh) = 0.90 (0.89 to 0.91), mortality hazard ratio (HRm) = 0.85 (0.82 to 0.89)), CHD (HRh = 0.88 (0.85 to 0.91), HRm = 0.80 (0.75 to 0.86)), stroke (HRh = 0.89 (0.84 to 0.93)), HRm = 0.89 (0.82 to 0.98)), and HF (HRh = 0.90 (0.84-0.96), HRm = 0.84 (0.76 to 0.92)). Increased density of local food shops, fast food outlets, supermarkets, and convenience stores and decreased density of food delivery outlets and restaurants were associated with a higher risk of CVD, CHD, stroke, and HF hospitalization and mortality.

CONCLUSIONS

In this observational longitudinal study, changes in exposure to a healthier food environment over 14 years were associated with a risk reduction in CVD hospitalization and mortality, in particular in urbanized areas and for younger adults and those with higher incomes.

Moderators and mediators of the association between the obesogenicity of neighbourhoods and weight status in Dutch adults

This study aimed to assess sociodemographic, personality, and psychological moderators, and lifestyle behavioural mediators, of the association between obesogenicity of neighbourhoods and weight status in Dutch adults. This cross-sectional study used baseline data of 150,506 adult participants of the Lifelines study. To quantify obesogenicity of Dutch neighbourhoods, the Obesogenic Built Environment CharacterisTics (OBCT) index was used, calculated for 1000 m circular buffers around participant's residencies. Z-scores of components across food and physical activity (PA) environments were averaged, and rescaled from 0 to 100. Weight status was operationalised as objectively measured waist circumference. Stratified linear regression analyses by (self-reported) sociodemographic factors, perceived stress, impulsivity, self-discipline, and deliberation were conducted when interaction terms were significant (P < .01). Mediation by adherence to the Dutch PA guidelines and dietary behaviour was examined using the difference-in-coefficients approach. Every 10% increase in OBCT index was associated with a 0.65 (P < .001, 95%CI [0.59, 0.71]) centimetre larger waist circumference. The association was largest for respondents who were younger, had the lowest income, the highest educational level, the least self-discipline, the highest impulsivity scores and the most perceived stress. Adherence to PA guidelines and dietary behaviour mediated 13.3% of this association; however, the difference in coefficients was not statistically significant. Our findings enable to better target lifestyle interventions to individuals most vulnerable to obesogenic environments. Furthermore, they provide guidance for policymakers and urban planners in promoting health-enhancing environments.

Effect of fast-food environments on children's eating behaviour: A random effect within between analysis within the Generation R Study

BACKGROUND

Focussing on appetitive traits associated with obesity, this study aimed to estimate the association between the fast-food environment and satiety responsiveness, enjoyment of food and food responsiveness.

METHODS

We used data from the Generation R Study. We included 2008 children with repeated measurements at the age of 4-10 years old. Three eating behaviour subscales from the Child Eating Behaviour Questionnaire (CEBQ) were used as outcomes. Geographical Information System data were used to map individual-level exposure to fast-food outlets within 400 m from home. Random Effect Within Between (REWB) models were used to derive estimates. We tested for moderation of the associations with parental restriction at baseline using the parent-reported Child Feeding Questionnaire (CFQ).

RESULTS

We did not find evidence of between-associations of fast-food exposure and eating behaviour subscales. Considering within-associations, an increase in absolute fast-food exposure was associated with a significant marginal increase in satiety responsiveness (β: 0.02 [95% confidence interval: 0.00-0.03]). No moderation by parental restriction was found.

CONCLUSIONS

In environments with ubiquitous fast-food outlets, an increased exposure to fast-food outlets does not seem to have a substantial impact on eating behaviour. Further research is needed to better understand how fast-food exposure contributes to overweight.

The association of obesogenic environments with weight status, blood pressure, and blood lipids: A cross-sectional pooled analysis across five cohorts

In this observational cross-sectional study, we investigated the relationship between combined obesogenic neighbourhood characteristics and various cardiovascular disease risk factors in adults, including BMI, systolic blood pressure, and blood lipids, as well as the prevalence of overweight/obesity, hypertension, and dyslipidaemia. We conducted a large-scale pooled analysis, comprising data from five Dutch cohort studies (n = 183,871). Neighbourhood obesogenicity was defined according to the Obesogenic Built-environmental CharacterisTics (OBCT) index. The index was calculated for 1000m circular buffers around participants' home addresses. For each cohort, the association between the OBCT index and prevalence of overweight/obesity, hypertension and dyslipidaemia was analysed using robust Poisson regression models. Associations with continuous measures of BMI, systolic blood pressure, LDL-cholesterol, HDL-cholesterol, and triglycerides were analysed using linear regression. All models were adjusted for age, sex, education level and area-level socio-economic status. Cohort-specific estimates were pooled using random-effects meta-analyses. The pooled results show that a 10 point higher OBCT index score was significantly associated with a 0.17 higher BMI (95%CI: 0.10 to 0.24), a 0.01 higher LDL-cholesterol (95% CI: 0.01 to 0.02), a 0.01 lower HDL cholesterol (95% CI: -0.02 to -0.01), and non-significantly associated with a 0.36 mmHg higher systolic blood pressure (95%CI: -0.14 to 0.65). A 10 point higher OBCT index score was also associated with a higher prevalence of overweight/obesity (PR = 1.03; 95% CI: 1.02 to 1.05), obesity (PR = 1.04; 95% CI: 1.01 to 1.08) and hypertension (PR = 1.02; 95% CI: 1.00 to 1.04), but not with dyslipidaemia. This large-scale pooled analysis of five Dutch cohort studies shows that higher neighbourhood obesogenicity, as measured by the OBCT index, was associated with higher BMI, higher prevalence of overweight/obesity, obesity, and hypertension. These findings highlight the importance of considering the obesogenic environment as a potential determinant of cardiovascular health.

A spatial examination of alcohol availability and the level of disadvantage of schools in Ireland

BACKGROUND

The availability of alcohol is a major factor in underage drinking and according to the alcohol harm paradox, those living in more deprived communities are more susceptible to the negative consequences of alcohol use, despite drinking the same or less than those from more affluent areas. Alcohol availability within the vicinity of the home or school normalises alcohol for schoolchildren. For the first time in the Republic of Ireland, this study examines the number of premises licensed to sell alcohol within 300 m of all schools in Ireland and differences in this number between disadvantaged and non-disadvantaged schools.

METHODS

Using publicly available data from the Department of Education and Revenue, the addresses of all schools (n = 3,958) and all premises with at least one liquor licence (n = 14,840) were geocoded and analysed using the Geographic Information System software, Quantum GIS (QGIS). Schools were identified by their disadvantaged classification using the HP Pobal Deprivation Index and the number of liquor licences within 300 m of each school type was examined. To test for significant differences between schools' level of disadvantage, a combination of Mann-Whitney U tests, Kruskal-Wallis tests and Dunn-Bonferroni tests were used.

RESULTS

There was a mean of two licenced premises within 300 m of all schools in Ireland, but when disadvantaged schools were compared to non-disadvantaged schools, there was a significantly higher number of licenced premises around disadvantaged schools (p < .001). Primary schools are further classified according to their level of disadvantage and the results indicated that those schools classified as the most disadvantaged had a significantly greater number of liquor licences within 300 meters (p < .001). There was no significant difference in density of licenced premises when comparing disadvantaged secondary schools with non-disadvantaged secondary schools (p = .705).

CONCLUSION

Ireland is considering increasing alcohol availability through the Sale of Alcohol Bill, 2022. However, this analysis indicates already problematic numbers of licenced premises within close proximity of schools in Ireland. It is essential that the harms associated with alcohol availability are considered, especially for those living and attending school in disadvantaged communities, where higher numbers of licenced premises were identified.

Scanning for Obesogenicity of Primary School Environments in Tshwane, Gauteng, South Africa

The purpose of this study was to scan for the obesogenicity of primary school environments in Tshwane, Gauteng, South Africa. This study was carried out in ten public primary schools in the Tshwane West district of the Gauteng province. An observational design was used to collect the data. Data collection was conducted using an observational checklist guided by the Analysis Grid for Environments Linked to Obesity (ANGELO) framework. The findings revealed that although a nutrition policy was available in most schools, few schools were communicating the policy. Despite all the schools having sports fields, children were not exercising. Most schools also had a school nutrition programme. Most primary schoolchildren's lunchboxes contained sweets, sugar-sweetened beverages, and snacks. A few lunchboxes contained fruits and vegetables. Primary schools in Tshwane West did not comply with most aspects of the school mapping environment, indicating that the school environments were obesogenic. It is therefore essential to scan for obesogenicity in all South African schools so that tailor-made interventions can be implemented to rectify and further prevent obesogenic school environments.

Retail Food Environment around Schools in Barcelona by Neighborhood Socioeconomic Status: Implications for Local Food Policy

Childhood obesity is a relevant public health problem. The school food environment has been identified as an important factor for promoting healthy eating behaviors. This study assessed the availability of and proximity to unhealthy food stores around schools (n = 22) in the city of Barcelona and its association with neighborhood socioeconomic status (NSES). We conducted this cross-sectional study between 2019 and 2020. First, we identified all food retailers (n = 153) within a 400-m buffer around each school and identified those selling unhealthy food products. Then, we used Poison regression models to measure the association between NSES and the healthy food availability index (HFAI), adjusting for population density and distance. A total of 95% of the food establishments studied were classified as unhealthy (n = 146). In all, 90% of schools that had, at least, two unhealthy retailers in their proximity. There were significant differences in the mean distance to unhealthy establishments according to neighborhood SES and population density (p < 0.05). We found a positive association between schools located in higher SES neighborhoods and a higher availability and affordability of healthy food products (IIR = 1.67, 95% CI = 1.45−1.91 p = 0.000). We found strong social inequalities in the supply of healthy foods in Barcelona. Local food policy interventions addressing retail food environment around schools should consider socioeconomic inequalities.

Adolescents' food intake changes during the COVID-19 pandemic: The moderating role of pre-pandemic susceptibility, COVID-19 related stressors, and the social food context

Although insight in how adolescents' food intake is affected by the COVID-19 pandemic is critical, knowledge is limited. Hence, this longitudinal study (N = 691, Mage = 14.30, SDage = 0.62; 52.5% female) investigated changes in adolescents' unhealthy (sugar-sweetened beverages, sweet snacks, savoury snacks) and healthy (fruit and vegetables) food intake (in total, obtained from home, and from outside the home) from pre-pandemic (Spring 2019) to the first lockdown (Spring 2020) and to six months later (Fall 2020). Moreover, several moderating factors were assessed. Results showed that the intake of unhealthy and healthy food in total and obtained from outside the home decreased during the lockdown. Six months later, unhealthy food intake returned to pre-pandemic levels, while healthy food intake remained lower. COVID-19 stressful life events and maternal food intake further qualified these longer-term changes in intake of sugar-sweetened beverages and fruit and vegetables, respectively. Future work is warranted to elucidate longer-term COVID-19 effects on adolescents' food intake.

Comparison between the Choices Five-Level Criteria and Nutri-Score: Alignment with the Dutch Food-Based Dietary Guidelines

The current food environment in The Netherlands is considered obesogenic. Eighty percent of the products in supermarkets are unhealthy. The Wheel of Five is the well-established, science-based Dutch food-based dietary guideline (FBDG) developed to stimulate healthier choices. In addition, simple directions on food packaging, such as front-of-package (FOP) health logos, could also be helpful. However, these tools should be in line with each other, in order not to confuse the consumer. To study this, we evaluated two FOP nutrient profiling systems (NPSs) for their alignment with the Wheel of Five: Choices five-level criteria and Nutri-Score. For this, a small but representative sample of 124 products was selected from the Dutch food composition database (NEVO). For these products, the scores for Choices and Nutri-Score were calculated using the published criteria, while compliance with the Wheel of Five was established by using the criteria from Netherlands Nutrition Center (NNC). The Wheel of Five food groups were used to categorize the products. Differences between the Wheel of Five and Choices are smaller than with Nutri-Score, concluding that Choices is more consistent with the Wheel of Five and might be an attractive alternation for a FOP health logo on the Dutch market.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

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

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

The Food Environment Around Primary Schools in a Diverse Urban Area in the Netherlands: Linking Fast-Food Density and Proximity to Neighbourhood Disadvantage and Childhood Overweight Prevalence

In the Netherlands, the neighbourhood food environment has received little attention in initiatives to combat overweight/obesity. This study maps the food environment around primary schools in The Hague, The Netherlands, and examines associations between neighbourhood disadvantage, the school food environment and childhood overweight using Geographic Information Systems (GIS). Linear regression analyses were performed to test the association between schools' disadvantage scores (proxy for neighbourhood disadvantage) and relative fast-food density within 400 m and 1000 m and fast-food proximity. Univariable and multivariable linear regression analyses were used to test the association between the school food environment and overweight prevalence among children in the respective sub-district in which the schools is found. Multivariable analyses were adjusted for the schools' disadvantage scores. Results show that fast-food outlets were available around most primary schools. Schools in disadvantaged neighbourhoods were closer to and surrounded by a higher number of fast-food restaurants, grillrooms and kebab shops. On the sub-district level, the density of such fast-food outlets was associated with overweight prevalence among children. These findings highlight the importance of national and local policies to improve the food environment, particularly in disadvantaged neighbourhoods.

Food Availability in Different Food Environments Surrounding Schools in a Vulnerable Urban Area of Santiago, Chile: Exploring Socioeconomic Determinants

The analysis of the food environment is used to identify areas with gaps in the availability of healthy foods and can be used as a public policy assessment tool. In recent decades, Chile has implemented several strategies and regulations to improve food environments, with encouraging results. Little is known about the scope of these measures in socially vulnerable environments. This study is part of a project that seeks to build an integrated intervention model for healthy school environments in a vulnerable area of Santiago, Chile. The objective of this study was to evaluate the availability of healthy and unhealthy foods around schools and the relationship between it and socioeconomic determinants of the school community in the Chilean context. A cross-sectional study to measure the food environment of informal markets (street food), formal markets (stores), and institutions (schools) was conducted in and around 12 schools (100 m surrounding schools) in a vulnerable urban area of Santiago, Chile. A lack of healthy foods was observed, which was related to some socio-economic determinants and the multidimensional poverty was the most relevant. The diagnosis of food environments around schools can represent an important target for governments to implement policies focused at improving the availability of healthy foods.

Associations of socioeconomic status indicators and migrant status with risk of a low vegetable and fruit consumption in children

Background

It is important to provide insight in potential target groups for interventions to reduce socioeconomic inequalities in children's vegetable/fruit consumption. In earlier studies often single indicators of socioeconomic status (SES) or migrant status have been used. However, SES is a multidimensional concept and different indicators may measure different SES dimensions. Our objective is to explore multiple associations of SES indicators and migrant status with risk of a low vegetable/fruit consumption in a large multi-ethnic and socioeconomically diverse sample of children.

Methods

We included 5,010 parents of 4- to 12-year-olds from a Dutch public health survey administered in 2018. Cross-sectional associations of parental education, material deprivation, perceived financial difficulties, neighbourhood socioeconomic status (NSES) and migrant status with low (≤4 days a week) vegetable and fruit consumption in children were assessed using multilevel multivariable logistic regression models. Results are displayed as odds ratios (OR) with 95% confidence intervals (CI).

Results

Of the 4- to 12-year-olds, 22.1% had a low vegetable consumption and 11.9% a low fruit consumption. Low (OR 2.51; 95%CI: 2.05, 3.07) and intermediate (OR 1.83; 95%CI: 1.54, 2.17) parental education, material deprivation (OR 1.45; 95%CI: 1.19, 1.76), low NSES (OR 1.28; 95%CI: 1.04, 1.58) and a non-Western migrant status (OR 1.94; 95%CI: 1.66, 2.26) were associated with a higher risk of a low vegetable consumption. Low (OR 1.68; 95%CI: 1.31, 2.17) and intermediate (OR 1.39; 95%CI: 1.12, 1.72) parental education and material deprivation (OR 1.63; 95%CI: 11.27, 2.08) were also associated with a higher risk of a low fruit consumption.

Conclusion

Our findings indicate associations of multiple SES indicators and migrant status with a higher risk of a low vegetable/fruit consumption in children and thus help to identify potential target groups.

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Vegetable and fruit consumptions on 4 days or less a week is reported for respectively 22.1% and 11.9% of children.

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Children's vegetable but not fruit consumption differs between neighbourhoods.

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A non-Western migrant status and a low socio-economic status of the neighbourhood are associated with low vegetable consumption.

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Low/intermediate education and material deprivation are associated with low vegetable and fruit consumption.

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This study provides clues to potential entry points for reducing inequalities in vegetable and fruit consumption.

The role of material and psychosocial resources in explaining socioeconomic inequalities in diet: A structural equation modelling approach

We examined whether material and psychosocial resources may explain socioeconomic differences in diet quality. Cross-sectional survey data from 1461 Dutch adults (42.5 (SD 13.7) years on average and 64% female) on socio-demographics, diet quality, psychosocial factors and perceptions of and objective healthiness of the food environment were used in a structural equation model to examine mediating pathways. Indicators for socioeconomic position (SEP) were income, educational, and occupational level and the 2015 Dutch Healthy Diet (DHD15) index assessed diet quality. Material resources included food expenditure, perceptions of healthy food accessibility and healthfulness of the food retail environment. Psychosocial resources were cooking skills, resilience to unhealthy food environments, insensitivity to food cues and healthy eating habits. Higher SEP was associated with better diet quality; Beducation 8.5 (95%CI 6.7; 10.3), Bincome 5.8 (95%CI 3.7; 7.8) and Boccupation 7.5 (95%CI 5.5; 9.4). Material resources did not mediate the association between SEP and diet quality and neither did the psychosocial resources insensitivity to food cues and eating habits. Cooking skills mediated between 13.3% and 19.0% and resilience to unhealthy food environments mediated between 5.9% and 8.6% of the relation between SEP and the DHD15-index. Individual-level factors such as cooking skills can only explain a small proportion of the SEP differences in diet quality. On top of other psychosocial and material resources not included in this study, it is likely that structural factors outside the individual, such as financial, work and living circumstances also play an important role.

Human spatial memory is biased towards high-calorie foods: a cross-cultural online experiment

Background

Human memory appears to prioritise locations of high-calorie foods, likely as an adaptation for foraging within fluctuating ancestral food environments. Importantly, this “high-calorie bias” in human spatial memory seems to yield consequences for individual eating behaviour in modern food-abundant settings. However, as studies have mainly been conducted in European (Dutch) populations to date, we investigated whether the existence of the cognitive bias can be reasonably generalised across countries that vary on culturally-relevant domains, such as that of the USA and Japan. Furthermore, we investigated whether sociodemographic factors moderate the expression of the high-calorie spatial memory bias in different populations.

Methods

In a cross-cultural online experiment, we measured the food location memory of diverse participants from the USA (N = 72; 44.4% Male; 54 ± 15.99 years) and Japan (N = 74; 56.8% Male; 50.85 ± 17.32 years), using a validated computer-based spatial memory task with standardised images of high-calorie and low-calorie foods. To directly compare the magnitude of the high-calorie spatial memory bias in a broader cultural scope, we also included data from a previous online experiment that identically tested the food spatial memory of a Dutch sample (N = 405; 56.7% Male; 47.57 ± 17.48 years).

Results

In the US sample, individuals more accurately recalled (i.e. had lower pointing errors for) locations of high-calorie foods versus that of low-calorie alternatives (Mean difference = -99.23 pixels, 95% CI = [-197.19, -1.28]) – regardless of one’s hedonic preferences, familiarity with foods, and encoding times. Likewise, individuals in the Japanese sample displayed an enhanced memory for locations of high-calorie (savoury-tasting) foods (Mean difference = -40.41 pixels, 95% CI = [-76.14, -4.68]), while controlling for the same set of potential confounders. The magnitude of the high-calorie bias in spatial memory was similar across populations (i.e. the USA, Japan, and the Netherlands), as well as across diverse sociodemographic groups within a population.

Conclusions

Our results demonstrate that the high-calorie bias in spatial memory transcends sociocultural boundaries. Since the cognitive bias may negatively impact on our dietary decisions, it would be wise to invest in strategies that intervene on our seemingly universal ability to efficiently locate calorie-rich foods.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-022-01252-w.

Association between food-outlet availability near secondary schools and junk-food purchasing among Australian adolescents

OBJECTIVES

We sought to investigate the association between food-outlet availability near Australian secondary schools and frequency of Australian students' discretionary food purchases.

METHODS

Secondary-school students in Perth (Western Australia) reported the frequency of their discretionary food purchases from food outlets near their school (17 schools, n = 2389 students grades 7-12, ages 12-17 y). Food-outlet availability was sourced from local governments, then geocoded. A mixed-effects model was used in analyses.

RESULTS

Almost half of students (45%) purchased discretionary foods from food outlets near their secondary school at least weekly. Only the density of top-ranking fast-food chain outlets near secondary schools was associated with a significant increase in the frequency of discretionary food purchases.

CONCLUSIONS

Availability of major fast-food chains near Australian secondary schools appears to be a key driver of Australian students' discretionary food purchasing. Restricting these outlets near schools may help reduce adolescents' discretionary food intake.

Does the neighbourhood food environment contribute to ethnic differences in diet quality? Results from the HELIUS study in Amsterdam, the Netherlands

OBJECTIVE

The aim of the current study was to establish whether the neighbourhood food environment, characterised by the healthiness of food outlets, the diversity of food outlets and fast-food outlet density within a 500 m or 1000 m street network buffer around the home address, contributed to ethnic differences in diet quality.

DESIGN

Cross-sectional cohort study.

SETTING

Amsterdam, the Netherlands.

PARTICIPANTS

Data on adult participants of Dutch, South-Asian Surinamese, African Surinamese, Turkish and Moroccan descent (n total 4728) in the HELIUS study were analysed.

RESULTS

The neighbourhood food environment of ethnic minority groups living in Amsterdam is less supportive of a healthy diet and of less diversity than that of participants of Dutch origin. For example, participants of Turkish, Moroccan and South-Asian Surinamese descent reside in a neighbourhood with a significantly higher fast-food outlet density (≤1000 m) than participants of Dutch descent. However, we found no evidence that neighbourhood food environment characteristics directly contributed to ethnic differences in diet quality.

CONCLUSION

Although ethnic minority groups lived in less healthy food environments than participants of ethnic Dutch origin, this did not contribute to ethnic differences in diet quality. Future research should investigate other direct or indirect consequences of residing in less supportive food environments and gain a better understanding of how different ethnic groups make use of their neighbourhood food environment.

Opportunities for Capacity Building to Create Healthy School Communities in the Netherlands: Focus Group Discussions With Dutch Pupils

Background: To sustainably implement a healthy school community in which stakeholders, including pupils, feel ownership over health-promotion activities, building community capacity is important. Pupils have experiential knowledge that is complementary to professional knowledge, but their perspectives on capacity-building processes are underexposed. This study aims to explore secondary-school pupils' perceptions about key influencers on physical activity and dietary choices and starting points for building community capacity.

Methods: Seven focus groups with forty one pupils were held in four secondary schools engaged in a capacity-building intervention. Transcripts were analysed thematically regarding key influencers about choices in the home and school setting and capacity-building strategies (leadership, participation, tailored health-promotion activities and local networks).

Results: Parents remained important influencers for making healthy choices, but snacking choices were increasingly made independently from parents based on attractiveness, availability and cost. Choices to engage in physical activity depended on social aspects and opportunities in the physical environment. Pupils considered their influence over the healthy school community limited, desired more involvement, but require this to be facilitated. They identified leaders mainly within formal structures, for example, student councils. They believed health-promotion activities related to the physical environment and project-based activities within the curriculum have the maximum potential to stimulate healthy behaviours in school communities.

Conclusion: This study shows that pupils can reflect critically on their physical activity and dietary choices, and on how this can contribute to processes in creating a healthy school community. In order to take an active role, they need to be considered as full partners and leadership roles should be facilitated in existing structures.

Socioeconomic inequalities in the food environment and body composition among school-aged children: a fixed-effects analysis

BACKGROUND

There is limited evidence regarding socioeconomic inequalities of exposure to the food environment and its contribution to childhood obesity.

METHODS

We used data from 4235 children from the Generation R Study, a large birth-cohort conducted in the city of Rotterdam, The Netherlands. We included 11,277 person-observations of body mass index (BMI) and 6240 person-observations of DXA-derived fat mass index (FMI) and fat-free mass index (FFMI) when children were between 4 and 14 years. We applied linear regression models to evaluate changes in the relative and absolute exposure of fast-food outlets, and the healthiness of the food environment within 400 m from home by maternal education. Furthermore, we used individual-level fixed-effects models to study changes in the food environment to changes in BMI, FMI and FFMI.

RESULTS

Children from lower educated mothers were exposed to more fast-food outlets at any time-point between the age of 4 and 14 years. Over a median period of 7.1 years, the absolute (0.6 fast-food outlet (95% CI: 0.4-0.8)) and relative (2.0%-point (95% CI: 0.7-3.4)) amount of fast-food outlets increased more for children from lower as compared to higher educated mothers. The food environment became more unhealthy over time, but no differences in trends were seen by maternal education level. Changes in the food environment were not associated with subsequent changes in BMI, FMI and FFMI. For children from lower educated mothers not exposed to fast-food at first, we found some evidence that the introduction of fast-food was associated with small increases in BMI.

CONCLUSIONS

Our findings provide evidence of widening inequalities in exposure to fast-food in an already poor food environment. Access to more fast-food outlets does not seem to have an additional impact on BMI in contemporary contexts with ubiquitous fast-food outlets.

Effectiveness of behavioral interventions and behavior change techniques for reducing soft drink intake in disadvantaged adolescents: A systematic review and meta-analysis

Reducing sugar-sweetened beverage (SSB) intake is an important dietary target, especially among socioeconomically disadvantaged ethnic minority adolescents. This review and meta-analysis evaluated the effectiveness of behavioural interventions aiming to reduce SSB intake in socioeconomically disadvantaged ethnic minority adolescents and examined which behaviour change techniques (BCTs) were most effective. A systematic search was conducted using the PRISMA criteria. Quality assessments were done using the Cochrane criteria. In a narrative synthesis, studies were divided into effective and non-effective, and relative effectiveness ratios of individual BCTs were calculated. Pooled standardized mean differences (SMDs) and their 95% confidence intervals were estimated with random-effects models using cluster robust methods. Twenty-two studies were included in the qualitative synthesis. A meta-analysis (n = 19) revealed no significant between-group differences in reduction of SSB intake. Five self-regulatory BCTs had an effectiveness ratio >50%: feedback, goal-setting, action planning, self-monitoring and problem-solving/barrier identification. The risk of bias assessments were judged to be moderate to high risk for randomized controlled trials (RCTs) studies and low to moderate for pre-post studies. There was no indication of publication bias. In conclusion, self-regulatory BCTs may be effective components to change SSB behaviour. However, high-quality research is needed to evaluate the effectiveness of behavioural interventions and identify BCTs effective for reducing SSB intake among disadvantaged adolescents with ethnic minority backgrounds.

Deep phenotyping meets big data: the Geoscience and hEalth Cohort COnsortium (GECCO) data to enable exposome studies in The Netherlands

Environmental exposures are increasingly investigated as possible drivers of health behaviours and disease outcomes. So-called exposome studies that aim to identify and better understand the effects of exposures on behaviours and disease risk across the life course require high-quality environmental exposure data. The Netherlands has a great variety of environmental data available, including high spatial and often temporal resolution information on urban infrastructure, physico-chemical exposures, presence and availability of community services, and others. Until recently, these environmental data were scattered and measured at varying spatial scales, impeding linkage to individual-level (cohort) data as they were not operationalised as personal exposures, that is, the exposure to a certain environmental characteristic specific for a person. Within the Geoscience and hEalth Cohort COnsortium (GECCO) and with support of the Global Geo Health Data Center (GGHDC), a platform has been set up in The Netherlands where environmental variables are centralised, operationalised as personal exposures, and used to enrich 23 cohort studies and provided to researchers upon request. We here present and detail a series of personal exposure data sets that are available within GECCO to date, covering personal exposures of all residents of The Netherlands (currently about 17 M) over the full land surface of the country, and discuss challenges and opportunities for its use now and in the near future.

Adolescents' Food Purchasing Patterns in The School Food Environment: Examining the Role of Perceived Relationship Support and Maternal Monitoring

The school food environment plays a role in adolescents’ dietary behaviors. In this study, adolescents’ food purchasing patterns in and around school and its potential relationship with perceived maternal relationship support and maternal monitoring were examined. Data were collected in The Netherlands in 2017. A total of 726 adolescents (45.8% boys; M_age = 13.78 ± 0.49) and 713 mothers (M_age = 45.05 ± 4.45) participated. Adolescents’ frequency of bringing and purchasing foods was assessed via a Food Frequency Questionnaire (FFQ). Relationship support and monitoring were measured via self-report questionnaires. Structural Equation Modelling (SEM) was conducted to examine associations between adolescents’ food purchasing patterns, relationship support, and monitoring. Results indicated that adolescents brought food and drinks mostly from home, and infrequently purchased these products in and around school. Yet, differences exist between subgroups of adolescents. Relationship support was positively associated with bringing fruit, vegetables and salad and negatively associated with purchasing sweet snacks. No associations were found for monitoring. These findings indicate that family-home determinants of healthy and unhealthy eating are important factors to consider when examining the impact of the school food environment on adolescents’ food purchasing patterns. This has implications for policy makers who aim to develop and implement measures to improve adolescents’ eating in and around school.

Food democracy, health disparities and the New York City trans fat policy

OBJECTIVE

To investigate food democracy and health disparities in the New York City (NYC) trans fat policy process.

DESIGN

Texts from semi-structured interviews, public testimony and comments on the policy were analysed using categorization and thematic coding. A priori content analysis for themes of food democracy was followed by open, axial and selective coding for sub-themes on health disparities. Data and method triangulation and respondent validation were used to establish data dependability, trustworthiness and representativeness.

SETTING

NYC.

PARTICIPANTS

Interviews from a purposive, snowballed sample of thirty-three participants included restaurateurs, scientists, health and consumer advocates, consumers and policy makers. Additionally, 261 pages of transcript from public testimony of fifty-three participants and a purposive sample of public comments on the policy from a pool of 2157 were analysed.

RESULTS

Principles of food democracy involving inclusive citizenship, access to information, collaborative participation and focus on collective good were well represented in the data. Additionally, sub-themes linked to health disparities included: government responsibility for fairer access to healthier foods; recognition that people made choices based on circumstances; concern for vulnerable groups; and outrage with a food industry viewed as unconcerned for public health.

CONCLUSIONS

Principles of food democracy present in the successful process of adoption of the 2006 NYC trans fat policy addressed nutrition-related health. Food democracy is a contemporary food system and policy approach with potential for public health benefits in reducing nutrition-related health disparities.

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

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

Where is the fruit? Multidimensional inequalities in food retail environments around public elementary schools

BACKGROUND

The increasing number of convenience and small food stores may be contributing to the rising childhood obesity rate in the United States; however, the literature assessing food environments surrounding elementary schools in this country is relatively limited. This study determines (a) whether the food environments around public elementary schools is of significantly lower quality than those of other areas in the United States and (b) how the quality of the school food environment is associated with local socio-economic factors and geographical components.

METHODS

Data for 52,375 public elementary schools as well as 96,652 convenience stores, 65,044 small food stores, and 44,383 supermarkets/grocery stores were obtained from the National Center of Education Statistics and the U.S. Department of Agriculture. A two-sample t test was applied to compare the food environment within 0.5-mile buffer around schools and that in the remaining area of each county. A binomial regression model was constructed to examine the impact of socio-economic and geographical factors on unequal food environments.

RESULTS

The food environment within 0.5 mile around schools is of significantly poorer quality than that of the rest of the test area (p < .001). The quality of the food environment around schools is highly associated with such socio-economic factors as median household income (OR = 1.000, p < .01) and percentage of minority population (OR = 0.989, p < .01). Quality also varies geographically, with poorer quality in the Midwest (OR = 0.722, p < .05) and northeast (OR = 0.328, p < .001) than in the south and west and lower quality in metro counties (OR = 0.627, p < .01) than in rural and nonmetro counties.

CONCLUSION

Our findings stress the importance of awareness for improving food retail environments around elementary schools for the benefit of our children.

Obesity and Urban Environments

Obesity is a major public health issue, affecting both developed and developing societies. Obesity increases the risk for heart disease, stroke, some cancers, and type II diabetes. While individual behaviours are important risk factors, impacts on obesity and overweight of the urban physical and social environment have figured large in the recent epidemiological literature, though evidence is incomplete and from a limited range of countries. Prominent among identified environmental influences are urban layout and sprawl, healthy food access, exercise access, and the neighbourhood social environment. This paper reviews the literature and highlights the special issue contributions within that literature.

Development and Validation of a Simple Convenience Store SHELF Audit

Background This paper describes the development, reliability, and convergent validity of a practical tool—the Convenience Store Supportive Healthy Environment for Life-Promoting Food (SHELF) Audit. Methods Audit items included: a variety of fresh, processed, and frozen fruits and vegetables; low-fat dairy products; healthy staples and frozen meals; healthy food incentive programs; items sold in check-out areas; portion/cup sizes; and pricing. Each audit item was scored using a five-point semantic-differential scale (1 = provides little or no support for healthful foods to 5 = provides high support for healthful foods). Convergent validity was examined by comparing the SHELF audit to Ghirardelli et al. and Laska et al. store audits. Statistical analysis included: Factor analysis, ANOVA, and Spearman correlations. Results SHELF included three factors: a Fruits/Vegetables scale (eight items, α = 0.79; total potential points = 34); a Healthy Foods scale (four items, α = 0.72; total potential points = 16); and a Supports scale (four items, α = 0.685; total potential points = 16). Only 6% of the 124 convenience stores assessed scored in the most healthful range (46–66). The assessed drug stores (n = 15) scored higher than convenience stores (n = 81) on the Healthy Foods and Supports scales but not the Fruits/Vegetables scale. The SHELF sub-scores were highly correlated with other audit tools indicating convergent validity. Conclusion The SHELF convenience store audit is a valid, reliable tool for assessing the degree to which convenience stores support healthfulness regarding Fruits/Vegetables, Healthy Foods, and Supports for choosing healthy.

Does cultural capital contribute to educational inequalities in food consumption in the Netherlands? A cross-sectional analysis of the GLOBE-2011 survey

BACKGROUND

The importance of culture for food consumption is widely acknowledged, as well as the fact that culture-based resources ("cultural capital") differ between educational groups. Since current explanations for educational inequalities in healthy and unhealthy food consumption (e.g. economic capital, social capital) are unable to fully explain this gradient, we aim to investigate a new explanation for educational inequalities in healthy food consumption, i.e. the role of cultural capital.

METHODS

Data were obtained cross-sectionally by a postal survey among participants of the GLOBE study in the Netherlands in 2011 (N = 2953; response 67.1%). The survey measured respondents' highest attained educational level, food-related cultural capital (institutionalised, objectivised and incorporated cultural capital), economic capital (e.g. home ownership, financial strain), social capital (e.g. social support, health-related social leverage, interpersonal relationships), and frequency of consumption of healthy and unhealthy food products. Two general outcomes (overall healthy food consumption, and overall unhealthy food consumption), and seven specific food consumption outcomes were constructed, and prevalence ratios (PR) were estimated in Poisson regression models with robust variance.

RESULTS

Cultural capital was significantly associated with all food outcomes, also when social and economic capital were taken into account. Those with low levels of cultural capital were more likely to have a lower overall healthy food consumption (PR 1.35, 95% CI 1.22-1.49), a lower consumption of whole wheat bread (PR 1.21, 95% CI 1.05-1.38), vegetables (PR 1.55, 95% CI 1.40-1.71), and meat-substitutes and fish (PR 1.74, 95% CI 1.53-1.97), and a higher consumption of fried food (PR 1.59, 95% CI 1.31-1.93). Social capital was positively associated with overall healthy food consumption, whole wheat bread consumption, and the consumption of fish and meat-substitutes, and economic capital with none of the outcomes. The PR of the lowest educational group to have a low overall healthy food consumption decreased from 1.48 (95% CI 1.28-1.73) to 1.22 (95% CI 1.04-1.43) when cultural, social and economic capital were taken into account.

CONCLUSIONS

Cultural capital contributed to the explanation of educational inequalities in food consumption in The Netherlands, over and above economic and social capital. The socialisation processes through which cultural capital is acquired could offer new entry-points for the promotion of healthy food consumption among low educational groups.

Local fast-food environment, diet and blood pressure: the moderating role of mastery

Purpose

To examine the moderating role of mastery in the association of local fast-food restaurants (FFR) with diet quality and systolic blood pressure (SBP).

Methods

We used cross-sectional data from 1543 adults participating in wave six of the Netherlands Study of Depression and Anxiety (NESDA). Data were collected between 2013 and 2016. Diet quality was defined by adherence with the dietary approaches to stop hypertension (DASH) diet. Individuals reported on their food consumption through a food frequency questionnaire and SBP was measured. Density of FFR in 1600 m, 800 m and 400 m circular buffers around the home postal code was calculated using Geographic Information Systems. We assessed the association between density of FFR, diet and SBP using linear regression analyses, testing for moderation by mastery.

Results

Mean age was 52 years and 32.2% of the sample were men. Exposure to FFR ranged from 0 to 35 FFR per km². Density of FFR was not significantly associated with DASH adherence or SBP. Only one out of the six interaction terms was significant, suggesting that for individuals with lower levels of mastery, higher density of FFR in an 800-m buffer was negatively associated with DASH adherence, while for individuals with higher levels of mastery, this association was positive.

Conclusions

Exposure to FFR was not associated with diet quality and SBP, and we observed little evidence for moderation by level of mastery. This research question should be further explored in a large sample of healthy adults.